A practice pharmacist conducts an audit of patients aged over 75 taking 10 or more regular medications. She identifies that 22% are taking a benzodiazepine or Z-drug for more than 4 weeks, and 15% are taking a non-steroidal anti-inflammatory drug regularly. The practice decides to implement a targeted deprescribing program. According to evidence on deprescribing interventions in primary care, which single approach is most likely to achieve successful and sustained medication discontinuation?
Q72
A 67-year-old woman with heart failure (LVEF 38%), atrial fibrillation, type 2 diabetes, and depression attends for medication review. She takes bisoprolol 5mg once daily, ramipril 10mg once daily, furosemide 40mg once daily, spironolactone 25mg once daily, apixaban 5mg twice daily, metformin 500mg twice daily, empagliflozin 10mg once daily, and sertraline 50mg once daily. She reports significant fatigue limiting her daily activities and wonders if her tablets might be responsible. Her BP is 118/72 mmHg, pulse 58/min, and recent bloods show: Na+ 140 mmol/L, K+ 4.4 mmol/L, creatinine 94 µmol/L (eGFR 58 ml/min/1.73m²), HbA1c 52 mmol/mol, TSH 3.2 mU/L, Hb 118 g/L. Which single medication is most likely contributing to her fatigue?
Q73
A 76-year-old man with Parkinson's disease, type 2 diabetes, and benign prostatic hyperplasia takes co-careldopa 25/100mg four times daily, pramipexole 0.88mg three times daily, metformin 500mg twice daily, gliclazide 40mg twice daily, tamsulosin 400mcg once daily, and finasteride 5mg once daily. He presents with visual hallucinations and paranoid ideation that developed over 2 weeks. His wife reports he is also more confused. Examination shows BP 106/68 mmHg, pulse 78/min regular, temperature 36.8°C. Capillary blood glucose is 7.2 mmol/L. Neurological examination shows stable Parkinsonian features. What is the single most appropriate initial medication management?
Q74
During a practice-based quality improvement project, you are reviewing patients with multimorbidity taking 10 or more medications. You identify a 72-year-old man taking 14 medications including multiple cardiovascular drugs, metformin, and medications for BPH, GORD, and insomnia. He reports poor quality of life and feeling 'overwhelmed' by his tablets. When applying the principles of realistic medicine and shared decision-making for multimorbidity, what approach should be prioritized?
Q75
A 70-year-old woman with rheumatoid arthritis, hypertension, chronic kidney disease stage 3a, and osteoporosis attends for review. She takes methotrexate 15mg weekly, folic acid 5mg weekly, hydroxychloroquine 200mg twice daily, prednisolone 5mg once daily, alendronic acid 70mg weekly, calcium and vitamin D, ramipril 5mg once daily, and amlodipine 5mg once daily. She reports feeling generally well but has developed peripheral oedema. Blood tests show: Na+ 142 mmol/L, K+ 4.6 mmol/L, creatinine 118 µmol/L (eGFR 46 ml/min/1.73m², previously 52), albumin 38 g/L. Urinalysis shows protein ++. What is the most appropriate next investigation to guide medication review?
Q76
A 68-year-old man with ischaemic heart disease, type 2 diabetes, COPD, and gastro-oesophageal reflux disease is taking aspirin 75mg, atorvastatin 80mg, bisoprolol 2.5mg, ramipril 5mg, metformin 1g twice daily, tiotropium inhaler, salbutamol inhaler, and lansoprazole 30mg once daily. He has been on this regimen for 3 years. At a medication review, you consider deprescribing the lansoprazole as there is no clear ongoing indication. According to evidence-based deprescribing principles, what is the most appropriate approach to stopping the proton pump inhibitor?
Q77
A 73-year-old woman attends with her daughter who reports her mother has become increasingly confused over the past month. She has type 2 diabetes, hypertension, depression, and overactive bladder. Her medications include: metformin 500mg twice daily, gliclazide 80mg twice daily, ramipril 5mg once daily, amlodipine 5mg once daily, citalopram 20mg once daily, oxybutynin 5mg three times daily, and recently started amitriptyline 25mg at night for neuropathic pain. Cognitive screening shows AMTS 6/10. Blood glucose monitoring shows readings 4.2-6.8 mmol/L. What is the single most likely medication-related cause of her cognitive decline?
Q78
According to the Royal Pharmaceutical Society's guidance on structured medication reviews in primary care, which single patient group should be prioritized for medication review in a general practice setting?
Q79
A 66-year-old man attends for an annual review. He has hypertension, type 2 diabetes, dyslipidaemia, and obstructive sleep apnoea. His BMI is 38 kg/m². He takes ramipril 10mg once daily, amlodipine 10mg once daily, metformin 1g twice daily, gliclazide 160mg twice daily, atorvastatin 80mg at night, and uses CPAP nightly. Recent results show: BP 162/96 mmHg (average of 3 readings), HbA1c 76 mmol/mol, total cholesterol 5.8 mmol/L, eGFR 64 ml/min/1.73m². He reports good medication adherence. According to NICE guidance on managing multimorbidity, what is the most appropriate next step in his management?
Q80
A 77-year-old woman with atrial fibrillation, heart failure (LVEF 42%), type 2 diabetes, and hypertension is taking warfarin, bisoprolol, ramipril, furosemide, metformin, and atorvastatin. She presents with recurrent falls over the past 3 months, having fallen four times without clear precipitant. Her INR has been stable (range 2.2-2.8 over past 6 months), and her CHA₂DS₂-VASc score is 6. During assessment, her lying BP is 126/78 mmHg and standing BP is 98/64 mmHg. Her mobility is reduced due to fear of falling. What is the single most appropriate next management step regarding her medications?
Chronic Disease Management UK Medical PG Practice Questions and MCQs
Question 71: A practice pharmacist conducts an audit of patients aged over 75 taking 10 or more regular medications. She identifies that 22% are taking a benzodiazepine or Z-drug for more than 4 weeks, and 15% are taking a non-steroidal anti-inflammatory drug regularly. The practice decides to implement a targeted deprescribing program. According to evidence on deprescribing interventions in primary care, which single approach is most likely to achieve successful and sustained medication discontinuation?
A. Practice nurse telephoning patients to discuss stopping problematic medications
B. GP sending personalized letter to each patient recommending medication review
C. Pharmacist conducting face-to-face structured medication reviews with patients (Correct Answer)
D. Pharmacist sending educational leaflets about medication risks to identified patients
E. System-generated alerts in electronic medical records when prescribing these medications
Explanation: ***Pharmacist conducting face-to-face structured medication reviews with patients***
- **Pharmacist-led structured reviews** are the most effective intervention for sustained **deprescribing**, as they allow for comprehensive assessment, **shared decision-making**, and development of **individualized tapering plans**.
- This approach facilitates addressing patient fears, managing **withdrawal symptoms**, and ensuring follow-up, which yields higher success rates than passive methods.
*Practice nurse telephoning patients to discuss stopping problematic medications*
- While useful for initial outreach, **telephone consultations** may lack the depth of engagement and comprehensive assessment required for complex deprescribing of long-term medications.
- Success in stopping chronic medications like **benzodiazepines** often requires the specialized pharmacological knowledge and systematic approach typically associated with **clinical pharmacists** in face-to-face settings.
*GP sending personalized letter to each patient recommending medication review*
- **Personalized letters** are a form of **passive intervention** that, while identifying a potential issue, often result in **low patient engagement** and minimal behavior change without direct interaction.
- A letter alone does not provide the crucial **clinical support**, patient education, or monitoring necessary to safely navigate the **withdrawal symptoms** or address psychological dependence associated with deprescribing.
*Pharmacist sending educational leaflets about medication risks to identified patients*
- **Educational leaflets** used in isolation are considered a **passive strategy** and have been shown to have limited impact on actual medication cessation and **long-term discontinuation**.
- Evidence suggests that providing information without a **structured clinical intervention**, personalized plan, or direct patient interaction rarely leads to successful changes in chronic medication use.
*System-generated alerts in electronic medical records when prescribing these medications*
- **Electronic alerts** are primarily effective for preventing **new inappropriate prescriptions** or flagging *current* problematic prescribing, rather than actively *deprescribing* established, long-term medications.
- These alerts are often subject to **alert fatigue** and do not address the crucial **patient-side barriers** such as motivation, fears, or the need for a personalized tapering plan.
Question 72: A 67-year-old woman with heart failure (LVEF 38%), atrial fibrillation, type 2 diabetes, and depression attends for medication review. She takes bisoprolol 5mg once daily, ramipril 10mg once daily, furosemide 40mg once daily, spironolactone 25mg once daily, apixaban 5mg twice daily, metformin 500mg twice daily, empagliflozin 10mg once daily, and sertraline 50mg once daily. She reports significant fatigue limiting her daily activities and wonders if her tablets might be responsible. Her BP is 118/72 mmHg, pulse 58/min, and recent bloods show: Na+ 140 mmol/L, K+ 4.4 mmol/L, creatinine 94 µmol/L (eGFR 58 ml/min/1.73m²), HbA1c 52 mmol/mol, TSH 3.2 mU/L, Hb 118 g/L. Which single medication is most likely contributing to her fatigue?
A. Apixaban
B. Bisoprolol (Correct Answer)
C. Ramipril
D. Empagliflozin
E. Sertraline
Explanation: ***Bisoprolol***
- **Beta-blockers** like bisoprolol are notorious for causing **fatigue**, lethargy, and reduced exercise tolerance by limiting peak cardiac output.
- Her heart rate of **58/min** is near the lower clinical limit, suggesting the current dose may be excessive for her metabolic needs and causing symptomatic **bradycardia**.
*Apixaban*
- As a **Direct Oral Anticoagulant (DOAC)**, apixaban is generally well-tolerated and is not classically associated with systemic fatigue.
- While it can increase bleeding risk leading to **anemia**, this patient's **hemoglobin (118 g/L)** is near-normal and does not explain her significant exhaustion.
*Ramipril*
- **ACE inhibitors** are more frequently associated with a dry cough or **hypotension** rather than isolated fatigue.
- The patient's blood pressure of **118/72 mmHg** is within a healthy range for heart failure and does not suggest the fatigue is due to **low perfusion pressure**.
*Empagliflozin*
- **SGLT2 inhibitors** typically improve heart failure symptoms; their primary side effects are **urinary tract infections** and volume depletion.
- There is no clinical evidence of **dehydration** or electrolyte imbalance (sodium and creatinine are normal) to suggest this is causing her fatigue.
*Sertraline*
- While **SSRIs** can cause initial somnolence, they are often used to treat the lethargy associated with **depression**.
- Her fatigue is specifically limiting her daily activities and occurred in the context of heart failure medications, making a pharmacological **beta-blockade** effect more likely than the antidepressant.
Question 73: A 76-year-old man with Parkinson's disease, type 2 diabetes, and benign prostatic hyperplasia takes co-careldopa 25/100mg four times daily, pramipexole 0.88mg three times daily, metformin 500mg twice daily, gliclazide 40mg twice daily, tamsulosin 400mcg once daily, and finasteride 5mg once daily. He presents with visual hallucinations and paranoid ideation that developed over 2 weeks. His wife reports he is also more confused. Examination shows BP 106/68 mmHg, pulse 78/min regular, temperature 36.8°C. Capillary blood glucose is 7.2 mmol/L. Neurological examination shows stable Parkinsonian features. What is the single most appropriate initial medication management?
A. Reduce co-careldopa to three times daily dosing
B. Reduce gliclazide dose to 40mg once daily
C. Stop tamsulosin
D. Reduce pramipexole to 0.88mg twice daily (Correct Answer)
E. Stop finasteride
Explanation: ***Reduce pramipexole to 0.88mg twice daily***
- In patients with Parkinson's presenting with **hallucinations**, the standard management is to reduce or stop medications in a specific order, prioritising the withdrawal of **dopamine agonists** like **pramipexole** before levodopa.
- **Pramipexole** is more frequently associated with **neuropsychiatric side effects** (confusion, paranoia, and visual hallucinations) in the elderly compared to levodopa-based treatments.
*Reduce co-careldopa to three times daily dosing*
- **Levodopa** (co-careldopa) is the most effective drug for motor symptom control and should be the **last medication** to be reduced or stopped.
- Reducing it prematurely could lead to significant **motor deterioration** while leaving the more likely culprit (the dopamine agonist) unchanged.
*Reduce gliclazide dose to 40mg once daily*
- **Gliclazide** can cause confusion secondary to **hypoglycemia**; however, this patient's capillary blood glucose is **7.2 mmol/L**, which is within the normal range.
- There is no clinical indication that **sulfonylurea** toxicity is the driver of his acute paranoid ideation and hallucinations.
*Stop tamsulosin*
- While **tamsulosin** can cause orthostatic hypotension, it is rarely the primary cause of complex **visual hallucinations** and paranoid ideation.
- **Anticholinergic** medications used for bladder issues are more likely to cause confusion, but the **dopamine agonist** remains a much stronger suspect for psychosis.
*Stop finasteride*
- **Finasteride** is a 5-alpha reductase inhibitor with few **psychiatric side effects**; it is not a recognized cause of acute visual hallucinations in this clinical context.
- The management of Parkinson-related psychosis focuses on **dopaminergic modulation**, making the discontinuation of this BPH medication inappropriate as an initial step.
Question 74: During a practice-based quality improvement project, you are reviewing patients with multimorbidity taking 10 or more medications. You identify a 72-year-old man taking 14 medications including multiple cardiovascular drugs, metformin, and medications for BPH, GORD, and insomnia. He reports poor quality of life and feeling 'overwhelmed' by his tablets. When applying the principles of realistic medicine and shared decision-making for multimorbidity, what approach should be prioritized?
A. Apply STOPP/START criteria systematically to identify inappropriate medications
B. Calculate anticholinergic burden score and deprescribe high-risk medications first
C. Explore what matters most to the patient and align treatment with his priorities (Correct Answer)
D. Reduce medication burden by switching to combination products where possible
E. Review each condition separately against relevant clinical guidelines
Explanation: ***Explore what matters most to the patient and align treatment with his priorities***
- In the context of **multimorbidity** and **realistic medicine**, the primary goal is to shift from a disease-centered to a **patient-centered approach** that prioritizes the individual's values.
- Since the patient feels **overwhelmed** and reports **poor quality of life**, identifying his specific goals is the essential first step to guide **shared decision-making** and subsequent **deprescribing**.
*Apply STOPP/START criteria systematically to identify inappropriate medications*
- The **STOPP/START criteria** are useful evidence-based tools for identifying potentially inappropriate medications in older adults but are secondary to the patient's own priorities.
- Relying solely on a systematic tool fails to address the patient's reported feeling of being **overwhelmed** by the **treatment burden** and individual preferences.
*Calculate anticholinergic burden score and deprescribe high-risk medications first*
- Calculating the **anticholinergic burden** is a specific technical maneuver to reduce risk (e.g., falls, cognitive decline) but does not encompass the holistic requirements of **realistic medicine**.
- This approach addresses safety but may not address the medications the patient finds most burdensome or least beneficial to his **quality of life**.
*Reduce medication burden by switching to combination products where possible*
- While **combination products** may reduce the number of physical pills, they do not necessarily reduce the **polypharmacy burden** or the biological complexity of the treatment regimen.
- This is a technical solution for **adherence** that bypasses the necessary discussion regarding whether the drugs are desired or medically necessary for this specific patient, failing to address his feeling of being **overwhelmed**.
*Review each condition separately against relevant clinical guidelines*
- Traditional **single-disease guidelines** often conflict in multimorbid patients, leading to **polypharmacy** and potential harm from drug-drug or drug-disease interactions.
- This approach is the antithesis of **realistic medicine**, as it prioritizes clinical metric targets over the patient's overall **functional status** and preference.
Question 75: A 70-year-old woman with rheumatoid arthritis, hypertension, chronic kidney disease stage 3a, and osteoporosis attends for review. She takes methotrexate 15mg weekly, folic acid 5mg weekly, hydroxychloroquine 200mg twice daily, prednisolone 5mg once daily, alendronic acid 70mg weekly, calcium and vitamin D, ramipril 5mg once daily, and amlodipine 5mg once daily. She reports feeling generally well but has developed peripheral oedema. Blood tests show: Na+ 142 mmol/L, K+ 4.6 mmol/L, creatinine 118 µmol/L (eGFR 46 ml/min/1.73m², previously 52), albumin 38 g/L. Urinalysis shows protein ++. What is the most appropriate next investigation to guide medication review?
A. 24-hour urinary protein quantification
B. Echocardiogram to assess cardiac function
C. Renal ultrasound scan
D. Serum methotrexate level
E. Urine albumin:creatinine ratio (Correct Answer)
Explanation: ***Urine albumin:creatinine ratio***- The **Urine albumin:creatinine ratio (uACR)** is the preferred first-line test according to **NICE guidelines** for the quantification of **proteinuria** in chronic kidney disease (CKD).- Assessing the severity of proteinuria is critical here to guide the adjustment of potentially nephrotoxic medications like **methotrexate** and to manage her **declining eGFR**.*24-hour urinary protein quantification*- This method is cumbersome for patients and has largely been replaced by **spot uACR** or **uPCR** in routine clinical practice for quantifying proteinuria.- It does not offer significant clinical advantages over the more convenient **uACR** for initial medication review and risk stratification.*Echocardiogram to assess cardiac function*- While **peripheral oedema** can indicate heart failure, the presence of **proteinuria (++ on dipstick)** and a decrease in **eGFR** more directly points toward a renal cause.- An echocardiogram would be indicated if there were symptoms like orthopnoea or paroxysmal nocturnal dyspnoea, rather than as a primary tool for drug-induced nephrotoxicity review.*Renal ultrasound scan*- **Renal ultrasound** is useful for assessing kidney size and excluding **obstruction**, but it does not quantify the degree of protein leak or functional damage.- It is generally reserved for patients with rapid declines in eGFR, visible **haematuria**, or suspected structural abnormalities rather than initial protein quantification.*Serum methotrexate level*- **Serum methotrexate levels** are used to monitor toxicity in high-dose oncology regimens but are not routinely measured for patients on low-dose **weekly methotrexate** for rheumatoid arthritis.- Monitoring for methotrexate toxicity in primary care involves regular **Full Blood Count (FBC)** and **Liver/Renal function tests**, rather than serum concentrations.
Question 76: A 68-year-old man with ischaemic heart disease, type 2 diabetes, COPD, and gastro-oesophageal reflux disease is taking aspirin 75mg, atorvastatin 80mg, bisoprolol 2.5mg, ramipril 5mg, metformin 1g twice daily, tiotropium inhaler, salbutamol inhaler, and lansoprazole 30mg once daily. He has been on this regimen for 3 years. At a medication review, you consider deprescribing the lansoprazole as there is no clear ongoing indication. According to evidence-based deprescribing principles, what is the most appropriate approach to stopping the proton pump inhibitor?
A. Advise patient to stop immediately and contact the surgery if symptoms develop
B. Gradually reduce lansoprazole by 50% every 2 weeks before stopping completely
C. Gradually reduce lansoprazole dose over 4-6 weeks and switch to alginate therapy (Correct Answer)
D. Stop lansoprazole and replace with ranitidine 150mg twice daily for 2 weeks
E. Switch to on-demand lansoprazole 30mg when symptoms occur
Explanation: ***Gradually reduce lansoprazole dose over 4-6 weeks and switch to alginate therapy***
- Long-term **proton pump inhibitor (PPI)** use leads to **rebound acid hypersecretion** due to gastrin elevation, making a gradual taper essential to prevent symptom flare-ups.
- A structured reduction (e.g., halving the dose for several weeks) combined with **alginate therapy** or **on-demand** use manages breakthrough symptoms and improves the success rate of deprescribing.
*Advise patient to stop immediately and contact the surgery if symptoms develop*
- **Abrupt cessation** of long-term PPIs frequently causes sudden rebound dyspepsia, which the patient may misinterpret as a return of their original condition.
- This approach has a higher failure rate and often leads to the **unnecessary restarting** of the medication.
*Gradually reduce lansoprazole by 50% every 2 weeks before stopping completely*
- While tapering is correct, a 2-week total reduction period is often **too rapid** for someone who has been on the medication for several years.
- Current evidence-based guidelines generally recommend a more prolonged **4-to-8 week tapering window** to minimize the physiological effects of hypergastrinemia.
*Stop lansoprazole and replace with ranitidine 150mg twice daily for 2 weeks*
- **Ranitidine** and other H2-receptor antagonists are largely unavailable or withdrawn in many markets due to **NDMA contamination** concerns.
- Switching to another daily acid suppressant does not effectively facilitate the goal of **deprescribing** and physiological adjustment.
*Switch to on-demand lansoprazole 30mg when symptoms occur*
- Moving directly to on-demand use from a high-dose daily regimen without a **step-down phase** often fails due to the severity of rebound symptoms.
- On-demand therapy is better utilized as the **final stage** of a tapering protocol rather than the initial step for a patient on long-term therapy.
Question 77: A 73-year-old woman attends with her daughter who reports her mother has become increasingly confused over the past month. She has type 2 diabetes, hypertension, depression, and overactive bladder. Her medications include: metformin 500mg twice daily, gliclazide 80mg twice daily, ramipril 5mg once daily, amlodipine 5mg once daily, citalopram 20mg once daily, oxybutynin 5mg three times daily, and recently started amitriptyline 25mg at night for neuropathic pain. Cognitive screening shows AMTS 6/10. Blood glucose monitoring shows readings 4.2-6.8 mmol/L. What is the single most likely medication-related cause of her cognitive decline?
A. Anticholinergic burden from combination of oxybutynin and amitriptyline (Correct Answer)
B. Cerebral hypoperfusion from ramipril and amlodipine combination
C. Hypoglycaemia from combination of metformin and gliclazide
D. Hyponatraemia secondary to citalopram
E. Worsening depression inadequately treated with current citalopram dose
Explanation: ***Anticholinergic burden from combination of oxybutynin and amitriptyline***- Elderly patients are highly sensitive to medications with **anticholinergic activity**, and the cumulative effect of **oxybutynin** and the recently added **amitriptyline** significantly increases the risk of delirium and cognitive impairment.- **Amitriptyline** and **oxybutynin** both cross the blood-brain barrier, leading to central adverse effects such as **confusion**, memory loss, and a reduced **AMTS** score.*Cerebral hypoperfusion from ramipril and amlodipine combination*- While antihypertensives can cause **postural hypotension** and falls in the elderly, they are less likely to cause a subacute 1-month progressive cognitive decline without associated syncopal or presyncopal symptoms.- The patient's primary issue is **confusion** rather than physical instability or documented **orthostatic hypotension**.*Hypoglycaemia from combination of metformin and gliclazide*- The provided blood glucose monitoring results (4.2-6.8 mmol/L) are within a **safe range**, making symptomatic **hypoglycaemia** an unlikely cause for the confusion.- **Metformin** itself does not typically cause hypoglycemia, and while **gliclazide** (a sulfonylurea) can, the readings do not support it in this scenario.*Hyponatraemia secondary to citalopram*- **SSRIs** like **citalopram** are known causes of **SIADH** and subsequent **hyponatraemia** in the elderly, which can present as confusion.- However, the pharmacological addition of **amitriptyline** recently makes the **anticholinergic burden** a more immediate and likely culprit for the acute-on-chronic change.*Worsening depression inadequately treated with current citalopram dose*- While **pseudodementia** (depression presenting as cognitive loss) is possible, the temporal relationship between starting a new **highly anticholinergic medication** (amitriptyline) and the onset of confusion points toward a drug side effect.- In any elderly patient with new-onset confusion, **medication review** for adverse drug-drug interactions is the priority over assuming a primary psychiatric decline.
Question 78: According to the Royal Pharmaceutical Society's guidance on structured medication reviews in primary care, which single patient group should be prioritized for medication review in a general practice setting?
A. All patients aged 65 years and over taking 5 or more regular medications
B. All patients with a single long-term condition requiring hospital admission in the past year
C. Patients experiencing harm or at high risk of harm from medications (Correct Answer)
D. Patients requesting medication reviews due to side effects
E. Patients with newly diagnosed chronic conditions requiring medication initiation
Explanation: ***Patients experiencing harm or at high risk of harm from medications***
- The **Royal Pharmaceutical Society (RPS)** guidance on **structured medication reviews (SMRs)** prioritizes patients based on their **clinical risk of harm** from medications.
- This includes individuals with **polypharmacy** (often 10+ medications), **severe frailty**, or those taking drugs with a **narrow therapeutic index**, where the potential for adverse drug reactions or medication errors is highest.
*All patients aged 65 years and over taking 5 or more regular medications*
- While **age over 65** and **polypharmacy** are known risk factors for medication-related problems, the RPS emphasizes a **risk-stratified approach** rather than solely relying on arbitrary age or medication count thresholds.
- Many patients in this demographic may be stable, whereas others, irrespective of age, with **complex multimorbidity** or **deteriorating renal function**, might be at higher clinical risk.
*All patients with a single long-term condition requiring hospital admission in the past year*
- A recent **unplanned hospital admission** is a significant trigger for review, but the **RPS guidance** specifically focuses on **multimorbidity** and the complexity of medication regimens as key drivers of risk.
- The priority group targets situations where **medication complexity** or specific drug-related issues are likely contributing to the patient's instability or readmission risk, rather than any single long-term condition.
*Patients requesting medication reviews due to side effects*
- Patient-initiated concerns, especially regarding **side effects**, are crucial for **patient-centered care** and must be addressed clinically; however, they do not automatically place a patient in the highest **population-level priority** for structured reviews.
- The SMR framework aims for a **proactive identification** of high-risk individuals through risk stratification, not solely a reactive response to patient requests, unless the reported harm is severe.
*Patients with newly diagnosed chronic conditions requiring medication initiation*
- Patients starting new medications for **chronic conditions** require careful prescribing and initial follow-up, which is typically covered by standard clinical consultations and services such as the **New Medicine Service (NMS)**.
- **Structured medication reviews** are primarily designed for the **optimization and deprescribing** of established, often complex regimens in patients with long-standing medication use and potential accumulated risks.
Question 79: A 66-year-old man attends for an annual review. He has hypertension, type 2 diabetes, dyslipidaemia, and obstructive sleep apnoea. His BMI is 38 kg/m². He takes ramipril 10mg once daily, amlodipine 10mg once daily, metformin 1g twice daily, gliclazide 160mg twice daily, atorvastatin 80mg at night, and uses CPAP nightly. Recent results show: BP 162/96 mmHg (average of 3 readings), HbA1c 76 mmol/mol, total cholesterol 5.8 mmol/L, eGFR 64 ml/min/1.73m². He reports good medication adherence. According to NICE guidance on managing multimorbidity, what is the most appropriate next step in his management?
A. Add dapagliflozin for additional cardiovascular and glycaemic benefit
B. Add indapamide for blood pressure control
C. Initiate insulin therapy to improve glycaemic control
D. Refer to weight management service and review treatment plan in 3 months (Correct Answer)
E. Switch gliclazide to sitagliptin to reduce hypoglycaemia risk
Explanation: ***Refer to weight management service and review treatment plan in 3 months***
- According to **NICE NG56** on multimorbidity, the priority is to address common **modifiable risk factors** like obesity (BMI 38 kg/m²) that adversely impact all his conditions simultaneously.
- This approach aims to reduce **treatment burden** and polypharmacy by potentially improving blood pressure, glucose, and OSA through **lifestyle intervention** rather than simply adding more medications.
*Add dapagliflozin for additional cardiovascular and glycaemic benefit*
- While beneficial for type 2 diabetes and cardiovascular risk, adding an **SGLT2 inhibitor** increases the patient's existing medication burden.
- The multimorbidity framework suggests prioritizing **non-pharmacological interventions** that address the root cause before intensifying drug therapy.
*Add indapamide for blood pressure control*
- Adding a **thiazide-like diuretic** is conventional for Step 3 hypertension treatment, but it ignores the patient's high BMI and the cumulative impact of multiple medications.
- A **holistic review** of clinical priorities and weight management is preferred over siloed management of individual clinical targets.
*Initiate insulin therapy to improve glycaemic control*
- Insulin would likely lead to further **weight gain**, exacerbating both his obesity and **obstructive sleep apnoea**.
- Transitioning to injectable therapy significantly increases **complexity of care**, which should be avoided in multimorbidity management if simpler lifestyle alternatives are available.
*Switch gliclazide to sitagliptin to reduce hypoglycaemia risk*
- While **DPP-4 inhibitors** have a lower hypo risk, there is no evidence the patient is currently experiencing hypoglycemia or that this switch would improve his **HbA1c of 76 mmol/mol**.
- This represents a lateral shift in medication that does not address the fundamental issue of **metabolic syndrome** and obesity.
Question 80: A 77-year-old woman with atrial fibrillation, heart failure (LVEF 42%), type 2 diabetes, and hypertension is taking warfarin, bisoprolol, ramipril, furosemide, metformin, and atorvastatin. She presents with recurrent falls over the past 3 months, having fallen four times without clear precipitant. Her INR has been stable (range 2.2-2.8 over past 6 months), and her CHA₂DS₂-VASc score is 6. During assessment, her lying BP is 126/78 mmHg and standing BP is 98/64 mmHg. Her mobility is reduced due to fear of falling. What is the single most appropriate next management step regarding her medications?
A. Reduce bisoprolol dose and monitor blood pressure response
B. Reduce furosemide dose and monitor fluid balance
C. Reduce ramipril dose and monitor renal function
D. Switch from warfarin to apixaban
E. Undertake comprehensive medication review addressing all contributors to falls (Correct Answer)
Explanation: ***Undertake comprehensive medication review addressing all contributors to falls***
- The patient exhibits significant **orthostatic hypotension** (systolic drop of 28 mmHg) and is on multiple medications (**bisoprolol, ramipril, furosemide**) that contribute to this risk.
- A **comprehensive medication review** is the standard of care for older adults with **recurrent falls** to evaluate polypharmacy, drug-drug interactions, and the overall benefit-risk ratio rather than adjusting drugs in isolation.
*Reduce bisoprolol dose and monitor blood pressure response*
- While **beta-blockers** can contribute to hypotension and falls, reducing this alone may be insufficient when several other agents are also involved.
- Bisoprolol is essential for **rate control in atrial fibrillation** and managing **heart failure**, so it should only be altered as part of a holistic review.
*Reduce furosemide dose and monitor fluid balance*
- **Furosemide** can cause **volume depletion**, leading to orthostatic hypotension, but it is a critical component of her **heart failure** management.
- Adjusting the diuretic without assessing other antihypertensives fails to address the combined **hypotensive effect** of her entire regimen.
*Reduce ramipril dose and monitor renal function*
- **ACE inhibitors** like **ramipril** are known causes of postural BP drops; however, simply reducing one drug does not tackle the underlying issue of **polypharmacy**.
- This ignores the potential contribution of other drugs, such as **metformin** (hypoglycemia risk) or the diuretic, to the patient's instability.
*Switch from warfarin to apixaban*
- While **DOACs (apixaban)** have a lower risk of **intracranial hemorrhage** compared to warfarin, this switch does not address the actual cause of her **orthostatic falls**.
- Clinical guidelines emphasize that a high **CHA₂DS₂-VASc score (6)** justifies anticoagulation, but focus must first be on preventing the mechanical cause of falling.
