Clinical Therapeutics Flashcards

A 62-year-old patient with type 2 diabetes and an eGFR of 25 mL/min/1.73m² is currently taking metformin 1g twice daily. According to NICE guidelines, what action should be recommended?

Answer: Discontinue metformin as eGFR is below 30 mL/min/1.73m²

NICE guidelines and the BNF recommend that metformin should be reviewed when eGFR falls below 45 mL/min/1.73m², the dose reduced if eGFR is 30-45, and discontinued when eGFR falls below 30 mL/min/1.73m² due to the risk of lactic acidosis from impaired renal clearance.

A patient is started on ramipril for hypertension. After two weeks, blood tests show a rise in serum creatinine of 35% from baseline. What is the most appropriate action?

Answer: Stop ramipril immediately and investigate for renal artery stenosis

A rise in serum creatinine of more than 30% from baseline after starting an ACE inhibitor suggests possible renal artery stenosis and the drug should be stopped. A rise of up to 30% is considered acceptable and the drug can be continued with monitoring. This patient's 35% rise exceeds the acceptable threshold.

Which antibiotic is recommended as first-line treatment for an uncomplicated lower urinary tract infection in a non-pregnant adult woman, according to NICE guidelines?

Answer: Nitrofurantoin 100mg modified-release twice daily for 3 days

NICE recommends nitrofurantoin 100mg MR twice daily for 3 days (or trimethoprim 200mg twice daily for 3 days if low risk of resistance) as first-line for uncomplicated lower UTI in non-pregnant women. Fluoroquinolones should be reserved for more serious infections due to resistance concerns and side effects.

A patient on long-term oral corticosteroids (prednisolone 15mg daily for 6 months) wants to stop the medication. What is the recommended approach?

Answer: Gradually taper the dose to avoid adrenal crisis

Long-term corticosteroid use suppresses the hypothalamic-pituitary-adrenal (HPA) axis. Abrupt withdrawal can cause adrenal crisis, which can be life-threatening. Gradual dose reduction allows the adrenal glands to recover their ability to produce cortisol naturally.

A 70-year-old patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4. Which of the following is the most appropriate anticoagulation strategy according to NICE?

Answer: A direct oral anticoagulant (DOAC) such as apixaban or edoxaban

NICE recommends offering anticoagulation to patients with a CHA₂DS₂-VASc score of 2 or above. DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are recommended as options. Aspirin monotherapy is no longer recommended for stroke prevention in atrial fibrillation.

A patient taking simvastatin reports new-onset muscle pain and weakness. Their creatine kinase (CK) level is found to be 12 times the upper limit of normal. What is the most appropriate action?

Answer: Stop simvastatin immediately due to risk of rhabdomyolysis

A CK level greater than 10 times the upper limit of normal with muscle symptoms indicates likely rhabdomyolysis, a serious and potentially life-threatening condition. The statin must be stopped immediately. Rhabdomyolysis can cause acute kidney injury from myoglobin release.