Chronic Disease Management

Chronic Disease Management UK Medical PG Question 1: During a practice audit of patients over 75 years taking 10 or more regular medications, you identify several patients who would benefit from structured medication reviews. You are prioritising which patients to review first based on risk stratification. According to best practice guidance on medication reviews in primary care, which patient characteristic indicates HIGHEST priority for urgent structured medication review?

• A. A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events
• B. A patient recently discharged from hospital with five new medications added to their existing regimen (Correct Answer)
• C. A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring
• D. A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework
• E. A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications

Chronic Disease Management Explanation: ***A patient recently discharged from hospital with five new medications added to their existing regimen*** - **Hospital discharge** is a high-risk transition point where medication errors, **therapeutic duplication**, and communication gaps between primary and secondary care frequently occur. - National guidelines (NICE and NHS England) prioritize patients with recent **regimen changes** for urgent review to ensure **medication reconciliation** and prevent adverse drug events. *A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events* - While **polypharmacy** (taking 10+ medications) is a risk factor, clinical **stability** over three years suggests the regimen is currently tolerated and less urgent than an acute transition. - This patient requires a review to reduce **pill burden**, but they do not meet the criteria for "highest priority" compared to a post-discharge patient. *A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring* - Patients on **narrow therapeutic index** drugs require careful supervision, but the fact they are attending **regular monitoring** indicates their risk is already being managed systematically. - Urgent intervention is typically reserved for those with **unmonitored** high-risk drugs or those experiencing active complications. *A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework* - Routine eligibility based on age or **QOF requirements** is a preventative and administrative trigger rather than an urgent clinical risk stratification. - This represents a **scheduled review** rather than an urgent need driven by clinical instability or a high-risk event like hospitalization. *A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications* - A gradual decline in **eGFR** over a year requires dose adjustments for renally cleared drugs, but the **12-month timeline** makes it less acute than a post-hospital change. - This scenario necessitates a review to prevent **nephrotoxicity**, but it does not represent the immediate high-risk window associated with discharge reconciliation.

Chronic Disease Management UK Medical PG Question 2: A 35-year-old woman presents with a 10-week history of severe fatigue, aching limbs, and subjective fever. She works as a veterinary nurse. She reports a flu-like illness that never fully resolved. Examination shows temperature 37.8°C, no rash or lymphadenopathy. Blood tests show: Hb 128 g/L, WCC 3.8 × 10⁹/L (lymphocytes 1.2 × 10⁹/L), platelets 156 × 10⁹/L, CRP 12 mg/L, ALT 124 U/L, AST 96 U/L. Blood film shows atypical lymphocytes. Monospot test is negative. What is the most appropriate next investigation?

• A. Serology for Coxiella burnetii (Q fever) (Correct Answer)
• B. HIV antibody and antigen test
• C. EBV serology (IgM and IgG)
• D. CMV serology (IgM and IgG)
• E. Toxoplasma serology

Chronic Disease Management Explanation: ***Serology for Coxiella burnetii (Q fever)*** - This patient's occupation as a **veterinary nurse** provides significant exposure to **Coxiella burnetii**, which is commonly found in livestock and birthed animals. - The clinical picture of **prolonged flu-like illness**, **fever**, **fatigue**, **hepatitis** (elevated ALT/AST), and **atypical lymphocytes** is highly characteristic of **acute Q fever**, especially with a negative Monospot test. *HIV antibody and antigen test* - While **acute HIV seroconversion** can present with a mononucleosis-like syndrome, symptoms typically resolve within 2-4 weeks, not persist for **10 weeks**. - The **occupational history** of a veterinary nurse strongly points towards a zoonotic infection, making HIV a less specific initial investigation in this context. *EBV serology (IgM and IgG)* - Although **Epstein-Barr virus (EBV)** can cause atypical lymphocytes and hepatitis, the **Monospot test was negative**, making acute infectious mononucleosis due to EBV less likely. - The specific **occupational exposure** to animals makes **Q fever** a more probable diagnosis than typical infectious mononucleosis given the overall presentation. *CMV serology (IgM and IgG)* - **Cytomegalovirus (CMV)** can cause a Monospot-negative mononucleosis syndrome with fever, fatigue, and hepatitis. - However, the patient's **veterinary nurse** profession makes **Q fever** a higher priority in the differential diagnosis due to direct zoonotic exposure, though CMV should be considered if initial tests are negative. *Toxoplasma serology* - **Toxoplasmosis** typically presents with **lymphadenopathy** and flu-like symptoms, which are not prominent features in this case (**no lymphadenopathy**). - While exposure is possible in this occupation, the characteristic combination of **prolonged fever**, **hepatitis**, and **atypical lymphocytes** without significant lymphadenopathy is less suggestive of toxoplasmosis and more aligned with Q fever.

Chronic Disease Management UK Medical PG Question 3: A 74-year-old man attends for medication review. He has heart failure (LVEF 32%), atrial fibrillation, type 2 diabetes, stage 3b CKD (eGFR 36 ml/min/1.73m²), and benign prostatic hyperplasia. Current medications: bisoprolol 10mg, ramipril 10mg, furosemide 40mg, spironolactone 25mg, apixaban 5mg twice daily, metformin 1g twice daily, empagliflozin 10mg, finasteride 5mg, tamsulosin 400mcg, atorvastatin 80mg. Blood tests show potassium 5.4 mmol/L, sodium 134 mmol/L, urea 12.8 mmol/L, creatinine 168 μmol/L (stable). He reports good symptom control but occasional dizziness on standing. Which represents the BEST management approach?

• A. Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications
• B. Reduce ramipril to 5mg daily to decrease potassium and improve renal function
• C. Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment
• D. Continue current regimen with close monitoring as benefits outweigh risks (Correct Answer)
• E. Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy

Chronic Disease Management Explanation: ***Continue current regimen with close monitoring as benefits outweigh risks*** - The patient is receiving the **'quadruple therapy'** for heart failure with reduced ejection fraction (HFrEF), which significantly reduces **mortality** and hospitalizations. - A potassium of 5.4 mmol/L is acceptable for transition to long-term monitoring as it remains **below 5.5 mmol/L**, and his creatinine/eGFR values are stable and within an acceptable range for these medications. *Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications* - Guidance suggests keeping mineralocorticoid receptor antagonists (MRAs) unless potassium consistently **exceeds 5.5 mmol/L**, as they provide a crucial **survival benefit**. - Routine cessation for mild elevations prevents the patient from receiving life-prolonging **aldosterone blockade**. *Reduce ramipril to 5mg daily to decrease potassium and improve renal function* - Reducing the **ACE inhibitor** dose for a stable eGFR of 36 ml/min/1.73m² and mild hyperkalemia would result in sub-optimal **neurohormonal blockade**. - Stable renal impairment (Stage 3b CKD) is not an indication for dose reduction if the serum **creatinine rise** from baseline is less than 30%. *Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment* - **SGLT2 inhibitors** like empagliflozin actually provide **renoprotective** benefits and reduce the risk of more severe hyperkalemia when used with MRAs. - There is no clinical indication to stop this medication as it is indicated for both **HFrEF** and **type 2 diabetes** with CKD. *Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy* - While **tamsulosin** can cause orthostatic hypotension, the patient's dizziness is occasional, and his overall symptom control is good. - Stopping an effective medication for **benign prostatic hyperplasia** (BPH) without a clear, overriding reason may worsen urinary symptoms, and dizziness could also stem from other cardiovascular medications.

Chronic Disease Management UK Medical PG Question 4: A 75-year-old man with COPD (post-bronchodilator FEV1 42% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes attends for medication review. He is on multiple inhalers: tiotropium, salmeterol/fluticasone 25/250 twice daily, and salbutamol as needed. Other medications include apixaban, bisoprolol, ramipril, atorvastatin, and metformin. He has had two exacerbations requiring oral steroids in the past year, the last one being 8 months ago. His current COPD symptoms are well-controlled with no exacerbations recently. Sputum cultures from his last exacerbation grew Pseudomonas aeruginosa. Which change to his inhaler therapy is MOST appropriate?

• A. Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection
• B. Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination) (Correct Answer)
• C. Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations
• D. Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk
• E. Add regular nebulised colistin for Pseudomonas suppression in COPD

Chronic Disease Management Explanation: ***Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)***- The patient is already on **triple therapy** (LAMA, LABA, ICS) using separate devices. Combining these into a single **LABA/LAMA/ICS** inhaler simplifies the regimen and improves **medication adherence**.- For patients with severe COPD (FEV1 42%) and frequent exacerbations (two in the past year), **triple therapy** is indicated to reduce exacerbation rates, and using a single device is preferred.*Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection*- **Azithromycin prophylaxis** is typically considered for frequent exacerbators despite **optimal inhaled therapy**, often after ensuring the current inhaler regimen is maximally effective and simplified.- While the patient has a history of exacerbations, the initial step should be to optimize and streamline their primary inhaled maintenance therapy before adding prophylactic antibiotics, which carry risks of **antibiotic resistance** and side effects.*Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations*- Stopping **inhaled corticosteroids (ICS)** is inappropriate in this patient due to a history of **frequent exacerbations** (two in the past year) and severe airflow limitation.- Discontinuing ICS in patients with a history of frequent exacerbations is associated with an increased risk of **future exacerbations** and worsening lung function.*Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk*- While **pneumonia risk** is a known concern with ICS, this patient's history of two exacerbations in the past year indicates a need for continued, effective anti-inflammatory therapy.- Reducing the **fluticasone dose** would be a step-down approach, which is not recommended for a patient who is a frequent exacerbator and has severe COPD.*Add regular nebulised colistin for Pseudomonas suppression in COPD*- **Nebulised colistin** is primarily used for chronic suppression of **Pseudomonas aeruginosa** in conditions like **bronchiectasis** or **cystic fibrosis**.- Its routine use for Pseudomonas suppression in COPD, especially without co-existing bronchiectasis, is not a standard recommendation in current guidelines and lacks strong evidence.

Chronic Disease Management UK Medical PG Question 5: You are conducting a structured medication review for an 80-year-old man with heart failure (NYHA class II), type 2 diabetes, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), and benign prostatic hyperplasia. He lives alone and manages his medications independently using a dosette box filled by his daughter. He takes 13 different medications at various times throughout the day. He mentions he sometimes forgets his evening doses and finds the regimen 'complicated'. Which approach BEST addresses medication adherence in this context according to principles of medicines optimisation?

• A. Simplify the regimen by switching to once-daily preparations where possible and aligning administration times (Correct Answer)
• B. Arrange for a district nurse to visit twice daily to supervise medication administration
• C. Provide detailed written instructions about each medication and the importance of adherence
• D. Reduce the total number of medications by stopping those not providing immediate symptom relief
• E. Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia

Chronic Disease Management Explanation: ***Simplify the regimen by switching to once-daily preparations where possible and aligning administration times***- Medicines optimisation principles prioritise reducing **regimen complexity** and dosing frequency to improve **treatment adherence**, especially in elderly patients with polypharmacy.- Aligning schedules and using **once-daily formulations** addresses the patient's specific struggle with evening doses and his perception that the regimen is too 'complicated'.*Arrange for a district nurse to visit twice daily to supervise medication administration*- This is an overly restrictive and **paternalistic intervention** that undermines the patient's independence while he is still largely capable of self-care.- Resource-heavy interventions like **supervised administration** are typically reserved for patients with severe cognitive or physical impairments who cannot use aids independently.*Provide detailed written instructions about each medication and the importance of adherence*- While education is helpful, it does not solve the **structural complexity** of a 13-medication regimen with multiple dosing times throughout the day.- Information alone is often insufficient to overcome **unintentional non-adherence** caused by a burdensome and confusing schedule.*Reduce the total number of medications by stopping those not providing immediate symptom relief*- Arbitrarily stopping medications based only on immediate symptoms ignores **preventative treatments** (like those for CKD or heart failure) that reduce long-term morbidity.- While **deprescribing** is a key part of review, it must be based on a clinical risk-benefit analysis rather than simply the absence of immediate symptoms.*Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia*- Forgetting parts of an exceptionally complex **13-medication regimen** is frequently a result of the system's burden rather than an indicator of **cognitive impairment**.- Formal cognitive assessment may be considered later, but the immediate priority should be the **optimisation** of a demonstrably difficult medication schedule.

Chronic Disease Management Flashcard 1 of 5

Question: Hypertension in patients under _____ years old should be considered for specialist referral to exclude secondary causes

Answer: 40

Chronic Disease Management Flashcard 2 of 5

Question: Patients with hypertension should be investigated with _____ for diabetes

Answer: HbA1c

Chronic Disease Management Flashcard 3 of 5

Question: With a ABPM/HBPM >=135/85 (stage 1 hypertension) treat if _____ AND any of the following: target organ damage established cardiovascular disease renal disease diabetes 10-year cardiovascular risk >10%

Answer: <80 years

Chronic Disease Management Flashcard 4 of 5

Question: Target clinic BP under 80 years is < _____/90 mmHg

Answer: 140

Chronic Disease Management Flashcard 5 of 5

Question: Target clinic BP over 80 years is < _____/90 mmHg

Answer: 150