A 67-year-old man with multiple sclerosis, recurrent urinary tract infections, depression, and insomnia takes solifenacin 10mg daily, trimethoprim prophylaxis 100mg nightly, mirtazapine 30mg at night, and zopiclone 7.5mg at night. He attends with his wife who reports he has become increasingly forgetful, had difficulty passing urine requiring catheterisation last month, and has been unsteady on his feet. What aspect of his medication regimen represents the MOST significant contributor to his cognitive and functional decline?
Q92
You are conducting a medication review for a 79-year-old woman with dementia (MMSE 18/30), type 2 diabetes, hypertension, and chronic constipation. Her daughter reports that her mother has become increasingly confused and had a fall last week. Current medications include: donepezil 10mg daily, gliclazide 80mg twice daily, amlodipine 5mg daily, codeine phosphate 30mg four times daily (for osteoarthritis pain), and docusate 100mg twice daily. Random blood glucose today is 16.2 mmol/L. What is the SINGLE most important medication-related concern to address?
Q93
A 74-year-old man with COPD, ischaemic heart disease, permanent atrial fibrillation, and stage 3a CKD attends for his annual review. His current medications are: tiotropium inhaler, salmeterol/fluticasone inhaler, bisoprolol 2.5mg daily, ramipril 5mg daily, atorvastatin 80mg daily, apixaban 5mg twice daily, and calcium carbonate/vitamin D3 daily. He reports increasing breathlessness on exertion. Spirometry shows FEV1 52% predicted with no significant reversibility. His heart rate is 76 bpm, blood pressure 132/78 mmHg, oxygen saturation 94% on air. Recent blood tests show eGFR 54 ml/min/1.73m², HbA1c 41 mmol/mol. What medication change would be MOST appropriate?
Q94
During a medication review for a 68-year-old woman with fibromyalgia, depression, type 2 diabetes, and hypertension, you note she has been taking amitriptyline 50mg at night for 4 years for pain management. She also takes sertraline, metformin, and amlodipine. She reports ongoing daytime drowsiness, dry mouth, and two falls in the past 6 months. Her blood pressure is 138/82 mmHg. What is the MOST appropriate management approach?
Q95
A 76-year-old man with heart failure, atrial fibrillation, type 2 diabetes, and benign prostatic hyperplasia takes 10 medications including warfarin, bisoprolol, furosemide, ramipril, metformin, tamsulosin, finasteride, atorvastatin, aspirin, and omeprazole. His INR is stable at 2.5. What is the MOST important medication-related issue to address?
Q96
A 70-year-old woman with type 2 diabetes, hypertension, osteoarthritis, and chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²) takes 9 regular medications. She reports good medication adherence but admits confusion about which tablets to take at different times of day. Which validated tool would be MOST appropriate to systematically assess medication-related problems during her review?
Q97
A 72-year-old man with multimorbidity is taking 11 regular medications. During his annual review, you decide to conduct a structured medication review using an evidence-based framework. According to NICE guidance on multimorbidity, what is the PRIMARY purpose of a structured medication review in patients with multimorbidity?
Q98
Your practice is implementing a quality improvement project for patients with multimorbidity and polypharmacy. The project aims to reduce potentially inappropriate prescribing and improve patient outcomes. The practice team has identified 240 patients aged 75+ taking ≥10 medications. You are asked to recommend an evidence-based approach to structuring medication reviews. Evaluating the available tools and frameworks, which combination would provide the MOST comprehensive approach to identifying and addressing prescribing issues in this population?
Q99
A 72-year-old man with COPD (post-bronchodilator FEV1 48% predicted), ischaemic heart disease, heart failure (LVEF 42%), and depression takes 13 medications. Following a comprehensive medication review using the NO TEARS tool, you identify that he is taking regular co-codamol 30/500 four times daily for chronic back pain, which he has taken for 3 years. He also takes senna regularly for constipation. His pain is reasonably well-controlled (average 4/10). Considering principles of deprescribing opioid therapy in chronic non-cancer pain, what is the MOST appropriate next step?
Q100
A 67-year-old woman with heart failure (LVEF 35%), atrial fibrillation, CKD stage 3a, and type 2 diabetes takes bisoprolol 10mg, ramipril 10mg, furosemide 40mg, apixaban 5mg BD, metformin 1g BD, and atorvastatin 80mg. She was recently admitted with acute heart failure exacerbation. At discharge, sacubitril-valsartan 49/51mg BD was initiated and ramipril stopped. She attends for post-discharge review 10 days later. Her BP is 108/66 mmHg, eGFR has decreased from 54 to 42 ml/min/1.73m², and potassium is 5.4 mmol/L. What is the MOST appropriate management approach?
Chronic Disease Management UK Medical PG Practice Questions and MCQs
Question 91: A 67-year-old man with multiple sclerosis, recurrent urinary tract infections, depression, and insomnia takes solifenacin 10mg daily, trimethoprim prophylaxis 100mg nightly, mirtazapine 30mg at night, and zopiclone 7.5mg at night. He attends with his wife who reports he has become increasingly forgetful, had difficulty passing urine requiring catheterisation last month, and has been unsteady on his feet. What aspect of his medication regimen represents the MOST significant contributor to his cognitive and functional decline?
A. Trimethoprim is causing folate deficiency leading to cognitive impairment
B. Mirtazapine and zopiclone combination is causing excessive sedation and cognitive impairment
C. Solifenacin anticholinergic effects are contributing to cognitive impairment and urinary retention (Correct Answer)
D. Zopiclone is causing paradoxical insomnia and rebound anxiety affecting cognition
E. The combination of all four medications is causing a rare serotonin syndrome
Explanation: ***Solifenacin anticholinergic effects are contributing to cognitive impairment and urinary retention***
- **Solifenacin** is a potent antimuscarinic agent, known to significantly contribute to **anticholinergic burden**, which manifests as cognitive impairment (forgetfulness), confusion, and increased fall risk (unsteadiness) in elderly patients.
- Its mechanism directly inhibits detrusor muscle contraction, leading to **urinary retention**, which aligns perfectly with the patient's recent need for catheterization and represents the most direct explanation for the combination of symptoms.
*Trimethoprim is causing folate deficiency leading to cognitive impairment*
- While **trimethoprim** is a folate antagonist, the prophylactic dose of 100mg nightly is generally well-tolerated, and significant **folate deficiency** leading to acute cognitive decline is a rare occurrence.
- This explanation does not account for the acute onset of **urinary retention** or the patient's reported unsteadiness on his feet.
*Mirtazapine and zopiclone combination is causing excessive sedation and cognitive impairment*
- Both **mirtazapine** and **zopiclone** are sedating agents that can contribute to cognitive impairment, drowsiness, and increased risk of falls, particularly in older adults.
- However, this combination does not typically cause acute **urinary retention** requiring catheterization, making it a less comprehensive explanation for the constellation of symptoms than solifenacin.
*Zopiclone is causing paradoxical insomnia and rebound anxiety affecting cognition*
- **Paradoxical reactions** to Z-drugs like zopiclone are uncommon and usually involve agitation, confusion, or hallucinations, rather than the memory loss, unsteadiness, and urinary retention described.
- This explanation also fails to address the significant symptom of **urinary retention** requiring catheterization, which is a key part of the patient's decline.
*The combination of all four medications is causing a rare serotonin syndrome*
- **Serotonin syndrome** is characterized by a triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities (e.g., clonus, hyperreflexia, rigidity).
- This patient's symptoms (forgetfulness, urinary retention, unsteadiness) do not align with the typical presentation of **serotonin syndrome**, and only mirtazapine has significant serotonergic activity in his regimen.
Question 92: You are conducting a medication review for a 79-year-old woman with dementia (MMSE 18/30), type 2 diabetes, hypertension, and chronic constipation. Her daughter reports that her mother has become increasingly confused and had a fall last week. Current medications include: donepezil 10mg daily, gliclazide 80mg twice daily, amlodipine 5mg daily, codeine phosphate 30mg four times daily (for osteoarthritis pain), and docusate 100mg twice daily. Random blood glucose today is 16.2 mmol/L. What is the SINGLE most important medication-related concern to address?
A. Donepezil may be causing confusion and should be stopped immediately
B. Gliclazide dose is inadequate as blood glucose is elevated and should be increased
C. Codeine is likely contributing to confusion, fall risk, and constipation despite laxative use (Correct Answer)
D. Amlodipine is causing postural hypotension leading to falls and should be stopped
E. Docusate is ineffective and should be changed to senna for better constipation management
Explanation: ***Codeine is likely contributing to confusion, fall risk, and constipation despite laxative use***- **Codeine** is an opioid that significantly increases the risk of **delirium**, sedation, and **falls** in elderly patients, particularly those with pre-existing **dementia**.- It is a major cause of **chronic constipation** which often remains refractory to stool softeners like docusate, necessitating a review of the analgesic regimen.*Donepezil may be causing confusion and should be stopped immediately*- **Donepezil** is an **acetylcholinesterase inhibitor** intended to improve cognitive function and should not be stopped abruptly as it may lead to a decline in **MMSE scores**.- Confusion is a symptom of progressive dementia or medication toxicity from other sources, rather than a typical side effect of **cholinergic therapy**.*Gliclazide dose is inadequate as blood glucose is elevated and should be increased*- Increasing **Gliclazide** (a sulfonylurea) in an elderly patient with cognitive impairment poses a critical risk of **hypoglycemia**, which can lead to further falls or coma.- Elevated **random blood glucose** may be transient or related to current illness and should be managed with caution rather than an immediate dose escalation in a high-risk patient.*Amlodipine is causing postural hypotension leading to falls and should be stopped*- While some antihypertensives cause **orthostatic hypotension**, **Amlodipine** is a calcium channel blocker more commonly associated with **peripheral edema** than significant postural drops.- There is no clinical objective evidence provided, such as **postural blood pressure** readings, to justify stopping an essential medication for hypertension management.*Docusate is ineffective and should be changed to senna for better constipation management*- While **Docusate** is a weak softener, the underlying issue is the **opioid-induced constipation** caused by the codeine, which requires addressing the primary cause.- Switching laxatives is a secondary management step that does not address the more dangerous risks of **confusion and falls** posed by the current medication profile.
Question 93: A 74-year-old man with COPD, ischaemic heart disease, permanent atrial fibrillation, and stage 3a CKD attends for his annual review. His current medications are: tiotropium inhaler, salmeterol/fluticasone inhaler, bisoprolol 2.5mg daily, ramipril 5mg daily, atorvastatin 80mg daily, apixaban 5mg twice daily, and calcium carbonate/vitamin D3 daily. He reports increasing breathlessness on exertion. Spirometry shows FEV1 52% predicted with no significant reversibility. His heart rate is 76 bpm, blood pressure 132/78 mmHg, oxygen saturation 94% on air. Recent blood tests show eGFR 54 ml/min/1.73m², HbA1c 41 mmol/mol. What medication change would be MOST appropriate?
A. Stop calcium carbonate/vitamin D3 as there is no documented osteoporosis (Correct Answer)
B. Reduce apixaban dose to 2.5mg twice daily due to CKD stage 3a
C. Increase bisoprolol to 5mg daily to improve heart rate control in atrial fibrillation
D. Stop salmeterol/fluticasone and prescribe salmeterol alone, as inhaled corticosteroids may increase cardiovascular risk
E. Continue all medications and add oral prednisolone for his worsening breathlessness
Explanation: ***Stop calcium carbonate/vitamin D3 as there is no documented osteoporosis***
- In a **multimorbidity** medication review, medications without a clear indication, documented **vitamin D deficiency**, or secondary hyperparathyroidism should be discontinued to reduce **polypharmacy**.
- There is no clinical evidence provided in the history of **osteoporosis** or bone fragility to justify the continued use of these supplements.
*Reduce apixaban dose to 2.5mg twice daily due to CKD stage 3a*
- **Apixaban dose reduction** is only indicated if at least two of the following are met: age ≥80 years, weight ≤60kg, or **serum creatinine** ≥133 micromol/L.
- A patient with an **eGFR of 54 ml/min** likely has a creatinine level below the threshold, meaning the full 5mg twice-daily dose remains appropriate.
*Increase bisoprolol to 5mg daily to improve heart rate control in atrial fibrillation*
- His current **heart rate of 76 bpm** indicates adequate rate control for **permanent atrial fibrillation**, typically targeted at <110 bpm at rest.
- Increasing the **beta-blocker** dose unnecessarily could risk bradycardia or potentially exacerbate his **COPD** symptoms if not tolerated well.
*Stop salmeterol/fluticasone and prescribe salmeterol alone, as inhaled corticosteroids may increase cardiovascular risk*
- **Inhaled corticosteroids (ICS)** are indicated in COPD for patients with persistent breathlessness or exacerbations despite LABA/LAMA therapy; they do not carry a primary **cardiovascular contraindication**.
- While ICS increase the risk of **pneumonia**, they are a standard component of triple therapy (LAMA + LABA + ICS) which this patient is correctly receiving for symptomatic disease.
*Continue all medications and add oral prednisolone for his worsening breathlessness*
- **Oral prednisolone** is indicated for acute **COPD exacerbations** but is not recommended for long-term maintenance therapy due to significant side effects like **osteoporosis** and diabetes.
- There is no evidence of an acute infection or increased sputum purulence to suggest an exacerbation requiring a steroid course at this time.
Question 94: During a medication review for a 68-year-old woman with fibromyalgia, depression, type 2 diabetes, and hypertension, you note she has been taking amitriptyline 50mg at night for 4 years for pain management. She also takes sertraline, metformin, and amlodipine. She reports ongoing daytime drowsiness, dry mouth, and two falls in the past 6 months. Her blood pressure is 138/82 mmHg. What is the MOST appropriate management approach?
A. Continue amitriptyline as it is effectively managing her fibromyalgia pain and drowsiness will improve with time
B. Increase amlodipine dose as postural hypotension from inadequate blood pressure control may be causing falls
C. Gradually reduce and stop amitriptyline, considering alternative pain management strategies (Correct Answer)
D. Add ondansetron to manage the anticholinergic side effects of amitriptyline
E. Switch sertraline to citalopram to reduce drug interactions with amitriptyline
Explanation: ***Gradually reduce and stop amitriptyline, considering alternative pain management strategies***- Amitriptyline is a **tricyclic antidepressant (TCA)** with significant **anticholinergic and sedative** effects, contributing to this patient's dry mouth, daytime drowsiness, and increased **fall risk**.- According to the **Beers Criteria** and **STOPP criteria**, TCAs should generally be avoided in older adults due to the risk of **orthostatic hypotension** and CNS depression; tapering is necessary to prevent **withdrawal symptoms**.*Continue amitriptyline as it is effectively managing her fibromyalgia pain and drowsiness will improve with time*- After four years of use, the patient is still experiencing **persistent sedation**, making it unlikely that she will develop further tolerance to this side effect.- The clinical priority is addressing the **two recent falls**, which represent a significant safety risk that outweighs the benefits of chronic TCA use in this age group.*Increase amlodipine dose as postural hypotension from inadequate blood pressure control may be causing falls*- The patient's blood pressure is 138/82 mmHg, which is within the acceptable range for a 68-year-old with **type 2 diabetes** and hypertension.- Increasing antihypertensives would more likely **increase the risk of falls** by worsening potential **orthostatic hypotension**, a common side effect of both TCAs and amlodipine.*Add ondansetron to manage the anticholinergic side effects of amitriptyline*- Ondansetron is an antiemetic that does not treat **anticholinergic symptoms** like dry mouth; it can actually worsen **constipation**, another common side effect.- Managing side effects by adding more medication (the "**prescribing cascade**") is inappropriate when the primary drug itself should be discontinued or replaced.*Switch sertraline to citalopram to reduce drug interactions with amitriptyline*- While both drugs can interact with TCAs, switching one **SSRI** for another does not address the patient's primary complaints of drowsiness and falls.- The combination of any SSRI with amitriptyline carries a risk of **Serotonin Syndrome** and increased TCA levels, but the most direct solution to her symptoms is the cessation of **amitriptyline**.
Question 95: A 76-year-old man with heart failure, atrial fibrillation, type 2 diabetes, and benign prostatic hyperplasia takes 10 medications including warfarin, bisoprolol, furosemide, ramipril, metformin, tamsulosin, finasteride, atorvastatin, aspirin, and omeprazole. His INR is stable at 2.5. What is the MOST important medication-related issue to address?
A. The combination of ramipril and bisoprolol increases the risk of hypotension and should be reviewed
B. Aspirin should be discontinued as it provides no additional benefit with warfarin and increases bleeding risk (Correct Answer)
C. Omeprazole should be stopped immediately due to interaction with warfarin
D. Metformin dose should be reduced due to increased risk of lactic acidosis with furosemide
E. Finasteride should be discontinued as it has no cardiovascular benefit
Explanation: ***Aspirin should be discontinued as it provides no additional benefit with warfarin and increases bleeding risk***
- Concurrent use of **aspirin** and **warfarin** significantly increases the risk of **major bleeding** without providing additional thromboembolic protection in patients with **atrial fibrillation** managed with warfarin.
- Unless there is a specific, recent indication such as an **acute coronary syndrome** or **coronary stenting** within the last 12 months, antiplatelet therapy in combination with oral anticoagulation should generally be avoided to minimize **bleeding risk**.
*The combination of ramipril and bisoprolol increases the risk of hypotension and should be reviewed*
- This combination of an **ACE inhibitor** (ramipril) and a **beta-blocker** (bisoprolol) is a cornerstone therapy for **heart failure with reduced ejection fraction** and provides significant **mortality benefits**.
- While these medications can lower blood pressure, they are essential for **cardiac remodeling** and **symptom control** in heart failure, and their combination is medically appropriate and not a primary issue to address in a stable patient.
*Omeprazole should be stopped immediately due to interaction with warfarin*
- While **omeprazole** (and other PPIs) can weakly inhibit **CYP2C19**, which metabolizes warfarin, the clinical significance is generally small, especially when the **INR is stable** at 2.5.
- In fact, **proton pump inhibitors (PPIs)** are often recommended for patients on anticoagulants to reduce the risk of **gastrointestinal bleeding**, making its discontinuation potentially harmful.
*Metformin dose should be reduced due to increased risk of lactic acidosis with furosemide*
- The primary concern for **lactic acidosis** with **metformin** is in patients with significant **renal impairment** or acute kidney injury, not a direct interaction with **furosemide**.
- While furosemide can cause dehydration and potentially affect kidney function, in a stable patient with adequate **renal function**, this combination does not warrant an immediate metformin dose reduction solely due to furosemide.
*Finasteride should be discontinued as it has no cardiovascular benefit*
- **Finasteride** is prescribed for **benign prostatic hyperplasia (BPH)**, a condition the patient has, and its benefit is to reduce prostate size and improve urinary symptoms.
- A medication does not need to have **cardiovascular benefit** to be appropriate; its indication is for the specific condition it is treating, which in this case is symptomatic BPH.
Question 96: A 70-year-old woman with type 2 diabetes, hypertension, osteoarthritis, and chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²) takes 9 regular medications. She reports good medication adherence but admits confusion about which tablets to take at different times of day. Which validated tool would be MOST appropriate to systematically assess medication-related problems during her review?
A. The FRAX tool
B. The MUST screening tool
C. The NO TEARS mnemonic (Correct Answer)
D. The PHQ-9 questionnaire
E. The ABCD2 score
Explanation: ***The NO TEARS mnemonic***- This tool is specifically designed for **medication reviews** in primary care, encompassing Need, Open questions, Tests, Evidence, Adverse events, Risk reduction, and **Simplification** components.- It is highly appropriate for patients with **polypharmacy** and medication confusion, as it systematically guides the clinician to assess the necessity, effectiveness, and safety of each drug, while also seeking opportunities for **simplification** of the regimen.*The FRAX tool*- This tool is used to estimate the **10-year probability of a major osteoporotic fracture** based on various clinical risk factors.- It does not assess the appropriateness of **multimorbidity medications** or help in resolving patient confusion regarding medication schedules.*The MUST screening tool*- The **Malnutrition Universal Screening Tool (MUST)** is used to identify adults who are malnourished, at risk of **malnutrition**, or obese.- While important for geriatric health, it has no utility in identifying or managing **medication-related problems** or confusion about medication timing.*The PHQ-9 questionnaire*- This is a validated **depression screening** and severity monitoring tool, assessing the presence and intensity of depressive symptoms over the past two weeks.- While depression could contribute to medication confusion, the PHQ-9 is not a **functional tool for systematic medication review** or addressing adherence issues directly.*The ABCD2 score*- This clinical prediction rule is used to estimate the risk of **stroke** within 2, 7, and 90 days following a **Transient Ischemic Attack (TIA)**.- It considers age, blood pressure, clinical features of TIA, duration of symptoms, and diabetes, but is entirely unrelated to **polypharmacy management** or medication adherence.
Question 97: A 72-year-old man with multimorbidity is taking 11 regular medications. During his annual review, you decide to conduct a structured medication review using an evidence-based framework. According to NICE guidance on multimorbidity, what is the PRIMARY purpose of a structured medication review in patients with multimorbidity?
A. To reduce the number of medications by at least 50% to improve adherence
B. To optimise treatment regimens, reduce potential harm, and improve patient outcomes (Correct Answer)
C. To ensure all medications are prescribed generically to reduce healthcare costs
D. To identify all drug interactions and switch to alternative medications without interactions
E. To consolidate prescribing to once-daily preparations to simplify medication regimens
Explanation: ***To optimise treatment regimens, reduce potential harm, and improve patient outcomes***\n- According to **NICE NG56**, the primary goal of a structured medication review is a holistic assessment to ensure each medication is beneficial while minimizing the risks of **polypharmacy** and drug-related harm.\n- It emphasizes **shared decision-making** with the patient, aligning treatment with their **personal priorities**, values, and overall quality of life.\n*To reduce the number of medications by at least 50% to improve adherence*\n- While **deprescribing** is often an outcome of a medication review, setting an arbitrary percentage reduction target is not a recommended primary purpose by clinical guidelines.\n- The focus should be on the **appropriateness**, clinical **utility**, and **safety** of each medication for the individual, rather than a fixed reduction in quantity.\n*To ensure all medications are prescribed generically to reduce healthcare costs*\n- **Cost-effectiveness** is a valid consideration in prescribing decisions and overall healthcare management, but it is not the **primary clinical purpose** of a structured medication review in multimorbidity.\n- The main objective remains **patient safety**, clinical effectiveness, and improving patient outcomes, rather than purely administrative or financial goals.\n*To identify all drug interactions and switch to alternative medications without interactions*\n- Identifying and managing **drug-drug interactions** is a crucial component of a medication review, but it is often impossible to eliminate all interactions in patients with complex multimorbidity.\n- The primary goal is to weigh the **risk-benefit ratio** of essential medications and manage interactions appropriately, rather than attempting to switch to entirely interaction-free alternatives which may not be clinically optimal.\n*To consolidate prescribing to once-daily preparations to simplify medication regimens*\n- **Regimen simplification**, such as consolidating to once-daily preparations, is a valuable strategy to improve **adherence** and reduce patient burden, but it is a secondary management approach rather than the overarching primary objective.\n- The fundamental purpose of the review is to assess the **overall appropriateness** and effectiveness of all therapies for the patient's specific health needs and goals.
Question 98: Your practice is implementing a quality improvement project for patients with multimorbidity and polypharmacy. The project aims to reduce potentially inappropriate prescribing and improve patient outcomes. The practice team has identified 240 patients aged 75+ taking ≥10 medications. You are asked to recommend an evidence-based approach to structuring medication reviews. Evaluating the available tools and frameworks, which combination would provide the MOST comprehensive approach to identifying and addressing prescribing issues in this population?
A. STOPP/START criteria combined with medication reconciliation at each review
B. Beers Criteria combined with comprehensive geriatric assessment tools
C. STOPP/START criteria combined with patient-centred discussion of goals and priorities (Correct Answer)
D. Anticholinergic Burden Calculator combined with falls risk assessment
E. Medication Appropriateness Index combined with QRISK3 cardiovascular risk assessment
Explanation: ***STOPP/START criteria combined with patient-centred discussion of goals and priorities***
- The **STOPP/START criteria** provide a validated, systematic framework for identifying **potentially inappropriate medications (PIMs)** and **potential prescribing omissions (PPOs)** specifically in the elderly.
- Combining these criteria with a **patient-centred discussion** ensures that clinical decisions align with the patient’s **quality of life**, preferences, and personal goals, which is a core recommendation of **NICE guidance (NG56)** on multimorbidity.
*STOPP/START criteria combined with medication reconciliation at each review*
- **Medication reconciliation** is vital for ensuring the list is accurate across care transitions, but it does not evaluate the **clinical appropriateness** of the medications themselves.
- While it prevents technical errors, it lacks the **holistic evaluation** of patient priorities required for complex multimorbidity management.
*Beers Criteria combined with comprehensive geriatric assessment tools*
- The **Beers Criteria** are primarily developed in the **USA** and include some medications and practices that do not directly translate to **UK primary care** settings.
- While **Comprehensive Geriatric Assessment (CGA)** is valuable, it is a resource-intensive diagnostic process rather than a specific structured tool for **polypharmacy rationalization** in a practice-wide project.
*Anticholinergic Burden Calculator combined with falls risk assessment*
- These tools are highly specific but only address a **subset of risks** (anticholinergic side effects and falls) rather than the total medication profile.
- This approach would miss many other **potentially inappropriate prescriptions**, such as long-term PPI use or inappropriate NSAID use, that STOPP/START would identify.
*Medication Appropriateness Index combined with QRISK3 cardiovascular risk assessment*
- The **Medication Appropriateness Index (MAI)** is thorough but very **time-consuming** to apply in routine clinical practice compared to the more efficient STOPP/START criteria.
- **QRISK3** is focused specifically on **cardiovascular risk** and does not provide a comprehensive framework for addressing the diverse issues found in geriatric polypharmacy.
Question 99: A 72-year-old man with COPD (post-bronchodilator FEV1 48% predicted), ischaemic heart disease, heart failure (LVEF 42%), and depression takes 13 medications. Following a comprehensive medication review using the NO TEARS tool, you identify that he is taking regular co-codamol 30/500 four times daily for chronic back pain, which he has taken for 3 years. He also takes senna regularly for constipation. His pain is reasonably well-controlled (average 4/10). Considering principles of deprescribing opioid therapy in chronic non-cancer pain, what is the MOST appropriate next step?
A. Switch from co-codamol to a sustained-release opioid preparation for better pain control
B. Discuss gradual opioid reduction plan with patient and optimize non-pharmacological approaches (Correct Answer)
C. Continue co-codamol at current dose as pain is well-controlled and changing risks pain exacerbation
D. Stop co-codamol immediately and replace with regular ibuprofen 400mg TDS
E. Refer to specialist pain service for consideration of opioid rotation
Explanation: ***Discuss gradual opioid reduction plan with patient and optimize non-pharmacological approaches***
- Long-term **opioid therapy** in older adults with **multimorbidity** (COPD, Heart Failure) poses significant risks, including respiratory depression and falls, necessitating a **deprescribing** review.
- A **gradual tapering plan** (e.g., 10% reduction every 2–4 weeks) combined with **non-pharmacological strategies** is the gold standard for managing chronic non-cancer pain safely.
*Switch from co-codamol to a sustained-release opioid preparation for better pain control*
- Sustained-release opioids do not address the underlying risks of **long-term opioid use** and may actually increase the total daily dose and side-effect profile.
- The patient’s pain is already **reasonably well-controlled**, so escalating to stronger forms of opioid therapy is not clinically indicated.
*Continue co-codamol at current dose as pain is well-controlled and changing risks pain exacerbation*
- Continuing high-dose codeine indefinitely ignores the **cumulative risks** of adverse effects, such as the **opioid-induced constipation** he is currently experiencing.
- **Polypharmacy management** (13 medications) requires active attempts to reduce potentially inappropriate medications to improve the patient's overall health outcomes.
*Stop co-codamol immediately and replace with regular ibuprofen 400mg TDS*
- **Abrupt cessation** of opioids after three years of use can trigger severe **withdrawal symptoms** and a significant flare-up of chronic pain.
- **NSAIDs** like ibuprofen are strictly **contraindicated** in patients with **heart failure** as they cause fluid retention and increase the risk of cardiovascular events.
*Refer to specialist pain service for consideration of opioid rotation*
- **Opioid rotation** is typically reserved for patients with poor pain control or intolerable side effects where clinical benefit is still expected, which is not the priority here.
- The primary care physician should first attempt a **patient-centered deprescribing** plan before considering escalation or specialist referral for rotation.
Question 100: A 67-year-old woman with heart failure (LVEF 35%), atrial fibrillation, CKD stage 3a, and type 2 diabetes takes bisoprolol 10mg, ramipril 10mg, furosemide 40mg, apixaban 5mg BD, metformin 1g BD, and atorvastatin 80mg. She was recently admitted with acute heart failure exacerbation. At discharge, sacubitril-valsartan 49/51mg BD was initiated and ramipril stopped. She attends for post-discharge review 10 days later. Her BP is 108/66 mmHg, eGFR has decreased from 54 to 42 ml/min/1.73m², and potassium is 5.4 mmol/L. What is the MOST appropriate management approach?
A. Stop sacubitril-valsartan immediately and restart ramipril due to decline in renal function
B. Reduce bisoprolol dose to 5mg to improve blood pressure and allow continuation of ARNI
C. Continue current medications and recheck renal function in 1-2 weeks (Correct Answer)
D. Stop metformin due to declining renal function and monitor renal function closely
E. Reduce furosemide dose to 20mg daily to improve renal perfusion
Explanation: ***Continue current medications and recheck renal function in 1-2 weeks***
- A decline in **eGFR of up to 25%** and a potassium level up to **5.5 mmol/L** are acceptable following the initiation of an **ARNI (sacubitril-valsartan)** or ACE inhibitor.
- This patient's eGFR reduction (approx. 22%) and potassium (5.4 mmol/L) remain within safe limits, and her **systolic BP (>95 mmHg)** is stable, necessitating monitoring rather than intervention.
*Stop sacubitril-valsartan immediately and restart ramipril due to decline in renal function*
- Discontinuation is only indicated if the **creatinine increases by >30%** or eGFR drops by >25%; her current decline is expected and often stabilizes within 4 weeks.
- Sacubitril-valsartan provides superior **mortality and hospitalization benefits** compared to ACE inhibitors in HFrEF, so it should be maintained if clinically safe.
*Reduce bisoprolol dose to 5mg to improve blood pressure and allow continuation of ARNI*
- The patient's blood pressure is **108/66 mmHg**, which is adequate and does not indicate **symptomatic hypotension** requiring a beta-blocker reduction.
- Reducing **bisoprolol**, a key pillar of HFrEF therapy, should be avoided unless the patient is bradycardic or severely hypotensive.
*Stop metformin due to declining renal function and monitor renal function closely*
- **Metformin** is generally safe to continue until the **eGFR falls below 30 ml/min/1.73m²**, although the dose may be reviewed when eGFR is between 30-45.
- The current eGFR of **42 ml/min** does not mandate immediate cessation, especially as the decline is likely a hemodynamic response to ARNI initiation.
*Reduce furosemide dose to 20mg daily to improve renal perfusion*
- There is no clinical evidence of **hypovolemia** or dehydration in this post-exacerbation review that would justify reducing the diuretic dose.
- Prematurely reducing **furosemide** in a recently hospitalized heart failure patient carries a high risk of triggering **fluid overload** and re-admission.
