A 67-year-old man attends for a structured medication review using the NO TEARS framework. He has type 2 diabetes, ischaemic heart disease with previous myocardial infarction 3 years ago, hypertension, hyperlipidaemia, and benign prostatic hyperplasia. His medications include aspirin, clopidogrel, bisoprolol, ramipril, atorvastatin, metformin, gliclazide, and tamsulosin. He reports no symptoms or concerns. His HbA1c is 54 mmol/mol, BP 132/78 mmHg, and he has had no angina for 2 years. When applying the 'T' component (Time beyond which the drug may be ceased) of NO TEARS, which medication should be prioritized for review regarding potential cessation?
Q52
A 71-year-old woman with rheumatoid arthritis, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), hypertension, and recurrent gout attends for a medication review. She takes methotrexate 15mg weekly, folic acid, hydroxychloroquine, prednisolone 5mg daily, ramipril, indapamide, and allopurinol. Blood tests show Hb 98 g/L (MCV 102 fL), WCC 3.2 × 10⁹/L, platelets 145 × 10⁹/L. She reports increasing fatigue and mouth ulcers over the past month. Understanding the interaction between her multiple conditions and medications, what is the most likely explanation for her presentation?
Q53
During a practice quality improvement initiative, you identify that several elderly patients with multimorbidity are taking potentially inappropriate medications. A 78-year-old man with dementia, type 2 diabetes, hypertension, and recurrent falls is taking donepezil, gliclazide, amlodipine, and long-term diazepam (5mg twice daily) for anxiety. His HbA1c is 48 mmol/mol and blood pressure is 128/76 mmHg. Understanding the principles of deprescribing in multimorbidity, which medication represents the highest priority for review and potential discontinuation?
Q54
A 73-year-old woman with heart failure (LVEF 38%), type 2 diabetes, hypertension, and osteoarthritis attends for a medication review. She takes bisoprolol, ramipril, furosemide, spironolactone, metformin, amlodipine, atorvastatin, and co-codamol. She reports feeling increasingly tired and dizzy on standing over the past 6 weeks. Her sitting blood pressure is 108/64 mmHg, standing blood pressure is 88/52 mmHg after 3 minutes, and pulse is 58 bpm. Her most recent eGFR is 42 ml/min/1.73m² (previously stable at 48 for 2 years). What is the most appropriate understanding of her presentation?
Q55
A 69-year-old man with type 2 diabetes, hypertension, chronic obstructive pulmonary disease, and stable angina attends for his annual medication review. He currently takes 8 regular medications and reports good adherence. His most recent blood pressure is 136/82 mmHg, HbA1c is 58 mmol/mol, and his COPD has been stable without exacerbations for 18 months. According to NICE guidance on multimorbidity, which time frame is recommended for scheduling his next structured medication review?
Q56
You are reviewing prescribing patterns in patients with multimorbidity in your practice. A 72-year-old man with COPD (post-bronchodilator FEV1 55% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes is taking multiple medications including regular prednisolone 5mg daily which was started 18 months ago following a COPD exacerbation and never discontinued. He has had no exacerbations in the past year. He recently sustained a fractured wrist following a minor fall. Which prescribing principle would best guide the management of his corticosteroid therapy?
Q57
A 73-year-old woman with heart failure (LVEF 42%), atrial fibrillation, hypertension, type 2 diabetes, and chronic kidney disease stage 3a attends for medication review. She takes bisoprolol 10mg OD, ramipril 10mg OD, furosemide 80mg OD, spironolactone 25mg OD, edoxaban 60mg OD, metformin 1g BD, atorvastatin 80mg ON, and amlodipine 10mg OD. Blood tests show: sodium 128 mmol/L (135-145), potassium 5.8 mmol/L (3.5-5.0), eGFR 48 ml/min/1.73m² (stable), glucose 6.2 mmol/L. She reports feeling weak and lethargic. Which medication adjustment should be prioritized?
Q58
During a practice audit of patients over 75 years taking 10 or more medications, you identify a 79-year-old man with heart failure (LVEF 35%), atrial fibrillation on apixaban, type 2 diabetes, and previous peptic ulcer disease. He takes 13 medications including aspirin 75mg daily which was started 8 years ago following a TIA. His CHADSVASC score is 5. According to current evidence on antithrombotic therapy in patients with atrial fibrillation and multimorbidity, what is the most appropriate action regarding his antiplatelet and anticoagulant therapy?
Q59
A 68-year-old man with ischaemic heart disease, type 2 diabetes, COPD, and osteoarthritis attends for review. He takes aspirin, atorvastatin, metformin, sitagliptin, ramipril, bisoprolol, tiotropium, salbutamol, beclometasone inhaler, paracetamol, and codeine. He reports chronic constipation requiring frequent laxative use, and daytime drowsiness affecting his daily activities. His pain control is adequate. Which medication is the highest priority to review for potential deprescribing based on the principle of reducing treatment burden?
Q60
You are implementing a quality improvement project for medication reviews in your practice. According to the Royal Pharmaceutical Society guidance on structured medication reviews, which component is considered essential to include in Level 3 (clinical medication review) but NOT required in Level 1 (prescription review)?
Chronic Disease Management UK Medical PG Practice Questions and MCQs
Question 51: A 67-year-old man attends for a structured medication review using the NO TEARS framework. He has type 2 diabetes, ischaemic heart disease with previous myocardial infarction 3 years ago, hypertension, hyperlipidaemia, and benign prostatic hyperplasia. His medications include aspirin, clopidogrel, bisoprolol, ramipril, atorvastatin, metformin, gliclazide, and tamsulosin. He reports no symptoms or concerns. His HbA1c is 54 mmol/mol, BP 132/78 mmHg, and he has had no angina for 2 years. When applying the 'T' component (Time beyond which the drug may be ceased) of NO TEARS, which medication should be prioritized for review regarding potential cessation?
A. Gliclazide should be reviewed as his diabetes is well controlled with HbA1c of 54 mmol/mol
B. Clopidogrel should be reviewed as dual antiplatelet therapy is typically recommended for only 12 months post-myocardial infarction (Correct Answer)
C. Tamsulosin should be reviewed as he reports no urinary symptoms currently
D. Bisoprolol should be reviewed as he has had no angina for 2 years
E. Atorvastatin dose should be reviewed as he may be overtreated for secondary prevention
Explanation: ***Clopidogrel should be reviewed as dual antiplatelet therapy is typically recommended for only 12 months post-myocardial infarction***
- In the **NO TEARS** framework, **'T'** stands for **Time** beyond which a drug may be ceased; **dual antiplatelet therapy (DAPT)** is indicated for **12 months** post-MI before reverting to monotherapy.
- This patient is **3 years post-MI**, making the continuation of **clopidogrel** unnecessary and increasing his risk of **major bleeding** without additional benefit.
*Gliclazide should be reviewed as his diabetes is well controlled with HbA1c of 54 mmol/mol*
- While **HbA1c** is well-controlled, this relates to the **'E' (Evidence/Effectiveness)** or **'N' (Need)** components of NO TEARS rather than a predefined **time limit** for cessation.
- **Sulfonylureas** like **gliclazide** are not time-limited medications but are adjusted based on ongoing clinical control and **hypoglycemia** risk.
*Tamsulosin should be reviewed as he reports no urinary symptoms currently*
- **Tamsulosin** is used for **Benign Prostatic Hyperplasia (BPH)**; the absence of symptoms indicates the drug is **effective** rather than ready for cessation based on a time limit.
- Stopping an **alpha-blocker** in a patient with BPH often leads to the **recurrence** of lower urinary tract symptoms (LUTS).
*Bisoprolol should be reviewed as he has had no angina for 2 years*
- **Beta-blockers** like **bisoprolol** are indicated for **long-term secondary prevention** following a **myocardial infarction** to reduce mortality and remodeling.
- The absence of **angina** does not mean the medication should be stopped, as its primary role in this context is **prognostic** rather than purely symptomatic.
*Atorvastatin dose should be reviewed as he may be overtreated for secondary prevention*
- **Statins** are indicated **indefinitely** for **secondary prevention** in patients with established **ischaemic heart disease** regardless of symptom status.
- There is no clinical evidence provided suggesting **side effects** or **overtreatment**, and statins are not considered time-limited medications in this setting.
Question 52: A 71-year-old woman with rheumatoid arthritis, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), hypertension, and recurrent gout attends for a medication review. She takes methotrexate 15mg weekly, folic acid, hydroxychloroquine, prednisolone 5mg daily, ramipril, indapamide, and allopurinol. Blood tests show Hb 98 g/L (MCV 102 fL), WCC 3.2 × 10⁹/L, platelets 145 × 10⁹/L. She reports increasing fatigue and mouth ulcers over the past month. Understanding the interaction between her multiple conditions and medications, what is the most likely explanation for her presentation?
A. Hydroxychloroquine toxicity manifesting as bone marrow suppression
B. Folate deficiency despite supplementation due to inadequate dosing in methotrexate therapy
C. Methotrexate toxicity precipitated by reduced renal clearance and drug interaction with indapamide (Correct Answer)
D. Anaemia of chronic disease secondary to active rheumatoid arthritis requiring biologics
E. Corticosteroid-induced immunosuppression leading to oral candidiasis
Explanation: ***Methotrexate toxicity precipitated by reduced renal clearance and drug interaction with indapamide*** - This patient presents with classic features of **methotrexate toxicity**, including **mucositis** (mouth ulcers) and **pancytopenia** (low Hb, WCC, and platelets) with **macrocytosis**. - Methotrexate is primarily **renally excreted**, making it high risk in **CKD stage 3b**; furthermore, **diuretics** like indapamide can compete for renal tubular secretion, further increasing toxic plasma levels.*Hydroxychloroquine toxicity manifesting as bone marrow suppression* - Hydroxychloroquine is generally considered **bone marrow-sparing** and is much more commonly associated with **retinal toxicity** than hematological suppression. - It does not cause the **macrocytic anemia** or mucosal ulcerations seen in this patient's clinical presentation.*Folate deficiency despite supplementation due to inadequate dosing in methotrexate therapy* - While folate deficiency causes macrocytosis, the patient is already receiving **folic acid supplementation**, making profound deficiency less likely than direct drug toxicity. - **Methotrexate toxicity** can occur even with standard folic acid dosing if renal clearance is impaired or if there are significant drug-drug interactions, leading to more severe effects than simple folate deficiency alone.*Anaemia of chronic disease secondary to active rheumatoid arthritis requiring biologics* - Anaemia of chronic disease is typically **normocytic** or **microcytic**, whereas this patient has a significantly elevated **MCV of 102 fL**. - This diagnosis does not explain the concurrent **leucopenia**, **thrombocytopenia**, or the presence of painful **mouth ulcers**.*Corticosteroid-induced immunosuppression leading to oral candidiasis* - Oral candidiasis (thrush) typically presents as **white plaques** rather than the painful ulcers (mucositis) characteristic of methotrexate toxicity. - Steroid use does not explain the **macrocytic pancytopenia**, as steroids typically cause **leukocytosis** (specifically neutrophilia) rather than leukopenia.
Question 53: During a practice quality improvement initiative, you identify that several elderly patients with multimorbidity are taking potentially inappropriate medications. A 78-year-old man with dementia, type 2 diabetes, hypertension, and recurrent falls is taking donepezil, gliclazide, amlodipine, and long-term diazepam (5mg twice daily) for anxiety. His HbA1c is 48 mmol/mol and blood pressure is 128/76 mmHg. Understanding the principles of deprescribing in multimorbidity, which medication represents the highest priority for review and potential discontinuation?
A. Donepezil due to limited efficacy in moderate-stage dementia
B. Gliclazide due to hypoglycaemia risk in elderly patients
C. Amlodipine as blood pressure is well controlled
D. Diazepam due to falls risk and long-term benzodiazepine dependence (Correct Answer)
E. All medications should be reviewed simultaneously with equal priority
Explanation: ***Diazepam due to falls risk and long-term benzodiazepine dependence***
- **Diazepam**, a long-acting benzodiazepine, significantly increases the risk of **recurrent falls** and cognitive impairment in elderly patients with dementia, making it a high priority for deprescribing.
- Its long-term use in the elderly is generally considered inappropriate according to criteria like **STOPP/START**, due to the heightened risks of sedation, fractures, and dependency.
*Donepezil due to limited efficacy in moderate-stage dementia*
- While the efficacy of **donepezil** can be modest in moderate-stage dementia, it does not pose the immediate, severe safety risk of **falls** that benzodiazepines do.
- Discontinuation of cholinesterase inhibitors should be a considered decision, but it's not the highest priority when acute safety issues like recurrent falls are present.
*Gliclazide due to hypoglycaemia risk in elderly patients*
- **Gliclazide** (a sulfonylurea) does carry a risk of **hypoglycemia** in the elderly, but the patient's HbA1c of **48 mmol/mol** indicates reasonable glycemic control that is not overly aggressive.
- While monitoring is essential, its immediate risk for the patient's presenting problem of **recurrent falls** is lower compared to long-term benzodiazepine use.
*Amlodipine as blood pressure is well controlled*
- The patient's blood pressure of **128/76 mmHg** is well within target range, indicating **amlodipine** is effective and contributing to cardiovascular health.
- Amlodipine is generally well-tolerated and not a primary contributor to **falls** in the same manner as sedative medications in elderly individuals.
*All medications should be reviewed simultaneously with equal priority*
- While a holistic **medication review** is always recommended in multimorbidity, clinical practice requires **prioritization** of medications that pose the greatest immediate harm or have the least benefit.
- A **staged approach** to deprescribing allows for careful monitoring of withdrawal effects and determination of which changes yield the most significant clinical improvement.
Question 54: A 73-year-old woman with heart failure (LVEF 38%), type 2 diabetes, hypertension, and osteoarthritis attends for a medication review. She takes bisoprolol, ramipril, furosemide, spironolactone, metformin, amlodipine, atorvastatin, and co-codamol. She reports feeling increasingly tired and dizzy on standing over the past 6 weeks. Her sitting blood pressure is 108/64 mmHg, standing blood pressure is 88/52 mmHg after 3 minutes, and pulse is 58 bpm. Her most recent eGFR is 42 ml/min/1.73m² (previously stable at 48 for 2 years). What is the most appropriate understanding of her presentation?
A. Symptomatic orthostatic hypotension likely related to excessive diuretic therapy requiring dose reduction
B. Bradycardia-induced hypotension requiring reduction of beta-blocker dose
C. Progressive heart failure requiring uptitration of diuretic therapy
D. Multifactorial symptoms related to the cumulative effect of multiple cardiovascular medications and declining renal function (Correct Answer)
E. Adverse effects of spironolactone requiring discontinuation of aldosterone antagonist
Explanation: ***Multifactorial symptoms related to the cumulative effect of multiple cardiovascular medications and declining renal function*** - The patient exhibits symptomatic **orthostatic hypotension** (standing SBP drop >20 mmHg and DBP drop >10 mmHg) and **declining eGFR**, which are likely consequences of **polypharmacy** involving multiple blood pressure-lowering agents. - The interaction between **ACE inhibitors** (ramipril), **beta-blockers** (bisoprolol), **diuretics** (furosemide, spironolactone), and **calcium channel blockers** (amlodipine) in the context of aging and reduced renal clearance creates a high risk for **adverse drug events** and systemic hypoperfusion.*Symptomatic orthostatic hypotension likely related to excessive diuretic therapy requiring dose reduction* - While **furosemide** and **spironolactone** contribute to volume depletion and orthostasis, they are only part of a larger regimen that collectively lowers blood pressure. - Focusing solely on **diuretics** ignores the vasodilatory and bradycardic effects of her other five cardiovascular medications, leading to an incomplete understanding of the cause.*Bradycardia-induced hypotension requiring reduction of beta-blocker dose* - Her pulse of 58 bpm, while low, does not fully account for the significant **postural drop** in blood pressure, suggesting a more complex issue than isolated bradycardia. - Decreasing the **beta-blocker** may be necessary, but this single adjustment fails to address the combined hypotensive risk from her **ACE inhibitor**, **calcium channel blocker**, and **diuretics** in the setting of declining renal function.*Progressive heart failure requiring uptitration of diuretic therapy* - The primary presentation is **hypotension** and **dizziness**, which strongly suggests **over-treatment** or toxicity rather than fluid overload or worsening heart failure. - Increasing **diuretics** would further decrease **circulating volume** and **renal perfusion**, potentially precipitating acute kidney injury and worsening her orthostatic symptoms.*Adverse effects of spironolactone requiring discontinuation of aldosterone antagonist* - While **spironolactone** can cause hyperkalemia and contribute to decreased renal function, it is unlikely to be the sole cause of profound **orthostatic hypotension** within such a complex regimen. - Discontinuing spironolactone without addressing the other **antihypertensives** and **diuretics** would be an incomplete management strategy for her overall clinical instability and polypharmacy-related symptoms.
Question 55: A 69-year-old man with type 2 diabetes, hypertension, chronic obstructive pulmonary disease, and stable angina attends for his annual medication review. He currently takes 8 regular medications and reports good adherence. His most recent blood pressure is 136/82 mmHg, HbA1c is 58 mmol/mol, and his COPD has been stable without exacerbations for 18 months. According to NICE guidance on multimorbidity, which time frame is recommended for scheduling his next structured medication review?
A. 3 months
B. 6 months (Correct Answer)
C. 12 months
D. 18 months
E. 24 months
Explanation: ***6 months***
- For patients with **multimorbidity** (2+ long-term conditions) and **polypharmacy** (taking 8 medications), **NICE guidance** recommends a structured medication review every **6 months** to monitor for complex drug interactions.
- This frequency is appropriate even when stable to ensure the ongoing rationale for each drug in a complex regimen and to adjust for potential **disease progression** or side effects.
*3 months*
- This shorter timeframe is typically reserved for patients experiencing **clinical instability**, such as recent **COPD exacerbations**, significant medication adjustments for **hypertension**, or uncontrolled diabetes.
- Since the patient is currently **clinically stable** and reports good adherence, a quarterly review may be unnecessarily frequent and burdensome.
*12 months*
- While an **annual review** is a standard minimum for chronic diseases, it is often insufficient for patients with complex **multimorbidity** and a high medication burden.
- Following **NICE guideline NG56**, more frequent reviews (6-monthly) are preferred when polypharmacy significantly increases the risk of **adverse drug events** or sub-optimal treatment.
*18 months*
- This interval is too long and fails to meet the **NICE guidelines** which mandate a minimum of an annual structured review for patients with chronic conditions.
- Waiting this long could lead to missed opportunities for timely detection of issues related to **HbA1c** or blood pressure control in a patient with both **diabetes** and **hypertension**.
*24 months*
- A biennial (every 2 years) review is inappropriate for a patient with four chronic conditions and high-risk **polypharmacy**.
- Standard primary care protocols for conditions like **Diabetes** and **Angina** require more frequent physiological monitoring and medication adjustment than a 2-year cycle allows.
Question 56: You are reviewing prescribing patterns in patients with multimorbidity in your practice. A 72-year-old man with COPD (post-bronchodilator FEV1 55% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes is taking multiple medications including regular prednisolone 5mg daily which was started 18 months ago following a COPD exacerbation and never discontinued. He has had no exacerbations in the past year. He recently sustained a fractured wrist following a minor fall. Which prescribing principle would best guide the management of his corticosteroid therapy?
A. Continue prednisolone long-term as it reduces COPD exacerbation frequency and improves lung function
B. Continue prednisolone but add calcium and vitamin D supplementation to prevent further fractures
C. Attempt to wean prednisolone gradually given limited benefit and significant potential harms (Correct Answer)
D. Switch from prednisolone to inhaled corticosteroid at high dose to maintain benefit with less systemic effect
E. Continue prednisolone but reduce to alternate-day dosing to minimize side effects
Explanation: ***Attempt to wean prednisolone gradually given limited benefit and significant potential harms***
- Long-term maintenance of **oral corticosteroids** in COPD is generally avoided because the risk of systemic adverse effects, such as **osteoporosis** and **fractures**, outweigh their clinical benefit.
- Gradual weaning is essential in this patient to prevent an **adrenal crisis**, as he has been on treatment for 18 months and is already showing signs of **steroid-induced bone loss**.
*Continue prednisolone long-term as it reduces COPD exacerbation frequency and improves lung function*
- Clinical evidence indicates that **maintenance oral steroids** do not significantly improve long-term lung function (FEV1) compared to inhaled therapies.
- Guidelines like **GOLD and NICE** explicitly discourage long-term oral use due to severe morbidity, including **weight gain**, **hypertension**, and **immunosuppression**.
*Continue prednisolone but add calcium and vitamin D supplementation to prevent further fractures*
- While **bone protection** is necessary for patients on steroids, this approach fails to address the underlying issue of **inappropriate prescribing** for a patient with stable COPD.
- Supplementation alone cannot fully mitigate the increased fracture risk caused by high-dose **corticosteroid-induced osteoporosis**.
*Switch from prednisolone to inhaled corticosteroid at high dose to maintain benefit with less systemic effect*
- While **inhaled corticosteroids (ICS)** are used in COPD, they are typically reserved for patients with frequent exacerbations or high **blood eosinophil counts**, unlike this stable patient.
- Switching does not negate the need for a **gradual taper** of the oral dose to avoid **secondary adrenal insufficiency**.
*Continue prednisolone but reduce to alternate-day dosing to minimize side effects*
- **Alternate-day dosing** is often insufficient for maintaining COPD control and does not significantly reduce the long-term risk of **osteoporotic fractures** in elderly patients.
- This strategy still represents **prescribing inertia**, continuing a harmful medication that the patient no longer clinically requires.
Question 57: A 73-year-old woman with heart failure (LVEF 42%), atrial fibrillation, hypertension, type 2 diabetes, and chronic kidney disease stage 3a attends for medication review. She takes bisoprolol 10mg OD, ramipril 10mg OD, furosemide 80mg OD, spironolactone 25mg OD, edoxaban 60mg OD, metformin 1g BD, atorvastatin 80mg ON, and amlodipine 10mg OD. Blood tests show: sodium 128 mmol/L (135-145), potassium 5.8 mmol/L (3.5-5.0), eGFR 48 ml/min/1.73m² (stable), glucose 6.2 mmol/L. She reports feeling weak and lethargic. Which medication adjustment should be prioritized?
A. Stop spironolactone due to hyperkalaemia and reduce furosemide to prevent hyponatraemia
B. Reduce ramipril to 5mg daily to address both hyperkalaemia and hyponatraemia
C. Stop furosemide and switch to increased spironolactone dose for heart failure management
D. Temporarily withhold spironolactone and reduce ramipril until electrolytes normalize (Correct Answer)
E. Add sodium chloride supplements to correct hyponatraemia and continue current medications
Explanation: ***Temporarily withhold spironolactone and reduce ramipril until electrolytes normalize***
- The patient exhibits symptomatic **hyperkalaemia (5.8 mmol/L)** and **hyponatraemia (128 mmol/L)**, necessitating urgent intervention to mitigate the risk of cardiac arrhythmias.
- Both **spironolactone** (a mineralocorticoid receptor antagonist) and **ramipril** (an ACE inhibitor) impair potassium excretion; therefore, reducing or temporarily withholding them is the priority to stabilize **serum potassium** and sodium.
*Stop spironolactone due to hyperkalaemia and reduce furosemide to prevent hyponatraemia*
- While stopping spironolactone appropriately addresses hyperkalaemia, reducing **furosemide** is counterproductive as loop diuretics contribute to potassium excretion and are crucial for managing **heart failure** fluid overload.
- Decreasing furosemide could exacerbate the patient's **congestive heart failure** symptoms and would not effectively lower the elevated potassium level.
*Reduce ramipril to 5mg daily to address both hyperkalaemia and hyponatraemia*
- A simple dose reduction of ramipril may be insufficient to promptly control a potassium level of **5.8 mmol/L**, especially while the patient continues on **spironolactone**.
- This approach neglects the substantial contribution of the **mineralocorticoid receptor antagonist** to the existing electrolyte imbalance.
*Stop furosemide and switch to increased spironolactone dose for heart failure management*
- Increasing the spironolactone dose in the context of current **hyperkalaemia** and **CKD stage 3a** is extremely dangerous and medically contraindicated.
- Discontinuing **furosemide** would eliminate a potassium-wasting mechanism, further worsening the potentially life-threatening **hyperkalaemia**.
*Add sodium chloride supplements to correct hyponatraemia and continue current medications*
- Administering **sodium chloride supplements** is inappropriate for a patient with heart failure as it promotes fluid retention and risks exacerbating **pulmonary edema**.
- This intervention critically overlooks the potentially fatal **hyperkalaemia** induced by the concurrent use of ACE inhibitors and potassium-sparing diuretics.
Question 58: During a practice audit of patients over 75 years taking 10 or more medications, you identify a 79-year-old man with heart failure (LVEF 35%), atrial fibrillation on apixaban, type 2 diabetes, and previous peptic ulcer disease. He takes 13 medications including aspirin 75mg daily which was started 8 years ago following a TIA. His CHADSVASC score is 5. According to current evidence on antithrombotic therapy in patients with atrial fibrillation and multimorbidity, what is the most appropriate action regarding his antiplatelet and anticoagulant therapy?
A. Continue both apixaban and aspirin as he has both atrial fibrillation and previous TIA
B. Stop aspirin and continue apixaban alone for stroke prevention (Correct Answer)
C. Stop apixaban and continue aspirin as dual therapy increases bleeding risk
D. Add a proton pump inhibitor and continue both antiplatelet and anticoagulant
E. Replace both with clopidogrel which has lower bleeding risk than combination therapy
Explanation: ***Stop aspirin and continue apixaban alone for stroke prevention***- In patients with **atrial fibrillation (AF)** and a high **CHA2DS2-VASc score**, oral anticoagulants (OACs) like **apixaban** are superior to antiplatelets for stroke prevention and are generally sufficient as monotherapy.- For patients with stable vascular disease (TIA >12 months ago), guidelines recommend stopping **aspirin** because dual therapy significantly increases the **major bleeding risk** without providing additional cardiovascular benefit.*Continue both apixaban and aspirin as he has both atrial fibrillation and previous TIA*- Long-term **combination therapy** with an anticoagulant and an antiplatelet is unnecessary for a stable TIA occurring 8 years ago and doubles the risk of **gastrointestinal bleeding**.- The **apixaban** alone provides contemporary protection against both AF-related cardioembolic strokes and secondary prevention of arterial events.*Stop apixaban and continue aspirin as dual therapy increases bleeding risk*- Stopping **apixaban** would be inappropriate as a **CHA2DS2-VASc score of 5** indicates a high risk of thromboembolic stroke that aspirin cannot adequately mitigate.- **Direct Oral Anticoagulants (DOACs)** are the gold standard for AF management; replacing them with aspirin would leave the patient under-treated.*Add a proton pump inhibitor and continue both antiplatelet and anticoagulant*- While a **PPI** reduces the risk of aspirin-induced gastric injury, it does not justify the inclusion of a redundant medication that offers no proven extra benefit for **stroke prevention**.- The clinical priority in **polypharmacy audits** for the elderly is to deprescribe medications that lack a current evidence-based indication to reduce the **bleeding burden**.*Replace both with clopidogrel which has lower bleeding risk than combination therapy*- **Clopidogrel monotherapy** is not an evidence-based substitute for anticoagulation in the context of **atrial fibrillation** and high stroke risk.- Anticoagulation (DOACs or Warfarin) is specifically required for AF to prevent **cardioembolic events**, for which clopidogrel is significantly less effective.
Question 59: A 68-year-old man with ischaemic heart disease, type 2 diabetes, COPD, and osteoarthritis attends for review. He takes aspirin, atorvastatin, metformin, sitagliptin, ramipril, bisoprolol, tiotropium, salbutamol, beclometasone inhaler, paracetamol, and codeine. He reports chronic constipation requiring frequent laxative use, and daytime drowsiness affecting his daily activities. His pain control is adequate. Which medication is the highest priority to review for potential deprescribing based on the principle of reducing treatment burden?
A. Bisoprolol as it may be causing fatigue and drowsiness
B. Codeine as it is causing constipation and sedation without essential benefit (Correct Answer)
C. Sitagliptin as it adds complexity without clear advantage over metformin alone
D. Beclometasone inhaler as COPD treatment should focus on bronchodilators
E. Ramipril as multiple cardiovascular medications increase treatment burden
Explanation: ***Codeine as it is causing constipation and sedation without essential benefit***- **Codeine** is the highest priority for deprescribing because it is causing direct, symptomatic harm including **chronic constipation** (requiring more medications) and **daytime drowsiness**.- In the context of **osteoarthritis**, the long-term benefits of opioids are limited, and since pain control is adequate, the **treatment burden** and side effects outweigh the clinical utility.*Bisoprolol as it may be causing fatigue and drowsiness*- Although **beta-blockers** can cause fatigue, this medication is vital for **secondary prevention** in a patient with **ischaemic heart disease**.- It provides essential **cardioprotective benefits** that generally supersede the subjective side effect of mild drowsiness compared to avoidable opioid use.*Sitagliptin as it adds complexity without clear advantage over metformin alone*- **Sitagliptin** is an appropriate second-line agent for **Type 2 Diabetes** when metformin alone is insufficient to reach glycaemic targets.- While it adds to the pill count, it does not carry the significant **sedative** or **gastrointestinal side effects** contributing to this patient's current distress.*Beclometasone inhaler as COPD treatment should focus on bronchodilators*- **Inhaled corticosteroids (ICS)** like beclometasone are indicated in **COPD** for patients with frequent exacerbations or asthmatic features.- Discontinuing it without clinical justification could risk a **COPD exacerbation**, and it does not contribute to the patient's sedation or constipation.*Ramipril as multiple cardiovascular medications increase treatment burden*- **Ramipril** provides critical **renoprotection** in diabetic patients and essential **cardiovascular risk reduction** in those with ischaemic heart disease.- Reducing **treatment burden** focuses on removing harmful or non-essential drugs; ACE inhibitors are considered **prognostic medications** with high clinical value in this patient profile.
Question 60: You are implementing a quality improvement project for medication reviews in your practice. According to the Royal Pharmaceutical Society guidance on structured medication reviews, which component is considered essential to include in Level 3 (clinical medication review) but NOT required in Level 1 (prescription review)?
A. Review of the medication list for accuracy and completeness
B. Patient interview to discuss medication concerns and adherence (Correct Answer)
C. Check for potential drug interactions and contraindications
D. Assessment of prescription safety and legal requirements
E. Review of indication for each prescribed medication
Explanation: ***Patient interview to discuss medication concerns and adherence***- A **clinical medication review (Level 3)** is defined by **direct patient engagement**, incorporating their health beliefs, preferences, and actual usage patterns into the review process.- Unlike technical reviews, this level requires access to the **full clinical record** and a consultation to address **adherence** and personal treatment goals.*Review of the medication list for accuracy and completeness*- This is a fundamental component of a **Level 1 (prescription review)**, which focuses on the technical accuracy of the medication record.- It can be performed as a **desk-based exercise** by a clinician without the need for the patient to be present.*Check for potential drug interactions and contraindications*- Identifying **safety issues** and drug-drug interactions is a standard part of any **technical review** of a patient's prescription list.- These checks are essential at **Level 1** to ensure the immediate safety and appropriateness of the ongoing repeats.*Assessment of prescription safety and legal requirements*- Ensuring **legal compliance** and technical safety (e.g., correct dosing, appropriate duration) is the primary goal of a **Level 1 prescription review**.- This process is focused on the **administrative and clinical safety** of the documents rather than the patient's lived experience with the drug.*Review of indication for each prescribed medication*- Matching a drug to its **documented diagnosis** is a prerequisite for a Level 1 review to ensure that every repeat medication serves a valid clinical purpose.- While important, this does not require a **patient interview**, as it can often be confirmed through a review of the **medical notes** and historical data.
