PASSMEDICINE MCQs-PHARMACOLOGY

PHARMACOLOGY MCQs
Q-1
Mr Waering is a 67-year-old patient who presents with his ankles 'going into spasm' when using the
pedals of his car over the past couple of days. He also reports a slight tingling in his hands and feet. Apart
from this, he has been well recently, with no other new symptoms. His past medical history includes type
2 diabetes and dyspepsia. His regular medications include metformin, sitagliptin, omeprazole,
atorvastatin, and he uses sodium alginate with potassium bicarbonate after meals and before bed as
required. You arrange some urgent blood tests, suspecting an electrolyte disturbance. These come back
showing hypomagnesaemia.
Which of his medications should you stop?
A. Metformin
B. Sitagliptin
C. Omeprazole
D. Atorvastatin
E. Sodium alginate with potassium bicarbonate
ANSWER:
C. Omeprazole
EXPLANATION:
Proton pump inhibitors are a common cause of hypomagnesaemia
Omeprazole: correct answer. Proton pump inhibitors are known to cause hypomagnesaemia; the MHRA
advises consider testing magnesium levels prior to treatment and periodically throughout long term
treatment. In practice this is probably rarely done.
Metformin: incorrect answer. Metformin can decrease vitamin B12 absorption. Sitagliptin, atorvastatin
and sodium alginate with potassium bicarbonate do not cause hypomagnesaemia.
HYPOMAGNESAEMIA
Cause of low magnesium
 drugs: diuretics, proton pump inhibitors
 total parenteral nutrition
 diarrhoea
 alcohol
 hypokalaemia, hypocalcaemia
 conditions causing diarrhoea: Crohn's, ulcerative colitis
 metabolic disorders: Gitleman's and Bartter's
Features may be similar to hypocalcaemia:

 paraesthesia
 tetany
 seizures
 arrhythmias
 decreased PTH secretion → hypocalcaemia
 ECG features similar to those of hypokalaemia
 exacerbates digoxin toxicity
Treatment
<0.4 mmol/l
 intravenous replacement is commonly given. An example regime would be 40 mmol of magnesium
sulphate over 24 hours
>0.4 mmol/l
 oral magnesium salts (10-20 mmol orally per day)
 diarrhoea can occur with oral magnesium salts
Q-2
Your next patient is a 24-year-old man who complains of feeling depressed. He states that he is allergic to
all selective serotonin reuptake inhibitors and asks for dothiepin and temazepam. He is thin and unkempt.
You notice that he has rhinorrhoea, watering eyes and is constantly yawning. What is the most likely
underlying problem?
A. Schizophrenia
B. Cocaine abuse
C. Heroin abuse
D. Alcohol withdrawal
E. Cannabis abuse
ANSWER:
C. Heroin abuse
EXPLANATION:
The majority of people who abuse drugs take more than one type. Dothiepin has sedative properties but is
very dangerous in overdose.
OPIOID MISUSE
Opioids are substances which bind to opioid receptors. This includes both naturally occurring opiates such as
morphine and synthetic opioids such as buprenorphine and methadone.
Features of opioid misuse

 rhinorrhoea
 needle track marks
 pinpoint pupils
 drowsiness
 watering eyes
 yawning
Complications of opioid misuse

 viral infection secondary to sharing needles: HIV, hepatitis B & C
 bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising
fasciitis
 venous thromboembolism
 overdose may lead to respiratory depression and death
 psychological problems: craving
 social problems: crime, prostitution, homelessness
Emergency management of opioid overdose

 IV or IM naloxone: has a rapid onset and relatively short duration of action
Harm reduction interventions may include

 needle exchange
 offering testing for HIV, hepatitis B & C
Management of opioid dependence

 patients are usually managed by specialist drug dependence clinics although some GPs with a specialist
interest offer similar services
 patients may be offered maintenance therapy or detoxification
 NICE recommend methadone or buprenorphine as the first-line treatment in opioid detoxification
 compliance is monitored using urinalysis
 detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks
in the community
Q-3-5
Theme: Side-effects of anti-hypertensives drugs
A. Hyponatraemia
B. Reduced seizure threshold
C. Hypocalcaemia
D. Cold peripheries
E. Drug-induced lupus
F. Hypernatraemia
G. Ankle oedema
For each one of the following drugs choose the side-effect most characteristically associated with it
Q-3
Amlodipine
ANSWER:
G. Ankle oedema
Q-4
Bendroflumethiazide
ANSWER:
A. Hyponatraemia
Q-5
Atenolol
ANSWER:
D. Cold peripheries
EXPLANATION Q-3-5:
SIDE-EFFECTS OF COMMON DRUGS: ANTI-HYPERTENSIVES
The table below summarises characteristic (if not necessarily the most common) side-effects of drugs used
to treat hypertension
Drug Side-effect
ACE inhibitors • Cough
• Hyperkalaemia
Bendroflumethiazide • Gout
• Hypokalaemia
• Hyponatraemia
• Impaired glucose tolerance
Calcium channel blockers • Headache
• Flushing
• Ankle oedema
Beta-blockers • Bronchospasm (especially in asthmatics)
• Fatigue
• Cold peripheries
Doxazosin • Postural hypotension
Q-6
A 74-year-old female presents with weight loss and heat intolerance.She is on multiple medications for
atrial fibrillation, ischaemic heart disease and rheumatoid arthritis. You request thyroid function tests
which are shown in the table below:
Thyroid stimulating hormone (TSH) 0.2 mU/L

Free T4 35 pmol/L
Which of the following is most likely to be responsible for these results?
A. Prednisolone
B. Atorvastatin
C. Methotrexate
D. Digoxin
E. Amiodarone
ANSWER:
E. Amiodarone
EXPLANATION:
Amiodarone frequently causes abnormalities in thyroid function tests and may cause both hypothyroidism
and hyperthyroidism.
It may cause the former by interfering with the conversion of thyroxine (T4) to tri-iodothyronine (T3) and it
may produce the latter either through thyroiditis or donation of iodine (amiodarone contains a large
quantity of iodine).
Other side effects of amiodarone include pulmonary fibrosis, corneal deposits, photosensitivity reactions
and derangement in liver function tests.
AMIODARONE AND THE THYROID GLAND

Around 1 in 6 patients taking amiodarone develop thyroid dysfunction
Amiodarone-induced hypothyroidism
The pathophysiology of amiodarone-induced hypothyroidism (AIH) is thought to be due to the high iodine
content of amiodarone causing a Wolff-Chaikoff effect*
Amiodarone may be continued if this is desirable
Amiodarone-induced thyrotoxicosis
Amiodarone-induced thyrotoxicosis (AIT) may be divided into two types:
AIT type 1 AIT type 2

Pathophysiology Excess iodine-induced thyroid Amiodarone-related
hormone synthesis destructive thyroiditis
Goitre Present Absent
Management Carbimazole or potassium perchlorate Corticosteroids
Unlike in AIH, amiodarone should be stopped if possible in patients who develop AIT
*an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating
iodide
Q-7
You are asked to review a 79-year-old man who reports new onset yellow tinting of his vision. He reports
he is on numerous medications but cannot remember their names. His past medical history is significant
for heart failure, benign prostatic hyperplasia and COPD. Which of the following medications is most likely
responsible for this side effect?
A. Furosemide
B. Ramipril
C. Digoxin
D. Sildenafil
E. Salbutamol
ANSWER:
C. Digoxin
EXPLANATION:
Digoxin may cause yellow-green vision
Due to its narrow therapeutic range, digoxin has a high risk of causing toxicity in patients. A characteristic
feature of toxicity is xanthopsia or yellow-tinted vision.
Sildenafil can cause blue-tinted vision or cyanopsia.
DIGOXIN AND DIGOXIN TOXICITY

Digoxin is a cardiac glycoside now mainly used for rate control in the management of atrial fibrillation. As it
has positive inotropic properties it is sometimes used for improving symptoms (but not mortality) in patients
with heart failure.
Mechanism of action
 decreases conduction through the atrioventricular node which slows the ventricular rate in atrial
fibrillation and flutter
 increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also
stimulates vagus nerve
 digoxin has a narrow therapeutic index
Monitoring
 digoxin level is not monitored routinely, except in suspected toxicity
 if toxicity is suspected, digoxin concentrations should be measured within 8 to 12 hours of the last dose
Digoxin toxicity
Plasma concentration alone does not determine whether a patient has developed digoxin toxicity. Toxicity
may occur even when the concentration is within the therapeutic range. The BNF advises that the likelihood
of toxicity increases progressively from 1.5 to 3 mcg/l.
Features
 generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
 arrhythmias (e.g. AV block, bradycardia)
 gynaecomastia
Precipitating factors
 classically: hypokalaemia
o digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin
more easily bind to the ATPase pump → increased inhibitory effects
 increasing age
 renal failure
 myocardial ischaemia
 hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis
 hypoalbuminaemia
 hypothermia
 hypothyroidism
 drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal
convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g.
thiazides and loop diuretics
Management
 Digibind
 correct arrhythmias
 monitor potassium
Q-8
A woman who is 24-weeks pregnant presents with a productive cough. On examination crackles can be
heard in the left base and a decision is made to give an antibiotic. Which one of the following is least
suitable to prescribe?
A. Ciprofloxacin
B. Erythromycin
C. Co-amoxiclav
D. Cefalexin
E. Cefaclor
ANSWER:
A. Ciprofloxacin
EXPLANATION:
The BNF advises avoiding quinolones in pregnancy due to arthropathy in animal studies.
There have been some reports of an increased risk of necrotizing enterocolitis following the use of co-
amoxiclav in pregnancy. The evidence is however inconclusive and the BNF states that co-amoxiclav is 'not
known to be harmful'. A link is provided both to the BNF and the UK teratology information service.
PRESCRIBING IN PREGNANT PATIENTS

Very few drugs are known to be completely safe in pregnancy. The list below largely comprises of those
known to be harmful. Some countries have developed a grading system - see the link.
Antibiotics
 tetracyclines
 aminoglycosides
 sulphonamides and trimethoprim
 quinolones: the BNF advises to avoid due to arthropathy in some animal studies
Other drugs
 ACE inhibitors, angiotensin II receptor antagonists
 statins
 warfarin
 sulfonylureas
 retinoids (including topical)
 cytotoxic agents
The majority of antiepileptics including valproate, carbamazepine and phenytoin are known to be potentially
harmful. The decision to stop such treatments however is difficult as uncontrolled epilepsy is also a risk
Q-9
A 65-year-old man with a history of type 2 diabetes mellitus and ischaemic heart disease presents with
erectile dysfunction. It is decided to try sildenafil therapy. Which one of the following existing medications
may be continued without making any adjustments?
A. GTN spray
B. Nicorandil
C. Nateglinide
D. Doxazosin
E. Isosorbide mononitrate
ANSWER:
C. Nateglinide
EXPLANATION:
The BNF recommends avoiding alpha-blockers for 4 hours after sildenafil
PHOSPHODIESTERASE TYPE V INHIBITORS

Phosphodiesterase type V (PDE5) inhibitors are used in the treatment of erectile dysfunction. They are also
used in the management of pulmonary hypertension. PDE5 inhibitors cause vasodilation through an increase
in cGMP leading to smooth muscle relaxation in blood vessels supplying the corpus cavernosum.
Examples
 sildenafil (Viagra) - this was the first phosphodiesterase type V inhibitor
 tadalafil (Cialis)
 vardenafil (Levitra)
Contraindications
 patients taking nitrates and related drugs such as nicorandil
 hypotension
 recent stroke or myocardial infarction (NICE recommend waiting 6 months)
Side-effects
 visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy
 nasal congestion
 flushing
 gastrointestinal side-effects
 headache
The blue pill, Viagra (sildenafil), causes blue discolouration of vision

Q-10
A 28-year-old male presents to the Emergency Department with 12 hours of worsening agitation,
restlessness, vomiting, diarrhoea and tremor. On examination, he has hyperthermia, tachycardia, muscle
rigidity, hyperreflexia and myoclonus, particularly pronounced in the lower extremities. He has a past
medical history of depression for which he takes fluoxetine. He recently started taking St John's wort to
help his depression.
What is the most likely diagnosis?
A. Anticholinergic toxicity
B. Malignant hyperthermia
C. Meningitis
D. Neuroleptic malignant syndrome
E. Serotonin syndrome
ANSWER:
E. Serotonin syndrome
EXPLANATION:
St. John's Wort may interact with SSRIs to cause serotonin syndrome
Serotonin syndrome is often misdiagnosed for neuroleptic malignant syndrome (NMS). However, NMS
develops over days to weeks, whereas serotonin syndrome develops over 24 hours. NMS is more
characterised by rigidity and bradyreflexia. Hyperreflexia and myoclonus are rare in NMS.
Malignant hyperthermia occurs in susceptible individuals exposed to halogenated volatile anaesthetics

and depolarising muscle relaxants (eg, succinylcholine). It classically presents with increased
concentrations of end-tidal carbon dioxide, rigor mortis-like muscle rigidity, tachycardia, hyperthermia,
and acidosis.
Meningitis typically presents with fever, nuchal rigidity and a change in mental status, usually of sudden
onset. The most common clinical features include a severe headache, which was not part of this
presentation, fever greater than 38ºC, a stiff neck, Glasgow Coma Score < 14 and nausea.
Anticholinergic toxicity typically presents with hyperthermia, agitation, altered mental status, mydriasis,
dry mucous membranes, urinary retention and decreased bowel sounds. Muscular tone and reflexes are
normal in anticholinergic poisoning.
Serotonin syndrome is a life-threatening condition associated with increased serotonergic activity in the
central nervous system (CNS). It is seen with therapeutic medication use and inadvertent interactions
between drugs for example, between St Johns wort and SSRIs. It typically presents with hyperthermia,
agitation, dilated pupils, tremor, deep tendon hyperreflexia, bilateral Babinski signs, nausea and vomiting
with onset within 24 hours.
SEROTONIN SYNDROME
Causes
 monoamine oxidase inhibitors
 SSRIs
 ecstasy
 amphetamines
Features
 neuromuscular excitation (e.g. hyperreflexia, myoclonus, rigidity)
 autonomic nervous system excitation (e.g. hyperthermia)
 altered mental state
Management
 supportive including IV fluids
 benzodiazepines
 more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
Venn diagram showing contrasting serotonin syndrome with neuroleptic malignant syndrome. Note that
both conditions can cause a raised creatine kinase (CK) but it tends to be more associated with NMS.
Q-11
A 62-year-old man presents four weeks after initiating metformin for type 2 diabetes mellitus. His body
mass index is 27.5 kg/m^2. Despite slowly titrating the dose up to 500mg tds he has experienced
significant diarrhoea. He has tried reducing the dose back down to 500mg bd but his symptoms persisted.
What is the most appropriate action?
A. Switch to pioglitazone 15mg od

B. Switch to gliclazide 40mg od
C. Start modified release metformin 500mg od with evening meal
D. Add loperamide as required
E. Arrange colonoscopy
ANSWER:
C. Start modified release metformin 500mg od with evening meal
EXPLANATION:
Metformin should be titrated slowly, leave at least 1 week before increasing dose
If a patient is intolerant to standard metformin then modified-release preparations should be tried. There
is some evidence that these produce fewer gastrointestinal side-effects in patients intolerant of standard-
release metformin.
METFORMIN
Metformin is a biguanide used mainly in the treatment of type 2 diabetes mellitus. It has a number of
actions which improves glucose tolerance (see below). Unlike sulphonylureas it does not cause
hypoglycaemia and weight gain and is therefore first-line, particularly if the patient is overweight.
Metformin is also used in polycystic ovarian syndrome and non-alcoholic fatty liver disease
Mechanism of action
 acts by activation of the AMP-activated protein kinase (AMPK)
 increases insulin sensitivity
 decreases hepatic gluconeogenesis
 may also reduce gastrointestinal absorption of carbohydrates
Adverse effects
 gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20%
 reduced vitamin B12 absorption - rarely a clinical problem
 lactic acidosis* with severe liver disease or renal failure
Contraindications
 chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130
µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)
 metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples
include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
 iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary
angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment
due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48
hours thereafter
 alcohol abuse is a relative contraindication
Starting metformin
 metformin should be titrated up slowly to reduce the incidence of gastrointestinal side-effects
 if patients develop unacceptable side-effects then modified-release metformin should be considered
*it is now increasingly recognised that lactic acidosis secondary to metformin is rare, although it remains
important in the context of exams
Q-12
A 65-year-old man with a history of ischaemic heart disease is admitted with chest pain. The 12-hour
troponin T is negative. During admission his medications were altered to reduce the risk of cardiovascular
disease and to treat previously undiagnosed type 2 diabetes mellitus. Shortly after discharge he presents
to his GP complaining of diarrhoea. Which one of the following medications is most likely to be
responsible?
A. Gliclazide
B. Clopidogrel
C. Rosiglitazone
D. Metformin
E. Atorvastatin
ANSWER:
D. Metformin
EXPLANATION:
Gastrointestinal side-effects such as diarrhoea and bloating are a common side effect with metformin
Gastrointestinal problems are a common side-effect of many medications but are frequently seen in
patients taking metformin
If this patient had a raised troponin T then metformin may not be suitable as it is contraindicated
following recent episodes of tissue hypoxia.
Please see Q-11 for Metformin
Q-13
A 72-year-old man who has chronic heart failure secondary to ischaemic heart disease presents with knee
pain. A recent x-ray has shown osteoarthritis. Which one of the following medications should be avoided
if possible?
A. Oral ibuprofen
B. Oral paracetamol
C. Oral codeine
D. Oral tramadol
E. Topical diclofenac
ANSWER:
A. Oral ibuprofen
EXPLANATION:
NSAIDs should be used with caution in patients with heart failure
Oral NSAIDs such as ibuprofen should be avoided in heart failure as they may cause fluid retention.
PRESCRIBING IN PATIENTS WITH HEART FAILURE

The following medications may exacerbate heart failure:
 thiazolidinediones
o pioglitazone is contraindicated as it causes fluid retention
 verapamil
o negative inotropic effect
 NSAIDs/glucocorticoids
o should be used with caution as they cause fluid retention
o low-dose aspirin is an exception - many patients will have coexistent cardiovascular disease and the
benefits of taking aspirin easily outweigh the risks
 class I antiarrhythmics
o flecainide (negative inotropic and proarrhythmic effect)
Q-14
A 44-year-old woman with oestrogen receptor positive breast cancer comes for review, three months
after starting tamoxifen. Which one of the following adverse effects is most likely to occur in this patient?
A. Myalgia
B. Cataracts
C. Alopecia
D. Hot flushes
E. Cervical cancer
ANSWER:
D. Hot flushes
EXPLANATION:
Tamoxifen may cause hot flushes
Alopecia and cataracts are listed in the BNF as possible side-effects. They are however not as prevalent as
hot flushes, which are very common in pre-menopausal women
TAMOXIFEN
Tamoxifen is a Selective oEstrogen Receptor Modulator (SERM) which acts as an oestrogen receptor
antagonist and partial agonist. It is used in the management of oestrogen receptor positive breast cancer
Adverse effects
 menstrual disturbance: vaginal bleeding, amenorrhoea
 hot flushes - 3% of patients stop taking tamoxifen due to climateric side-effects
 venous thromboembolism
 endometrial cancer
 osteoporosis
Tamoxifen is typically used for 5 years following removal of the tumour.
Raloxifene is a pure oestrogen receptor antagonist, and carries a lower risk of endometrial cancer
Q-15
A 25-year-old man who is usually fit and well presents with a three day history of a cough productive of
clear sputum associated with general malaise. His doctor gives him a delayed script for antibiotics. On
average, what percentage of patients will eventually take antibiotics if this strategy is employed?
A. 90%
B. 75%
C. 66%
D. 50%
E. 33%
ANSWER:
E. 33%
EXPLANATION:
Delayed prescribing reduces antibiotic use by two-thirds
DELAYED PRESCRIBING
Delayed prescribing has come in and out of fashion for many years. NICE currently advocate it as a strategy
to reduce antibiotic prescriptions for a respiratory tract infections. There is however still some debate about
how effective this is and whether patients find it acceptable.
Cochrane published a review in 2013 of 10 studies looking at the delayed prescription of antibiotics for acute
respiratory tract infections. Findings included:
 delayed prescribing reduced antibiotic use from 93% to 32%
 the method of delayed prescribing (e.g. post-dated script, same-day script but with advice to use after 48
hours etc) did not significantly effect whether antibiotics were used
 patient satisfaction levels were not significantly affected
Critics of delayed prescribing point to the other findings of the study suggesting that patient satisfaction
levels were just as high for patients who were refused antibiotics.
Q-16-18
Theme: Drug monitoring
A. U&E, LFT
B. TFT, LFT
C. TFT, U&E
D. LFT
E. FBC, U&E
F. FBC, LFT
G. LFT, creatine kinase
H. Calcium
I. ECG
J. No routine monitoring required
For each of the following drugs select the most appropriate monitoring tests once treatment has
commenced
Q-16
Gliclazide
ANSWER:
Q-17
Azathioprine
ANSWER:
F. FBC, LFT
EXPLANATION:
Q-18
Simvastatin (first 12 months of treatment)
ANSWER:
D. LFT
EXPLANATION:
Creatine kinase levels do not need to be routinely monitored unless there is a suspicion of myopathy
EXPLANATION Q-16-18:
DRUG MONITORING
The tables below show the monitoring requirements of common drugs. It should be noted these are basic
guidelines and do not relate to monitoring effectiveness of treatment (e.g. Checking lipids for patients taking
a statin)
Cardiovascular drugs
Drug Main monitoring parameters Details of monitoring

Statins LFT LFTs at baseline, 3 months and 12 months
ACE U&E U&E prior to treatment
inhibitors U&E after increasing dose
U&E at least annually
Amiodarone TFT, LFT TFT, LFT, U&E, CXR prior to treatment
TFT, LFT every 6 months
Rheumatology drugs

Methotrexate FBC, LFT, U&E The Committee on Safety of Medicines recommend
'FBC and renal and LFTs before starting treatment
and repeated weekly until therapy stabilised,
thereafter patients should be monitored every 2-3
months'
Azathioprine FBC, LFT FBC, LFT before treatment
FBC weekly for the first 4 weeks
FBC, LFT every 3 months
Neuropsychiatric drugs

Lithium Lithium level, TFT, U&E TFT, U&E prior to treatment
Lithium levels weekly until stabilised then every 3
months
TFT, U&E every 6 months
Sodium LFT LFT, FBC before treatment
valproate LFT 'periodically' during first 6 months
Endocrine drugs

Glitazones LFT LFT before treatment
LFT 'regularly' during treatment
Q-19
You go on a home visit to see Mr Bell, an elderly man who is suffering from an acute diarrhoeal illness he
picked up from his grandchildren. His past medical history includes: ischaemic heart disease, type 2
diabetes, hypercholesterolaemia, and osteoarthritis. His medications are bisoprolol 2.5mg OD, ramipril
2.5mg OD, aspirin 75mg, lansoprazole 30mg OD, metformin 1g BD, atorvastatin 40mg ON, and
paracetamol 1g PRN. His pulse is 92/min, blood pressure 152/82mmHg, oxygen saturations 97%,
respiratory rate 16/min. His tongue looks a little dry, abdomen is soft and non-tender, with very active
bowel sounds. After examining him, you feel he is well enough to stay at home, and you prescribe some
rehydration sachets and arrange telephone review for the following day.
What else should you advise he change about his medication with immediate effect?
A. Increase dose ramipril

B. Double the dose of lansoprazole
C. Suspend metformin
D. Reduce dose paracetamol to 500mg
E. Increase dose bisoprolol
ANSWER:
C. Suspend metformin
EXPLANATION:
Metformin increases the risk of lactic acidosis - suspend during intercurrent illness eg. diarrhoea and
vomiting
Increase dose ramipril. Incorrect. Although his blood pressure is a little high today, it is not the priority and
might increase risk of electrolyte disturbance whilst he is unwell - you may even consider suspending it.
Blood pressure could be reviewed when he is feeling better.
Double the dose of lansoprazole. Incorrect, no indication for this.

Suspend ramipril. Incorrect. Blood pressure is a little high, and there is no evidence of acute electrolyte
disturbance.
Suspend metformin. Correct answer - metformin is associated with an increased risk of lactic acidosis and
therefore should be suspended when there is risk eg. dehydration, sepsis, CT with contrast, renal failure,
heart failure; particularly if the patient is frail or elderly.
Reduce dose paracetamol to 500mg. Incorrect. Dose might be reduced when patient has a low body
weight.
Increase dose bisoprolol. Incorrect. No indication for increasing bisoprolol here.
SIDE-EFFECTS OF COMMON DRUGS: DIABETES DRUGS

to treat diabetes mellitus
Drug Side-effect
Metformin Gastrointestinal side-effects
Lactic acidosis
Sulfonylureas Hypoglycaemic episodes
Increased appetite and weight gain
Syndrome of inappropriate ADH secretion
Liver dysfunction (cholestatic)
Glitazones Weight gain
Fluid retention
Liver dysfunction
Fractures
Gliptins Pancreatitis
Q-20
A 56-year-old man from Pakistan presents to his GP with numbness and tingling in his feet for 1 week. He
tells you he has recently started some new medications. Looking at his medical history you discover he has
recently been diagnosed with tuberculosis and hypertension.
Which of the following medications are most likely to be causing the problem?
A. Rifampicin
B. Amlodipine
C. Ramipril
D. Isoniazid
E. Pyrazinamide
ANSWER:
D. Isoniazid
EXPLANATION:
Peripheral neuropathy is a commonly recognised side effect of isoniazid. Although paraesthesia is listed
under the side effects for amlodipine in the BNF, it is uncommon. In this case isoniazid is the most likely
answer.
Drug Most common side effects

Rifampicin Orange bodily fluids, rash, hepatotoxicity, drug interactions
Isoniazid Peripheral neuropathy, psychosis, hepatotoxicity
Pyrazinamide Arthralgia, gout, hepatotoxicity, nausea
Ethambutol Optic neuritis, rash
Source: BNF
TUBERCULOSIS: DRUG SIDE-EFFECTS AND MECHANISM OF ACTION

Rifampicin
 mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA
into mRNA
 potent liver enzyme inducer
 hepatitis, orange secretions
 flu-like symptoms
Isoniazid
 mechanism of action: inhibits mycolic acid synthesis
 peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
 hepatitis, agranulocytosis
 liver enzyme inhibitor
Pyrazinamide
 mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid
synthase (FAS) I
 hyperuricaemia causing gout
 arthralgia, myalgia
 hepatitis
Ethambutol
 mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into
arabinan
 optic neuritis: check visual acuity before and during treatment
 dose needs adjusting in patients with renal impairment
Q-21
27-year-old Jack is on methadone 60mg once a day to manage his symptoms from heroin withdrawal. He
collects his methadone daily from the pharmacy and is supervised consuming it. One Wednesday morning
Jack fails to turn up to the pharmacy. What is the most appropriate course of action for the pharmacist?
A. Give him his usual 60mg methadone when he turns up the next day on Thursday and forfeit the dose
from the day before
B. Give him 120mg methadone when he turns up the next day on Thursday(60mg for Wednesday + 60 mg
for Thursday)
C. Give him his usual 60mg methadone when he turns up the next day on Thursday but offer him another
60mg to take later on in the day
D. Ask the patient to book an appointment with the GP to consider lowering his usual dose as he has not
suffered any withdrawal symptoms on Thursday from missing his usual methadone dose the day
before
E. Give him his usual 60mg methadone when he turns up the next day on Thursday and give him an
additional 30mg (half of Wednesdays dose)
ANSWER:
A. Give him his usual 60mg methadone when he turns up the next day on Thursday and forfeit the dose
from the day before
EXPLANATION:
Methadone is a long-acting synthetic opioid analgesic. It acts as a full opioid agonist. It is used in the
treatment of opioid dependence as a support agent in detoxification. The peak clinical effect of
methadone is two to six hours post oral dose and the half life of methadone is around 15 hours. It takes
approximately five days for plasma levels of methadone in the body to stabilise (there is a cumulative
effect until steady state is reached), and after that variations in the blood level of methadone are small.
Methadone is metabolised through the liver via the P450 enzymes.
Due to the cumulative effect methadone should be prescribed starting at a low dose and titrating
upwards. Methadone is typically taken once daily. The standard concentration is 1mg/ml oral solution.
The starting dose of methadone should be between 10 mg and 30 mg daily, depending on the amount of
heroin, the length and method of use or other opioids being used.
Missed doses can cause an opioid withdrawal syndrome after two or three days as this is how long it takes
for blood levels of methadone to normalise. For this reason the GP does not need to review a patient who
has missed a dose of methadone unless they have missed 3 or more consecutive days. Should they have
missed 3 or more consecutive days and still have no symptoms of opioid withdrawal an assessment can be
made as to whether a reduced dose of methadone would be appropriate. Patients who also repeatedly
miss doses should have their treatment reviewed. Any missed methadone dose should not be replaced and
is forfeited by the pharmacist.
Please see Q-2 for Opioid Misuse
Q-22
A 42-year-old man who has drank excessively for the past 18 months presents to surgery. His current
alcohol intake is around 80 units per week. For the past few months he has been feeling 'generally down'
and not sleeping well. He describes having little interest in the things he previously enjoyed doing and
losing contact with friends and family. What is the most appropriate management?
A. Offer help with stopping drinking - if abstinent for 1 week then offer treatment for depression
B. Offer help with stopping drinking + refer to the primary care mental health team
C. Offer help with stopping drinking - if abstinent for 4 weeks then offer treatment for depression
D. Offer help with stopping drinking + start sertaline
E. Offer help with stopping drinking + start citalopram
ANSWER:
C. Offer help with stopping drinking - if abstinent for 4 weeks then offer treatment for depression
EXPLANATION:
NICE recommend 'For people who misuse alcohol and have comorbid depression or anxiety disorders, treat
the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If
depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, undertake an assessment of
the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for
the particular disorder.'
ALCOHOL - PROBLEM DRINKING: MANAGEMENT

Nutritional support
 SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be deficient'
Drugs used
 benzodiazepines for acute withdrawal
 disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde
dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods,
mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and
psychosis
 acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence
in placebo controlled trials
Q-23
Which one of the following is an established indication for the use of Botulinum toxin?
A. Strabismus
B. Hirschsprung's disease
C. Blepharospasm
D. Bell's palsy
E. Upper limb rigidity in Parkinson's disease
ANSWER:
C. Blepharospasm
EXPLANATION:
BOTULINUM TOXIN
As well as the well-publicised cosmetic uses of Botulinum toxin ('Botox') there are also a number of licensed
indications:
 blepharospasm
 hemifacial spasm
 focal spasticity including cerebral palsy patients, hand and wrist disability associated with stroke
 spasmodic torticollis
 severe hyperhidrosis of the axillae
 achalasia
Q-24
Which one of the following prescriptions is contraindicated in pregnancy?
A. Methyldopa for hypertension

B. Topical clindamycin for bacterial vaginosis
C. Doxycycline for malarial prophylaxis
D. Metoclopramide for vomiting
E. Prednisolone for an asthma exacerbation
ANSWER:
C. Doxycycline for malarial prophylaxis
EXPLANATION:
All tetracyclines should be avoided in pregnancy.
It should be noted that the above prescriptions are not necessarily the recommended first-line treatments
Please see Q-8 for Prescribing in Pregnant Patients

Q-25
A middle-aged patient with type 2 diabetes mellitus comes for review. He also has chronic heart failure
secondary to dilated cardiomyopathy (NYHA class II). His diabetes is currently diet-controlled but his
HbA1c has risen to 64 mmol/mol (8.0%). Which one of the following medications is contraindicated?
A. Metformin
B. Pioglitazone
C. Glipizide
D. Exenatide
E. Acarbose
ANSWER:
B. Pioglitazone
EXPLANATION:
Please see Q-13 for Prescribing in Patients with Heart Failure
Q-26
George is a 67-year-old man who has seen you previously with erectile dysfunction. You have previously
considered conservative treatment options, however, he comes back to see you as these have not been
successful. He is keen to try sildenafil. His past medical history comprises of a myocardial infarction 1 year
ago, hypertension, elevated cholesterol, type 2 diabetes and macular degeneration. He is currently taking
bisoprolol, atorvastatin, amlodipine, aspirin and metformin. Examination shows a blood pressure of
114/85mmHg and his pulse is 85 beats per minute. What would you advise?
A. Sildenafil is contraindicated due to a diagnosis of macular degeneration

B. Sildenafil is contraindicated due to recent myocardial infarction
C. It is safe to prescribe sildenafil
D. Sildenafil is contraindicated due to a diagnosis of hypertension
E. Sildenafil is contraindicated due to a diagnosis of type 2 diabetes
ANSWER:
C. It is safe to prescribe sildenafil
EXPLANATION:
George does not have a contraindication for sildenafil and so it is safe to prescribe.
Option 1 is incorrect as macular degeneration is not a contraindication for prescribing sildenafil.
Option 2 is incorrect as NICE advise it is safe to prescribe sildenafil if the myocardial infarction is more than
6 months ago.
Option 4 is incorrect as hypertension is not a contraindication for prescribing sildenafil.
Option 5 is incorrect as diabetes is not a contraindication for prescribing sildenafil.
AKT report 2015 - 'Several areas of mens health caused difficulty, including management of erectile
dysfunction'
Please see Q-9 for Phosphodiesterase Type V Inhibitors
Q-27
Which one of the following drugs should be prescribed using the proprietary, rather than the generic
name?
A. Mesalazine
B. Betahistine
C. Cabergoline
D. Azathioprine
E. Sulfasalazine
ANSWER:
A. Mesalazine
EXPLANATION:
PRESCRIBING GUIDANCE
The BNF issues guidance on good practice when prescribing, selected points include:
 drugs should generally be prescribed by their generic name, except for certain preparations where the
clinical effect may differ - please see the list below
 when writing numbers unnecessary decimal points should be avoided e.g. 250 ml not 0.25 l
 it is a legal requirement for children under the age of 12 that their age is specified on the prescription
Drugs which should be prescribed by brand

 modified release calcium channel blockers
 antiepileptics
 ciclosporin and tacrolimus
 mesalazine
 lithium
 aminophylline and theophylline
 methylphenidate
 CFC-free formulations of beclometasone
 dry powder inhaler devices
Q-28
A 37-year-old woman with a history of type 2 diabetes mellitus and obesity presents after a late period.
The urinary hCG test is positive. Her current medication is as follows:
Orlistat 120mg tds

Simvastatin 40mg on
Aspirin 75mg od
Metformin 1g bd
Paracetamol 1g qds
Aqueous cream prn
Which one of her medications must be stopped straight away?
A. Paracetamol
B. Aspirin
C. Simvastatin
D. Orlistat
E. Metformin
ANSWER:
C. Simvastatin
EXPLANATION:
Simvastatin is contraindicated in pregnancy and must be stopped immediately. Metformin is sometimes
used in pregnancy although many diabetic women are converted to insulin for the duration of the
pregnancy to try and maximise control and minimise complications.
Whilst orlistat is not a known teratogen it should be used with 'caution' in pregnancy according to the BNF
and the benefits are very likely outweighed by risks.
Q-29
A 25-year-old woman who is 20-weeks pregnant presents with acne vulgaris. Which one of the following
treatments is known to be harmful to the developing fetus?
A. Oral erythromycin
B. Topical isotretinoin
C. Topical benzyl peroxide
D. Topical azelaic acid
E. Topical clindamycin
ANSWER:
B. Topical isotretinoin
EXPLANATION:
Both oral and topical isotretinoin are strongly contraindicated in pregnancy. Effective contraception must
be taken by women when using these preparations.
Q-30
A patient presents to his GP following the development of an urticarial skin rash following the
introduction of a new drug. Which one of the following is most likely to be responsible?
A. Omeprazole
B. Sodium valproate
C. Aspirin
D. Paracetamol
E. Simvastatin
ANSWER:
C. Aspirin
EXPLANATION:
Aspirin is a common cause of urticaria
Although all medications can potentially cause urticaria it is commonly seen secondary to aspirin
DRUG CAUSES OF URTICARIA

The following drugs commonly cause urticaria:
 aspirin
 penicillins
 NSAIDs
 opiates
Q-31
A 40-year-old man attends the GP surgery requesting sildenafil (Viagra) as he is in a new relationship and
feels anxious every time they become intimate. He still gets morning erections and is able to achieve his
own erections. He is normotensive and his recent NHS health screen bloods were all normal. His GP
reviews his medication list and proceeds to advise him against the use of sildenafil. Which of the following
medication(s) in the list below is contraindicated in the use of sildenafil?
A. Rivaroxaban
B. Atorvastatin
C. Isosorbide mononitrate (ISMN)
D. Bisoprolol
E. All of the above
ANSWER:
C. Isosorbide mononitrate (ISMN)
EXPLANATION:
PDE 5 inhibitors (e.g. sildenafil) - contraindicated by nitrates and nicorandil
Nitrates can cause profound hypotension when used in combination with sildenafil so alternative options
should be discussed with this patient.
Q-32-34
Theme: Side-effects of common antibiotics
A. Suppression of haemopoiesis
B. Drug-induced lupus
C. Vomiting
D. Reaction following alcohol ingestion
E. Rash with infectious mononucleosis
F. Flushing
G. Cholestasis
H. Reduced seizure threshold
Select the side-effect most characteristically associated with the following antibiotics:
Q-32
Flucloxacillin
ANSWER:
G. Cholestasis
EXPLANATION:
The Committee on Safety of Medicines has issued a specific warning on the risk of cholestasis and hepatitis
in patients who have taken flucloxacillin
Q-33
Erythromycin
ANSWER:
C. Vomiting
EXPLANATION:
Erythromycin can cause cholestasis but gastrointestinal upset is by far the most common side-effect.
Q-34
Ciprofloxacin
ANSWER:
SIDE-EFFECTS OF COMMON DRUGS: ANTIBIOTICS
antibiotics
Drug Side-effect
Amoxicillin Rash with infectious mononucleosis
Co-amoxiclav Cholestasis
Flucloxacillin Cholestasis (usually develops several weeks after use)
Erythromycin Gastrointestinal upset
Prolongs QT interval
Ciprofloxacin Lowers seizure threshold
Tendonitis
Metronidazole Reaction following alcohol ingestion
Doxycycline Photosensitivity
Trimethoprim Rashes, including photosensitivity
Pruritus
Suppression of haematopoiesis
Q-35
What does it mean?
A. Newly licensed medicine

B. Not prescribable on the NHS
C. Denotes a preparation that is less suitable to prescribe
D. Should only be prescribed by a specialist
E. Controlled drug
ANSWER:
A. Newly licensed medicine
EXPLANATION:
British National Formulary symbols
The list below explains the meanings of the main symbols used in the BNF:
Denotes a preparation that is less suitable to prescribe
Newly licensed medicines

Not prescribable on the NHS
Prescription-only medicine
Controlled drug
Q-36
Chantelle is a 26-year-old woman with a history of depression and type 1 diabetes mellitus, for which she
takes citalopram and insulin.
Which of the following could dangerously interact with the medication she is taking?
A. Cannabis
B. Cheese
C. Cranberry juice
D. Paracetamol
E. St John’s wort
ANSWER:
E. St John’s wort
EXPLANATION:
St. John's Wort may interact with SSRIs to cause serotonin syndrome
Citalopram is a selective serotonin reuptake inhibitor (SSRI). St John’s Wort can interact with SSRIs to
cause serotonin syndrome.
Cranberry juice is an enzyme inhibitor but is not known to interact with SSRIs or insulin.
Paracetamol does not interact with SSRIs or insulin.
Cannabis is not known to interact with SSRIs.
Cheese interacts with monoamine oxidase inhibitors but not SSRIs.

Please see Q-10 for Serotonin Syndrome
Q-37
You are asked by the practice nurse about malarial prophylaxis. She is considering recommending
mefloquine for malarial prophylaxis for a 25-year-old woman. Her medical records show she uses the
combined oral contraceptive pill for contraception and has a history of anxiety, for which she briefly took
sertraline two years ago. What is the most appropriate advice to give?
A. Mefloquine may be safely prescribed

B. Mefloquine may not be prescribed due to the history of anxiety
C. Mefloquine may only be prescribed following a mental health assessment
D. A contraceptive not containing oestrogen should be used whilst taking mefloquine
E. Barrier methods should be used in addition to the combined oral contraceptive pill
ANSWER:
B. Mefloquine may not be prescribed due to the history of anxiety
EXPLANATION:
MEFLOQUINE
Mefloquine (brand name Lariam) is used for both the prophylaxis and treatment of certain types of malaria.
There has long been a concern about the neuropsychiatric side-effects of mefloquine. A recent review has
however led to 'strengthened warnings' about the potential risks.
The following advice is therefore given:

 certain side-effects such nightmares or anxiety may be 'prodromal' of a more serious neuropsychiatric
event
 suicide and deliberate self harm have been reported in patients taking mefloquine
 adverse reactions may continue for several months due to the long half-life or mefloquine
 mefloquine should not be used in patients with a history of anxiety, depression schizophrenia or other
psychiatric disorders
 patients who experience neuropsychiatric sife-effects should stop mefloquine and seek medical advice
Q-38
A 54-year-old man with a history of hypertension comes for review. He currently takes lisinopril 10mg od,
simvastatin 40mg on and aspirin 75mg od. His blood pressure is well controlled at 124/76 mmHg but he
also mentions that he is due to have a tooth extraction next week. What advice should be given with
regards to his aspirin use?
A. Take aspirin as normal but take tranexamic 1g tds acid 24 hours before and after procedure
B. Stop 72 hours before, restart 24 hours after procedure
C. Stop 24 hours before, restart 12 hours after procedure
D. Take aspirin as normal
E. Stop 48 hours before, restart 24 hours after procedure
ANSWER:
D. Take aspirin as normal
EXPLANATION:
In the BNF section 'Prescribing in dental practice' it advises that patients in this situation should continue
taking anti-platelets as normal
ASPIRIN
Aspirin works by blocking the action of both cyclooxygenase-1 and 2. Cyclooxygenase is responsible for
prostaglandin, prostacyclin and thromboxane synthesis. The blocking of thromboxane A2 formation in
platelets reduces the ability of platelets to aggregate which has lead to the widespread use of low-dose
aspirin in cardiovascular disease. Until recent guidelines changed all patients with established cardiovascular
disease took aspirin if there was no contraindication. Following the 2010 technology appraisal of clopidogrel
this is no longer the case*.
Two recent trials (the Aspirin for Asymptomatic Atherosclerosis and the Antithrombotic Trialists
Collaboration) have cast doubt on the use of aspirin in primary prevention of cardiovascular disease.
Guidelines have not yet changed to reflect this. However the Medicines and Healthcare products Regulatory
Agency (MHRA) issued a drug safety update in January 2010 reminding prescribers that aspirin is not
licensed for primary prevention.
What do the current guidelines recommend?

 first-line for patients with ischaemic heart disease
Potentiates
 oral hypoglycaemics
 warfarin
 steroids
Aspirin should not be used in children under 16 due to the risk of Reye's syndrome. An exception is Kawasaki
disease, where the benefits are thought to outweigh the risks.
*NICE now recommend clopidogrel first-line following an ischaemic stroke and for peripheral arterial
disease. For TIAs the situation is more complex. Recent Royal College of Physician (RCP) guidelines support
the use of clopidogrel in TIAs. However the older NICE guidelines still recommend aspirin + dipyridamole - a
position the RCP state is 'illogical'
Q-39
A 45-year-old female with a history of bipolar disorder presents with an acute confusional state. Which
one of the following drugs is most likely to precipitate lithium toxicity?
A. Sodium valproate
B. Atenolol
C. Aminophylline
D. Sodium bicarbonate
E. Bendroflumethiazide
ANSWER:
E. Bendroflumethiazide
EXPLANATION:
Lithium toxicity can be precipitated by thiazides
Both sodium bicarbonate and aminophylline may reduce plasma concentrations of lithium
LITHIUM TOXICITY
Lithium is a mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an
adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma
half-life being excreted primarily by the kidneys. Lithium toxicity generally occurs following concentrations >
1.5 mmol/L.
Toxicity may be precipitated by:

 dehydration
 renal failure
 drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and
metronidazole.
Features of toxicity
 coarse tremor (a fine tremor is seen in therapeutic levels)
 hyperreflexia
 acute confusion
 seizure
 coma
Management
 mild-moderate toxicity may respond to volume resuscitation with normal saline
 haemodialysis may be needed in severe toxicity
 sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the
alkalinity of the urine it promotes lithium excretion
Q-40
You are reviewing a 4-year-old boy who has serious physical disabilities. His parents feel he is
experiencing significant pain at the current time and you therefore decide to prescribe the paracetamol
dose per weight, rather than using the standard 'on the bottle' dose. His parents have a 300ml bottle of
paracetamol 120mg/5ml. The boy weighs 24kg. The local paediatric unit recommends using 20mg/kg
every 6 hours. What volume of paracetamol should be given for each dose?
_______ ml
ANSWER:
20
EXPLANATION:
The recommended dose for this child = 20mg/kg * 24kg = 480mg
The correct volume is therefore 480 / 120 = 4 * 5 = 20ml

The April 2014 AKT feedback report stated: 'Drug calculation questions are included in every AKT and we
have noted only a marginal improvement in candidates answering these correctly.'
DRUG DOSE CALCULATIONS

Questions requiring you to calculate drug doses are increasingly common due to concerns about the
frequency of prescription errors. There have been several high profile cases where such calculations have
been incorrect by a factor of 10 resulting in serious patient harm.
Whilst the calculations themselves are relatively simple it easy to make a mistake.
Many calculations involve drugs given either as solutions or infusions. These require you first to work out the
correct dose for the patients weight, e.g.
Paracetamol for a child: 20mg/kg, every 6-8 hours
The child weighs 18kg therefore 18 * 20 = 360mg.
Paracetamol oral suspension is available as 120mg/5ml
Therefore we divide 360 by the 'top' figure - 120 = 3 and times this by the 'bottom' figure - 5
i.e. 360mg / 120mg = 3 * 5ml = 15 ml of paracetamol oral suspension 120mg/5ml should be given every 6-8
hours
Q-41
Which one of the following statements regarding the Yellow Card scheme is correct?
A. Each Yellow Card requires two doctors to confirm the adverse event
B. Online reporting is currently limited to vaccines
C. All adverse events should be reported, even for established drugs
D. Patients can complete Yellow Cards
E. Only confirmed adverse events should be reported
ANSWER:
D. Patients can complete Yellow Cards
EXPLANATION:
YELLOW CARD SCHEME
The Yellow Card scheme has become the standard way to report adverse reactions to medications. It is run
by the Medicines and Healthcare products Regulatory Agency (MHRA).
The following should be reported (taken from the MHRA website)

 all suspected adverse drug reactions for new medicines (identified by the black triangle symbol) should
be reported
 all suspected adverse drug reactions occurring in children, even if a medicine
has been used off-label

 all serious* suspected adverse drug reactions for established vaccines and
medicines, including unlicensed medicines, herbal remedies, and medicines used off-label
Other information
 Yellow Cards are found at the back of the BNF or reports can be completed online
(www.yellowcard.gov.uk)
 any suspected reactions (not just confirmed) should be reported
 patients can report adverse events
 Yellow Cards are sent to the MHRA who in collate and assess the information. In turn the MHRA may
consult with the Commission on Human Medicines (CHM), an independent scientific advisory body on
medicines safety
*reactions which are fatal, life-threatening, disabling or incapacitating, result in or

prolong hospitalisation, or medically significant are considered serious.
Q-42
A 78-year-old gentleman attends for a medication review. He suffers from ischaemic heart disease,
cerebrovascular disease and heart failure. Which of the following medications should be prescribed by
brand name only?
A. Enalapril
B. Carvedilol
C. Bumetanide
D. Modified-release verapamil
E. Clopidogrel
ANSWER:
D. Modified-release verapamil
EXPLANATION:
Modified release calcium channel blockers should be prescribed by brand name only, as they have
different release characteristics. Hence, continuity of the same brand is required to ensure symptoms are
well controlled.
The following website contains a good summary of medications that should be prescribed by brand:
http://psnc.org.uk/walsall-lpc/wp-content/uploads/sites/56/2014/02/Drugs-to-consider-prescribing-by-
brand-name-or-where-brands-should-not-be-switched.pdf
Please see Q-27 for Prescribing Guidance
Q-43
A man you are treating for tuberculosis describes how, since starting treatment, he has noticed that his
urine has turned orange.
What drug is responsible?
A. Rifampicin
B. Isoniazid
C. Pyridoxine
D. Pyrazinamide
E. Ethambutol
ANSWER:
A. Rifampicin
EXPLANATION:
Rifampicin may cause orange tears and urine
Side effects of TB medication are commonly asked. Rather strangely, rifampicin can cause bodily
secretions to turn orange. The others are all medications that would be used in TB treatment, but none of
these cause bodily secretions to turn orange. Side effects of the other medications are outlined in the
notes below.
Please see Q-20 for Tuberculosis: Drug Side-Effects and Mechanism of Action
Q-44
NICE issued guidelines on the management of opioid detoxification in 2007. How long should community
detoxification programmes normally last?
A. 1 week
B. 2 weeks
C. 4 weeks
D. 8 weeks
E. 12 weeks
ANSWER:
E. 12 weeks
EXPLANATION:
Q-45
A 44-year-old man asks for advice. He is due to go on a long bus journey but suffers from debilitating
motion sickness. Which one of the following medications is most likely to prevent motion sickness?
A. Cyclizine
B. Chlorpromazine
C. Metoclopramide
D. Prochlorperazine
E. Domperidone
ANSWER:
A. Cyclizine
EXPLANATION:
Motion sickness - hyoscine > cyclizine > promethazine
MOTION SICKNESS
Motion sickness describes the nausea and vomiting which occurs when an apparent discrepancy exists
between visually perceived movement and the vestibular systems sense of movement
Management
 the BNF recommends hyoscine (e.g. transdermal patch) as being the most effective treatment. Use is
limited due to side-effects
 non-sedating antihistamines such as cyclizine or cinnarizine are recommended in preference to sedating
preparation such as promethazine
Q-46
A 54-year-old man with stage 4 chronic kidney disease presents for review. Which one of the following
drugs is it most important to avoid?
A. Erythromycin
B. Diazepam
C. Rifampicin
D. Tetracycline
E. Warfarin
ANSWER:
D. Tetracycline
EXPLANATION:
PRESCRIBING IN PATIENTS WITH RENAL FAILURE
Questions regarding which drugs to avoid in renal failure are common
Drugs to avoid in renal failure

 antibiotics: tetracycline, nitrofurantoin
 NSAIDs
 lithium
 metformin
Drugs likely to accumulate in chronic kidney disease - need dose adjustment

 most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
 digoxin, atenolol
 methotrexate
 sulphonylureas
 furosemide
 opioids
Drugs relatively safe - can sometimes use normal dose depending on the degree of chronic kidney disease
 antibiotics: erythromycin, rifampicin
 diazepam
 warfarin
Q-47
Which one of the following antibiotics should be avoided in patients with epilepsy?
A. Clindamycin
B. Clarithromycin
C. Levofloxacin
D. Nitrofurantoin
E. Trimethoprim
ANSWER:
C. Levofloxacin
EXPLANATION:
PRESCRIBING IN PATIENTS WITH EPILEPSY
The following drugs may worsen seizure control in patients with epilepsy:
 alcohol, cocaine, amphetamines
 ciprofloxacin, levofloxacin
 aminophylline, theophylline
 bupropion
 methylphenidate (used in ADHD)
 mefenamic acid
Some medications such as benzodiazepines, baclofen and hydroxyzine may provoke seizures whilst they are
being withdrawn.
Other medications may worsen seizure control by interfering with the metabolism of anti-epileptic drugs
(i.e. P450 inducers/inhibitors).
Q-48
A 50-year-old gentleman attends you GP surgery requesting a repeat prescription of sildenafil. He has
been taking this medication for years. You note in his records that he had a myocardial infarction 4
months ago. What should you do?
A. Prescribe this as the patient is established on this

B. Reduce the dose by half and issue
C. Double the dose and issue
D. Prescribe but as a private prescription
E. Do not prescribe as contraindicated
ANSWER:
E. Do not prescribe as contraindicated
EXPLANATION:
Recent myocardial infarction or unstable angina is a contraindication for PDE 5 inhibitor (e.g. sildenafil)
use
According to both the BNF and NICE, sildenafil is contraindicated in patients who have had a myocardial
infarction within the past 6 months. The patient in this question had a myocardial infarction 4 months ago
and therefore sildenafil is contraindicated. The answer to this questions is there do not prescribe as
contraindicated.
The January 2016 AKT feedback stated:

In particular there was a lack of awareness of drug interactions.
Q-49
Each of the following drugs are known to induce cytochrome p450 enzyme, except:
A. Rifampicin
B. Isoniazid
C. Phenobarbitone
D. Griseofulvin
E. Carbamazepine
ANSWER:
B. Isoniazid
EXPLANATION:
Isoniazid inhibits the P450 system
Isoniazid is an inhibitor of the P450 system
P450 ENZYME SYSTEM

Induction usually requires prolonged exposure to the inducing drug, as opposed to P450 inhibitors, where
effects are often seen rapidly
Inducers of the P450 system include

 antiepileptics: phenytoin, carbamazepine
 barbiturates: phenobarbitone
 rifampicin
 St John's Wort
 chronic alcohol intake
 griseofulvin
 smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include

 antibiotics: ciprofloxacin, erythromycin
 isoniazid
 cimetidine,omeprazole
 amiodarone
 allopurinol
 imidazoles: ketoconazole, fluconazole
 SSRIs: fluoxetine, sertraline
 ritonavir
 sodium valproate
 acute alcohol intake
 quinupristin
Q-50
A 23-year old woman has been asked to see you about alternative contraception. She has been seen by a
neurologist who has prescribed a new medication following a new diagnosis of epilepsy. She currently
takes the combined oral contraceptive pill. He told her that an alternative method of contraception is
needed because the new medication will make it less effective. Which of the following medications is she
likely to have started?
A. Carbamazepine
B. Ethosuximide
C. Sodium valproate
D. Clonazepam
E. Lamotrigine
ANSWER:
A. Carbamazepine
EXPLANATION:
Carbamazepine is a P450 enzyme inductor
The correct answer is carbamazepine. 'The effectiveness of combined oral contraceptives, progestogen-
only oral contraceptives (section 7.3.2.1), contraceptive patches, and vaginal rings can be considerably
reduced by interaction with drugs that induce hepatic enzyme activity (e.g. carbamazepine,
eslicarbazepine, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John's
Wort, topiramate, and, above all, rifabutin and rifampicin)' Quote from the BNF.
Ethosuximide, sodium valproate, clonazepam and lamotrigine are not hepatic enzyme inducers therefore
do not interfere with effectiveness.
April 2016 AKT report: 'Includes areas such as contraception and pregnancy.'
Please see Q-49 for P450 Enzyme System
Q-51
A 45-year-old man is started on ciclosporin following a renal transplant. Which one of the following
adverse effects is most likely to occur?
A. Depression
B. Increased risk of ischaemic heart disease
C. Pulmonary fibrosis
D. Impaired glucose tolerance
E. Nephrotoxicity
ANSWER:
E. Nephrotoxicity
EXPLANATION:
Ciclosporin may cause nephrotoxicity
Nephrotoxicity is common with ciclosporin use whereas impaired glucose tolerance is a relatively rare
side-effect
CICLOSPORIN
Ciclosporin is an immunosuppressant which decreases clonal proliferation of T cells by reducing IL-2 release.
It acts by binding to cyclophilin forming a complex which inhibits calcineurin, a phosphatase that activates
various transcription factors in T cells
Adverse effects of ciclosporin (note how everything is increased - fluid, BP, K+, hair, gums, glucose)
 nephrotoxicity
 hepatotoxicity
 fluid retention
 hypertension
 hyperkalaemia
 hypertrichosis
 gingival hyperplasia
 tremor
 impaired glucose tolerance
 hyperlipidaemia
 increased susceptibility to severe infection
Interestingly for an immunosuppressant, ciclosporin is noted by the BNF to be 'virtually non-myelotoxic'.
Indications
 following organ transplantation
 rheumatoid arthritis
 psoriasis (has a direct effect on keratinocytes as well as modulating T cell function)
 ulcerative colitis
 pure red cell aplasia
Q-52
A 54-year-old man consults you about erectile dysfunction. He has no past medical history of note other
than a brief episode of depression five years ago. Which one of the following statements regarding the
prescription of a sildenafil is correct?
A. It may be freely prescribed on the NHS

B. It should be prescribed on a private basis regardless of the past medical history
C. It should not be prescribed until other treatments have been tried
D. It may be prescribed on the NHS if the patient has a history of diabetes, prostate problems or a
neurological disorder under the 'SLS' scheme
E. It may be prescribed on a private basis if the patient has a history of diabetes, prostate problems or a
neurological disorder
ANSWER:
A. It may be freely prescribed on the NHS
EXPLANATION:
Sildenafil came off the 'blacklist' in 2014 and can now be freely prescribed.
Q-53
Which of the following relating to St John's Wort is false?
A. Adverse effects in trials is similar to placebo

B. May cause serotonin syndrome
C. Mechanism of action is similar to selective serotonin reuptake inhibitors
D. Causes inhibition of the P450 system
E. Has been shown to be effective in treating mild-moderate depression
ANSWER:
D. Causes inhibition of the P450 system
EXPLANATION:
St John's Wort is a known inducer of the P450 system
ST JOHN'S WORT
Overview
 shown to be as effective as tricyclic antidepressants in the treatment of mild-moderate depression
 mechanism: thought to be similar to SSRIs (although noradrenaline uptake inhibition has also been
demonstrated)
 NICE advise 'may be of benefit in mild or moderate depression, but its use should not be prescribed or
advised because of uncertainty about appropriate doses, variation in the nature of preparations, and
potential serious interactions with other drugs'
Adverse effects
 profile in trials similar to placebo
 can cause serotonin syndrome
 inducer of P450 system, therefore decreased levels of drugs such as warfarin, ciclosporin. The
effectiveness of the combined oral contraceptive pill may also be reduced
Q-54
A 67-year-old man comes to see you with problems with erectile dysfunction. After discussion, you decide
to give him a trial of a phosphodiesterase inhibitor (e.g. sildenafil). Which of the following would be a
contraindication to the prescription?
A. Blood pressure 165/100mmHg

B. Recent chest pain awaiting cardiology opinion
C. Current smoker
D. Insulin dependent diabetes
E. History of migraine with aura
ANSWER:
B. Recent chest pain awaiting cardiology opinion
EXPLANATION:
Recent myocardial infarction or unstable angina is a contraindication for PDE 5 inhibitor (e.g. sildenafil)
use
The correct answer in this case is recent chest pain awaiting cardiology opinion. Phosphodiesterase
inhibitors are supposed to be used with caution in patients with cardiovascular disease, and in someone
who has chest pain potentially cardiac in nature it would be unwise to prescribe until investigations are
complete.
It is also worth noting that if a patient with known angina has a GTN spray, they should not use it for at
least 24hrs after taking sildenafil or vardenafil, or 48hours after taking tadalafil (due to risk of excessive
hypotension precipitating myocardial infarction).
The AKT October 2015 feedback report stated:
Several areas of mens health caused difficulty, including management of erectile dysfunction and effects
of treatment for prostate conditions
Q-55
A 2-year-old boy is brought in by his mum with symptoms of croup. You decide to give him
dexamethasone. His weight is 10kg.
The British National Formulary states:
Dexamethasone (for croup):

A single dose of 150micrograms/kg by mouth is of benefit
Oral solution, sugar-free, dexamethasone (as sodium phosphate) 2mg/5ml
What is the correct dose of dexamethasone?
A. 1.5ml
B. 1.65ml
C. 3.75ml
D. 6.65ml
E. 10ml
ANSWER:
C. 3.75 ml
EXPLANATION:
We are told that a single dose of dexamethasone can be given at 150micrograms/kg.
This equates to 0.15mg/kg. His weight is 10kg.
He therefore needs 1.5mg as a single dose.
The formulation comes as a oral suspension of 2mg/5ml.
So, 1.5mg/2mg = 0.75.
Therefore, 0.75 x 5ml = 3.75ml as a single dose.
Please see Q-40 for Drug Dose Calculations
Q-56
You review a 5-year-old boy who has had a cough following an upper respiratory tract infection for the
past 10 days. Clinical examination is unremarkable. His mother is keen to try a cough mixture as she says it
is keeping him awake at night. Which one of the following may be considered?
A. Simple linctus (paediatric)

B. Chlorphenamine (paediatric)
C. Diphenhydramine (paediatric)
D. Dextromethorphan linctus (paediatric)
E. Pholcodeine linctus (paediatric)
ANSWER:
A. Simple linctus (paediatric)
EXPLANATION:
Cough mixtures are not normally recommended for minor illnesses in children but this question highlights
product ingredients, once widely used, which are now considered unsuitable.
The January 2010 AKT feedback report stated 'Increasingly, patients are encouraged to self-manage
conditions, perhaps with advice from a pharmacist. Candidates did not perform well with regard to issues
related to over the counter medication, such as side-effects and contraindications.'
OVER-THE-COUNTER TREATMENTS
Cough and cold remedies
In 2009 the Medicines and Healthcare products Regulatory Agency (MHRA) / Commission on Human
Medicines (CHM) announced a major change in the regulation of over-the-counter (OTC) preparations aimed
at children with coughs/colds (e.g. Tixylix, Medised etc)
This affected medicines containing a wide range of ingredients:

 cough suppressants: dextromethorphan and pholcodine
 expectorants: guaifenesin and ipecacuanha
 nasal decongestants: ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and xylometazoline
 antihistamines: brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine and
triprolidine
Products with these ingredients should therefore be avoided in children under the age of 6 years. Products
aimed at children aged 6-12 years which contain these ingredients will only be available after discussion with
a pharmacist, i.e. Not on the shelves.
Q-57
A 26-year-old woman with a history of hypothyroidism and antiphospholipid syndrome becomes
pregnant. Which one of the following is contraindicated in pregnancy?
A. Aspirin
B. Low-molecular weight heparin
C. Warfarin
D. Levothyroxine
E. Unfractionated heparin
ANSWER:
C. Warfarin
EXPLANATION:
Warfarin is contraindicated in pregnancy. Most women are switched to low-molecular weight heparin for
the duration of the pregnancy.

Q-58
A 67-year-old woman presents to her GP with symptoms of dysuria and increased urinary frequency. She
is otherwise systemically well with no signs of sepsis. Urine dip in the GP surgery shows blood, leukocytes,
protein and nitrites. The patients medical history is significant only for asthma for which she takes
salbutamol and beclomethasone inhalers, hypertension for which she takes amlodipine 10mg daily and
ramipril 5mg daily, and chronic kidney disease, stage 3.
Which of the following antibiotics is best avoided in the treatment of this patients urine infection?
A. Amoxicillin
B. Augmentin (amoxicillin and clavulinic acid)
C. Ciprofloxacin
D. Nitrofurantoin
E. Trimethoprim
ANSWER:
D. Nitrofurantoin
EXPLANATION:
Nitrofurantoin is best avoided in patients with CKD stage 3 or higher due to the significant risk of
treatment failure and occurrence of side effects due to drug accumulation
This question is about antibiotic prescribing in chronic kidney disease (CKD). Many drugs need dose
adjustment in renal disease due to changes in drug metabolism and also pharmacokinetics. Often this
dose adjustment is made on the level of the estimated glomerular filtration rate (eGFR) which is a
calculated surrogate of renal function using the serum creatinine. Stages of chronic kidney disease are
classified according to the eGFR; stage 3 CKD equates to an eGFR of 30-59ml/min.
Nitrofurantoin is a relatively old and unique antibiotic which has enjoyed a new lease of life with
increasing antibiotic resistance. It is actually an inactive pro-drug which is reduced in vivo to active forms
by the bacterial flavoprotein nitrofuran reductase, and it is these reduced forms of the drug which exert
their antibiotic properties by damaging bacterial proteins. In order to be effective at treating urinary tract
infections, nitrofurantoin needs to be concentrated in the urine and an adequate glomerular filtration is
required for this to occur. An eGFR of less than 40-60ml/min means that the drug is wholly ineffective as a
bactericidal agent and is not recommended in patients with CKD stage 3 or worse due to the likelihood of
treatment failure. Coupled with this is the risk of drug toxicity in the patient. Without adequate renal
filtration, the drug is likely to accumulate. Although bacterial flavoproteins activate nitrofurantoin more
readily, human enzymes can reduce this drug to generate many highly active radical species, which can
cause side effects including peripheral neuropathy, which may not be reversible, hepatotoxicity and acute
and chronic pulmonary reactions and fibrosis.
Patients taking nitrofurantoin should be advised that this drug will discolour the urine. It is also a safe
drug to use in pregnancy except at full term when there is a risk of haemolysis in the neonate.
Amoxicillin and co-amoxiclav are widely used antibiotics in the treatment of urinary tract infections and
are relatively safe in renal impairment. Dose reduction is recommended in severe chronic renal disease, i.e.
an eGFR <15-30ml/min to avoid the risk of crystalluria. Similarly, a reduction in dose is necessary for
ciprofloxacin in CKD to avoid crystalluria although this is recommended from an eGFR of 30-60ml/min.
Trimethoprim is an antibiotic which is entirely safe to use in all but the most severe forms of chronic kidney
disease where a modest dose adjustment is required. It should be noted however that use of trimethoprim
is likely to affect the results of renal function tests since the drug inhibits tubular secretion of creatinine
leading to a rise in serum levels in all patients, including those with previously normal renal function. This
is without any effect on the glomerular filtration rate.
Please see Q-46 for Prescribing in Patients with Renal Failure

Q-59
You see a 43-year-old lady who has experienced premature menopause. Her mother also had a premature
menopause and went on to suffer osteoporosis in later life. She asks what she can do to help decrease her
risk of developing osteoporosis. What treatment is recommended first-line by NICE in this situation?
A. Lifestyle advice only eg. exercise, stop smoking

B. Alendronate
C. Hormone replacement therapy
D. Strontium ranelate
E. Raloxifene
ANSWER:
C. Hormone replacement therapy
EXPLANATION:
NICE recommends that women who go through the menopause prior to the age of 45 should consider
taking hormone replacement therapy, to reduce the risk of developing osteoporosis and also to manage
menopausal symptoms. It should be reviewed at age 50. The patient should also be offered lifestyle advice
for bone health i.e. take weight-bearing exercise, stop smoking, not consume excess alcohol, and ensure
adequate intake of calcium and vitamin D.
Source: NICE CKS

http://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenario:1
HORMONE REPLACEMENT THERAPY: INDICATIONS

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with a
progestogen (in women with a uterus), to help alleviate menopausal symptoms.
The indications for HRT have changed significantly over the past ten years as the long-term risks became
apparent, primarily as a result of the Women's Health Initiative (WHI) study.
Indications
 vasomotor symptoms such as flushing, insomnia and headaches
 premature menopause: should be continued until the age of 50 years. Most important reason is
preventing the development of osteoporosis
The main indication is the control of vasomotor symptoms. The other indications such as reversal of vaginal
atrophy should be treated with other agents as first-line therapies
Other benefits include a reduced incidence of colorectal cancer
Q-60
Which one of the following statements regarding calcium channel blockers is correct?
A. Diltiazem is the most negatively inotropic calcium channel blocker

B. Amlodipine should not be prescribed to patients who are already taking a beta-blocker
C. Verapamil should not be used in the management of hypertension
D. Nifedipine can be used for rate-control in atrial fibrillation
E. Short-acting formulations of nifedipine should not be used for angina or hypertension
ANSWER:
E. Short-acting formulations of nifedipine should not be used for angina or hypertension
EXPLANATION:
The BNF warns that short-acting formulations of nifedipine are associated with large variations in blood
pressure and may cause reflex tachycardia
CALCIUM CHANNEL BLOCKERS

Calcium channel blockers are primarily used in the management of cardiovascular disease. Voltage-gated
calcium channels are present in myocardial cells, cells of the conduction system and those of the vascular
smooth muscle. The various types of calcium channel blockers have varying effects on these three areas and
it is therefore important to differentiate their uses and actions.
Examples Indications & notes Side-effects and cautions

Verapamil Angina, hypertension, Heart
arrhythmias failure, constipation, hypotension, bradycardia, flushing
Examples Indications & notes Side-effects and cautions
Highly negatively
inotropic
Should not be given

with beta-blockers as
may cause heart block
Diltiazem Angina, hypertension Hypotension, bradycardia, heart failure, ankle swelling
Less negatively inotropic

than verapamil
but caution should still
be exercised when
patients have heart
failure or are taking
beta-blockers
Nifedipine, Hypertension, angina, Flushing, headache, ankle swelling
amlodipine, Raynaud's
felodipine
(dihydropyridines) Affects the peripheral
vascular smooth muscle
more than the
myocardium and
therefore do not result
in worsening of heart
failure
Flow chart showing the management of hypertension as per current NICE guideliness
Q-61
During your morning surgery, you experience some technical problems with online prescribing and are
forced to write a written prescription for a child who presents with suspected bacterial tonsillitis.
For which patient group is it a legal requirement that their age is specified on a prescription?
A. Anyone under the age of 6

B. Anyone under the age of 12
C. Anyone under the age of 16
D. Anyone under the age of 18
E. Anyone under the age of 21
ANSWER:
B. Anyone under the age of 12
EXPLANATION:
It is a legal requirement for children under the age of 12 that their age is specified on the prescription
Whilst it is good practice to write any patient's age on their prescription, it is only a legal requirement that
all children under 12 must have their age written on the prescription.
Unless the age is specified, the BNF uses 'child' in reference to all people under 12 years of age. A person
between the ages of 12-18 are regarded as an 'adolescent'.
Q-62-64
Theme: Side-effects of common antibiotics
A. Suppression of haemopoiesis
B. Headaches
C. Photosensitivity
D. Reaction following alcohol ingestion
E. Rash with infectious mononucleosis
F. Flushing
G. Cholestasis
I. Tendonitis
Select the side-effect most characteristically associated with the following antibiotics:
Q-62
Amoxicillin
ANSWER:
E. Rash with infectious mononucleosis85%
Q-63
Metronidazole
ANSWER:
D. Reaction following alcohol ingestion85%
Q-64
Doxycycline
ANSWER:
C. Photosensitivity
Please see Q-34 for Side Effects of Common Drugs: Antibiotics
Q-65
A 21-year-old student is brought to the surgery by his friends due to him being confused. They report he
has been complaining of headaches for the past few weeks. He has a low-grade pyrexia and on
examination is noted to have abnormally pink mucosa. What is the most likely diagnosis?
A. Carbon monoxide poisoning

B. Meningitis
C. Paracetamol overdose
D. Subarachnoid haemorrhage
E. Methaemoglobinaemia
ANSWER:
A. Carbon monoxide poisoning
EXPLANATION:
Confusion and pink mucosae are typical features of carbon monoxide poisoning. A low-grade pyrexia is
seen in a minority of cases.
CARBON MONOXIDE POISONING

Carbon monoxide has a high affinity for haemoglobin and myoglobin resulting in a left-shift of the oxygen
dissociation curve and tissue hypoxia. There are approximately 50 per year deaths from accidental carbon
monoxide poisoning in the UK.
Pathophysiology
 in carbon monoxide poisoning the oxygen saturation of haemoglobin decreases leading to an early
plateau in the oxygen dissociation curve
Questions may hint at badly maintained housing e.g. student houses.
Features of carbon monoxide toxicity

 headache: 90% of cases
 nausea and vomiting: 50%
 vertigo: 50%
 confusion: 30%
 subjective weakness: 20%
 severe toxicity: 'pink' skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma,
death
Investigations
 pulse oximetry may be falsely high due to similarities between oxyhaemoglobin and
carboxyhaemoglobin
 therefore a venous or arterial blood gas should be taken
 typical carboxyhaemoglobin levels
o < 3% non-smokers
o < 10% smokers
o 10 - 30% symptomatic: headache, vomiting
o > 30% severe toxicity
 an ECG is a useful supplementary investgation to look for cardiac ischaemia
Management
 patients with suspected carbon monoxide poisoning should be assessed in the emergency department
 100% high-flow oxygen via a non-rebreather mask
o from a physiological perspective, this decreases the half-life of carboxyhemoglobin (COHb)
o should be administered as soon as possible, with treatment continuing for a minimum of six hours
o target oxygen saturations are 100%
o treatment is generally continued until all symptoms have resolved, rather than monitoring CO levels
 hyperbaric oxygen
o due to the small number of cases the evidence base is limited, but there is some evidence that long-
term outcomes may be better than standard oxygen therapy for more severe cases
o therefore, discussion with a specialist should be considered for more severe cases (e.g. levels > 25%)
o in 2008, the Department of Health publication 'Recognising Carbon Monoxide Poisoning' also listed
loss of consciousness at any point, neurological signs other than headache, myocardial ischaemia or
arrhythmia and pregnancy as indications for hyperbaric oxygen
Q-66
You are reviewing the latest blood results for a patient who has type 2 diabetes mellitus. His current
medication includes simvastatin 20mg on, metformin 1g bd and gliclazide 80mg bd. His latest renal
function results are shown below:
Na+ 141 mmol/l

K+ 3.9 mmol/l
Urea 5.2 mmol/l
Creatinine 115 µmol/l
At what creatinine threshold would NICE recommend that you should consider changing the dose of
metformin?
A. > 110 µmol/l

B. > 130 µmol/l
C. > 150 µmol/l
D. > 175 µmol/l
E. > 200 µmol/l
ANSWER:
B. > 130 µmol/l
EXPLANATION:
NICE recommend that the dose of metformin should be reviewed if the creatinine is > 130 micromol/l (or
eGFR < 45 ml/min) and stopped if the creatinine is > 150 micromol/l (or eGFR < 30 ml/min)

Q-67-69
Theme: Side-effects of diabetes mellitus drugs
A. Hypocalcaemia
B. Diarrhoea
C. Sinusitis
D. Worsening of heart failure
E. Headaches
F. Hypoglycaemia
Select the side-effect most characteristically associated with the following drugs:
Q-67
Metformin
ANSWER:
B. Diarrhoea
Q-68
Pioglitazone
ANSWER:
D. Worsening of heart failure
Q-69
Gliclazide
ANSWER:
F. Hypoglycaemia
Please see Q-19 for Side-Effects of Common Drugs: Diabetes Drugs
Q-70
A 34-year-old female with a history of depression is reviewed. She is currently taking St John's Wort which
she bought from the local health food shop and a combined oral contraceptive pill. What is the most likely
effect of taking both medications concurrently?
A. Worsening of depressive symptoms

B. Increased risk of severe skin reactions
C. Increased risk of serotonin syndrome
D. Increased risk of venous thromboembolism
E. Reduced effectiveness of combined oral contraceptive pill
ANSWER:
E. Reduced effectiveness of combined oral contraceptive pill
EXPLANATION:
Please see Q-53 for St John’s Wort
Q-71
Asha is a 27-year-old homeless woman who uses heroin on a regular basis. She wishes to stop heroin, and
requests her GP prescribes her methadone to control her withdrawal symptoms. What is the best way in
which Asha's GP can screen for opioid misuse?
A. Urine
B. Hair
C. Blood
D. Mouth swab
E. Clinical examination
ANSWER:
A. Urine
EXPLANATION:
Methadone is a long-acting synthetic opioid analgesic. It acts as a full opioid agonist. It is used in the
treatment of opioid dependence as a support agent in detoxification. The peak clinical effect of
methadone is two to six hours post oral dose and the half life of methadone is around 15 hours. It takes
approximately five days for plasma levels of methadone in the body to stabilise (there is a cumulative
effect until steady state is reached), and after that variations in blood level of methadone are small.
Methadone is metabolised through the liver via the P450 enzymes.
Due to the cumulative effect methadone should be prescribed starting at a low dose and titrating
upwards. Methadone is typically taken once daily. The standard concentration is 1mg/ml oral solution.
The starting dose of methadone should be between 10 mg and 30 mg daily, depending on the amount of
heroin, the length and method of use or other opioids being used.
Before starting methadone the GP must confirm opioid misuse. Urine is the easiest and most effective way
to detect opioid use. Heroin, codeine, dihydrocodeine and morphine can be detected in the urine up to 48
hours after use and methadone can be detected up to a week after use. Urine testing is also often used
during methadone treatment to confirm compliance with therapy and to detect continuing heroin misuse.
Mouth swabs have a shorter detection window than urine. Hair testing provides an average of opioid use
over each month and hence is less specific than urine tests. Hair testing is also expensive. Blood test are
invasive and not used to detect opioid use, and clinical examination (looking for things like pinpoint pupils)
is often non-reliable.
Q-72
A 19-year-old female is brought to the Emergency Department by her friends following a night out. Her
friends state she has taken an unknown drug whilst out clubbing. Which one of the following features
would most point towards the use of ecstasy?
A. Temperature of 39.5ºC
B. Respiratory depression
C. Hypernatraemia
D. Miosis
E. Urinary incontinence
ANSWER:
A. Temperature of 39.5ºC
EXPLANATION:
ECSTASY POISONING
Ecstasy (MDMA, 3,4-Methylenedioxymethamphetamine) use became popular in the 1990's during the
emergence of dance music culture
Clinical features
 neurological: agitation, anxiety, confusion, ataxia
 cardiovascular: tachycardia, hypertension
 hyponatraemia
 hyperthermia
 rhabdomyolysis
Management
 supportive
 dantrolene may be used for hyperthermia if simple measures fail
Q-73
A 62-year-old man presents to his GP for routine post-surgical blood tests.
He underwent an elective hip replacement 2 weeks previously and has been self-administering
subcutaneous venous thromboembolism (VTE) prophylaxis. He feels very well.
His other past medical history includes polymyalgia rheumatica and hypertension. His normal drugs have
been restarted after his hospital admission; these include co-codamol, prednisolone, and ramipril.
Blood tests show the following:
Hb 118 g/L Male: (135-180) Female: (115 - 160)

Platelets 36 * 109/L (150 - 400)
WBC 5.2 * 109/L (4.0 - 11.0)
What is the most likely cause of his thrombocytopaenia?
A. Haemolysis across the prosthesis

B. Enoxaparin
C. Prednisolone
D. Ramipril
E. Co-codamol
ANSWER:
B. Enoxaparin
EXPLANATION:
Heparin can cause drug induced thrombocytopaenia
Enoxaparin, a type of low molecular weight heparin, can cause thrombocytopaenia.
Prosthetic joints are not likely to cause thrombocytopaenia.
The other drugs listed are not common causes of thrombocytopaenia.
If heparin-induced thrombocytopenia is strongly suspected or confirmed, the heparin should be stopped

and an alternative anticoagulant, such as danaparoid, should be given. Ensure platelet counts return to
normal range in those who require warfarin.
DRUG-INDUCED THROMBOCYTOPENIA
Drug-induced thrombocytopenia (probable immune-mediated)
 quinine
 abciximab
 NSAIDs
 diuretics: furosemide
 antibiotics: penicillins, sulphonamides, rifampicin
 anticonvulsants: carbamazepine, valproate
 heparin
Q-74
A 59-year-old man with a known history of type 2 diabetes mellitus, atrial fibrillation and epilepsy
presents as he is feeling generally unwell. His main complaint is a blue tinge to his vision. Which one of his
medications is most likely to be responsible?
A. Phenytoin
B. Metformin
C. Sildenafil
D. Pioglitazone
E. Digoxin
ANSWER:
C. Sildenafil
EXPLANATION:
Visual changes secondary to drugs
 blue vision: Viagra ('the blue pill')
 yellow-green vision: digoxin

Q-75
name?
A. Amiodarone
B. Modified release beta-blockers
C. Long-acting beta 2 agonists
D. Modified release calcium channel blockers
E. Atypical antipsychotic agents such as olanzapine
ANSWER:
D. Modified release calcium channel blockers
EXPLANATION:
Q-76
Which one of the following statements regarding metformin is false?
A. Does not cause hypoglycaemia

B. Increases insulin sensitivity
C. Decreases hepatic gluconeogenesis
D. Increases endogenous insulin secretion
E. Reduces GI absorption of carbohydrates
ANSWER:
D. Increases endogenous insulin secretion
EXPLANATION:
Sulphonylureas have the property of increasing endogenous insulin secretion
Q-77
You receive a request from one of the local Paediatric consultants to prescribe trimethoprim as
prophylaxis against urinary tract infection (UTI). Two months ago you referred a 2-year-old girl who had
repeated UTIs. She currently weighs 15kg. The recommended trimethoprim dose for UTI prophylaxis is
2mg/kg at night. Trimethoprim suspension is available in a concentration of 50mg/5ml. What volume of
trimethoprim should be given at night?
_______ ml
ANSWER:
3
EXPLANATION:
The recommended dose for this child = 2mg/kg * 15kg = 30mg
The correct volume is therefore 30 / 50 = 0.6 * 5 = 3ml
The October 2011 AKT feedback stated: 'We regularly test candidates' ability to calculate drug doses, for
example where the drugs need to be given in mg/kg. A worrying number of candidates were apparently
unable to correctly perform a relatively simple calculation regarding a drug dose for a child, and this poses
concerns about patient safety. '
Q-78
Mr Phalen is a 48-year-old civil engineer who was recently diagnosed with type 2 diabetes at his NHS over-
40 health check. Your colleague started him on metformin two weeks ago, but he has asked for a
telephone consultation as he is still experiencing nausea with it. He says he has tried to persevere but now
he has had enough and wants to stop it. His HbA1c at diagnosis was 52mmol/l. His body mass index is
31kg/m². His renal function is normal.
What is the most appropriate medication option to try next?
A. Sulphonylurea
B. Pioglitazone
C. Sitagliptin
D. Modified-release metformin
E. Orlistat
ANSWER:
D. Modified-release metformin
EXPLANATION:
If metformin is not tolerated due to GI side-effects, try a modified-release formulation before switching to
a second-line agent
Sulphonylurea - this could be considered as a second-line agent if metformin is not tolerated, but NICE
advises consider a trial of modified-release metformin first.
Pioglitazone - this could be considered as a second-line agent if metformin is not tolerated, but NICE
advises consider a trial of modified-release metformin first.
Sitagliptin - this could be considered as a second-line agent if metformin is not tolerated, but NICE advises
consider a trial of modified-release metformin first.
Orlistat - this is a medication to aid weight loss; it may be helpful in reducing insulin resistance by reducing
weight, but is not the recommended course of action.
Q-79
An elderly man with a history atrial fibrillation is prescribed aspirin 75mg od and digoxin 125mcg od. You
have been asked to change the digoxin tablet to digoxin elixir. The patient weighs 75kg. Digoxin elixir is
available at a concentration of 50mcg/ml in 60ml bottles. What volume of digoxin elixir should he be
given for each dose?
_____ ml
ANSWER:
2.5
EXPLANATION:
The correct volume is 125mcg / 50mcg/ml = 2.5ml
Q-80
A 35-year-old man with a known history of peanut allergy presents to the surgery with a swollen face. On
examination blood pressure is 85/60 mmHg, pulse 120 bpm and there is a bilateral expiratory wheeze.
What is the most appropriate form of adrenaline to give?
A. 10ml 1:10,000 IV
B. 0.5ml 1:1,000 IM
C. 0.5ml 1:10,000 IM
D. 5ml 1:1,000 IM
E. Nebulised adrenaline
ANSWER:
B. 0.5ml 1:1,000 IM
EXPLANATION:
Recommend Adult Life Support (ALS) adrenaline doses
 anaphylaxis: 0.5ml 1:1,000 IM
 cardiac arrest: 10ml 1:10,000 IV or 1ml of 1:1000 IV
ADRENALINE
Adrenaline is a sympathomimetic amine with both alpha and beta adrenergic stimulating properties
Indications
 anaphylaxis
 cardiac arrest

 anaphylaxis: 0.5ml 1:1,000 IM
 cardiac arrest: 10ml 1:10,000 IV or 1ml of 1:1000 IV
Management of accidental injection

 local infiltration of phentolamine
Background
 responsible for the fight or flight response
 released by the adrenal glands
 acts on α 1 and 2, β 1 and 2 receptors
 acts on β 2 receptors in skeletal muscle vessels-causing vasodilation
 increases cardiac output and total peripheral resistance
 causes vasoconstriction in the skin and kidneys causing a narrow pulse pressure
Actions on α adrenergic receptors:

 inhibits insulin secretion by the pancreas
 stimulates glycogenolysis in the liver and muscle
 stimulates glycolysis in muscle
Actions onβ adrenergic receptors:

 stimulates glucagon secretion in the pancreas
 stimulates ACTH
 stimulates lipolysis by adipose tissue
Q-81
Caution should always be exercised when combining diuretics. However, which one of the following
combinations is always contraindicated?
A. Metolazone + bumetanide
B. Bendroflumethiazide + furosemide
C. Amiloride + spironolactone
D. Bendroflumethiazide + triamterene
E. Spironolactone + furosemide
ANSWER:
C. Amiloride + spironolactone
EXPLANATION:
Amiloride and spironolactone are both potassium-sparing diuretics. Combining the two may result in life-
threatening hyperkalaemia.
POTASSIUM-SPARING DIURETICS
Potassium-sparing diuretics may be divided into the epithelial sodium channel blockers (amiloride and
triamterene) and aldosterone antagonists (spironolactone and eplerenone).
Amiloride is a weak diuretic which blocks the epithelial sodium channel in the distal convoluted tubule.
Usually given with thiazides or loop diuretics as an alternative to potassium supplementation.
Spironolactone is an aldosterone antagonist which acts act in the distal convoluted tubule.
Indications
 ascites: patients with cirrhosis develop a secondary hyperaldosteronism. Relatively large doses such as
100 or 200mg are often used
 heart failure
 nephrotic syndrome
 Conn's syndrome
Q-82
A heroin user is referred to the local drugs unit for community based detoxification. Which heroin
substitutes is he most likely to be offered?
A. Methadone or morphine
B. Lofexidine or naloxone
C. Methadone or buprenorphine
D. Methadone or naloxone
E. Methadone or lofexidine
ANSWER:
C. Methadone or buprenorphine
EXPLANATION:
Q-83
A 14-year-old girl is taken to the Emergency Department, after being found lying on her bed next to an
empty bottle of pills prescribed for her mother. On examination she is agitated, has a clenched jaw and
her eyes are deviated upwards. Which drug is she most likely to have consumed?
A. Phenytoin
B. Metoclopramide
C. Amitriptyline
D. Carbamazepine
E. Nifedipine
ANSWER:
B. Metoclopramide
EXPLANATION:
This is a classic description of an oculogyric crisis, a form of extrapyramidal disorder
OCULOGYRIC CRISIS
An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions
Features
 restlessness, agitation
 involuntary upward deviation of the eyes
Causes
 antipsychotics
 metoclopramide
 postencephalitic Parkinson's disease
Management
 intravenous antimuscarinic: benztropine or procyclidine
Q-84
A 50-year-old man with Tourette's and poorly controlled type 2 diabetes comes in to see you. This patient
drinks 21 units of alcohol per week and smokes 20 cigarettes a day. He is concerned as he has been
experiencing intermittent episodes of chest pain on exertion and requests an angiogram as his father died
of a myocardial infarction aged 56 years. You refer the patient for suspected angina, give him advice about
what to do if he develops chest pain and prescribe a glyceryl trinitrate (GTN) spray for use as required.
When you are prescribing this you notice a medication on this patient's prescription list and advise him
that he should not be taking this medication while being investigated for chest pain or if he is using his
GTN spray. What medication does this relate to?
A. Metformin
B. Sildenafil
C. Sitagliptin
D. Gliclazide
E. Atorvastatin
ANSWER:
B. Sildenafil
EXPLANATION:
The answer here is sildenafil. Concomitant use of both a nitrate and phosphodiesterase inhibitor may have
lead to significant hypotension and the potential to precipitate myocardial infarction. There are no noted
interactions in the BNF between nitrates and metformin, gliclazide, sitagliptin or atorvastatin.
(AKT feedback report October 2016) Source NICE CKS Angina, BNF
Q-85
A 57-year-old gentleman with a background of atrial fibrillation and hypertension, was recently diagnosed
with type 2 diabetes. After initial management with dietary changes alone, his HbA1c deteriorated. He
was thus commenced on metformin.
Which one of the following blood tests are now important to monitor on an annual basis?
A. Liver function tests (LFT)

B. Full blood count (FBC)
C. Urea and electrolytes (U&E)
D. Creatine kinase (CK)
E. Glucose
ANSWER:
C. Urea and electrolytes (U&E)
EXPLANATION:
Monitor renal function annually in patients on metformin
Renal function must be checked before starting metformin, and then monitored regularly once it has been
prescribed.
It should be monitored at least once per year in patients with a normal renal function, and at least twice
per year in those with additional risk factors for renal impairment.
 if eGFR is below 30, then metformin should not be started

 if eGFR drops below 45, the metformin dose should be reviewed
Q-86
Which of the following drugs is most likely to cause impaired glucose tolerance?
A. Bendroflumethiazide
B. Perindopril
C. Salicylates
D. Co-amoxiclav
E. Beta-blockers
ANSWER:
EXPLANATION:
Thiazides are a cause of impaired glucose tolerance
Bendroflumethiazide is more likely than beta-blockers to cause impaired glucose tolerance.
DRUG-INDUCED IMPAIRED GLUCOSE TOLERANCE

Drugs which are known to cause impaired glucose tolerance include:
 thiazides, furosemide (less common)
 steroids
 tacrolimus, ciclosporin
 interferon-alpha
 nicotinic acid
 antipsychotics
Beta-blockers cause a slight impairment of glucose tolerance. They should also be used with caution in
diabetics as they can interfere with the metabolic and autonomic responses to hypoglycaemia
Q-87
Which one of the following statements regarding the reporting of medication related adverse events using
the Yellow Card scheme is correct?
A. A persistent cough secondary to ramipril should be reported
B. A patient who dies of a myocardial infarction four years after starting a statin should be reported
C. Diarrhoea occurring after starting a black triangle medicine should be reported
D. There is no need to report a rash secondary to lymecycline in a 14-year-old girl
E. An allergic rash that develops in an elderly man secondary to co-amoxiclav should be reported
ANSWER:
C. Diarrhoea occurring after starting a black triangle medicine should be reported
EXPLANATION:
Please see Q-41 for Yellow Card Scheme
Q-88
A 62-year-old woman with a history of recurrent deep vein thrombosis secondary to antiphospholipid
syndrome presents for review. She has taken warfarin for the past 7 years, with a target INR of 2.0 - 3.0.
Her control is normally very good but her last reading was 1.2. Which one of the following would explain
her current INR?
A. Starting fluoxetine for depression

B. The formation of lupus anticoagulant autoantibodies
C. Giving up smoking
D. Recent rifampicin as she was a contact of a patient with meningococcal meningitis
E. A course of ciprofloxacin for a urinary tract infection
ANSWER:
D. Recent rifampicin as she was a contact of a patient with meningococcal meningitis
EXPLANATION:
Rifampicin is a P450 enzyme inductor
Q-89
A 44-year-old Bangladeshi man with a history of mitral stenosis and atrial fibrillation is diagnosed with
tuberculosis. He is commenced on anti-tuberculosis therapy. Three weeks after starting treatment his INR
has increased to 5.6. Which one of the following medications is most likely to be responsible for this
increase?
A. Pyrazinamide
B. Isoniazid
C. Rifampicin
D. Ethambutol
E. Streptomycin
ANSWER:
B. Isoniazid
EXPLANATION:
Isoniazid inhibits the P450 system
It is important when answering questions relating to liver enzymes to be sure whether the question is
asking about induction or inhibition. Drugs causing induction are often well known and candidates may
rush to give these as the answer. A raised INR is a result of inhibited liver enzymes
Q-90
You receive a clinic letter from a paediatric rheumatologist requesting that you prescribe ibuprofen. The
patient is a 9-year-old girl who has juvenile idiopathic arthritis. The consultant wants you to prescribe
ibuprofen 30mg/kg daily in 3 divided doses. The girl prefers to take liquid medication so you prescribe
ibuprofen suspension 100mg/5ml. She currently weighs 30kg. What volume of ibuprofen suspension
should she take per dose?
_______ ml
ANSWER:
15
EXPLANATION:
The recommended daily dose of ibuprofen is 30mg/kg * 30kg = 900mg
This is divided into 3 doses per day: 900 / 3 = 300mg
The correct volume is therefore 300 / 100 = 3 * 5 = 15ml
Q-91
Which one of the following is least associated with cocaine toxicity?
A. Metabolic alkalosis
B. Hyperthermia
C. Psychosis
D. Rhabdomyolysis
E. Seizures
ANSWER:
A. Metabolic alkalosis
EXPLANATION:
COCAINE
Cocaine is an alkaloid derived from the coca plant. It is widely used as a recreational stimulant. The price of
cocaine has fallen sharply in the past decade resulting in cocaine toxicity becoming a much more frequent
clinical problem. This increase has made cocaine a favourite topic of question writers.
Mechanism of action
 cocaine blocks the uptake of dopamine, noradrenaline and serotonin
The use of cocaine is associated with a wide variety of adverse effects:
Cardiovascular effects
 myocardial infarction
 both tachycardia and bradycardia may occur
 hypertension
 QRS widening and QT prolongation
 aortic dissection
Neurological effects
 seizures
 mydriasis
 hypertonia
 hyperreflexia
Psychiatric effects
 agitation
 psychosis
 hallucinations
Others
 ischaemic colitis is recognised in patients following cocaine ingestion. This should be considered if
patients complain of abdominal pain or rectal bleeding
 hyperthermia
 metabolic acidosis
 rhabdomyolysis
Management of cocaine toxicity

 in general, benzodiazepines are generally first-line for most cocaine-related problems
 chest pain: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary
percutaneous coronary intervention
 hypertension: benzodiazepines + sodium nitroprusside
 the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue. The
American Heart Association issued a statement in 2008 warning against the use of beta-blockers (due to
the risk of unopposed alpha-mediated coronary vasospasm) but many cardiologists since have
questioned whether this is valid. If a reasonable alternative is given in an exam it is probably wise to
choose it
Q-92
A 60-year-old Indian man with newly diagnosed atrial fibrillation is commenced on warfarin. He presents
to the GP surgery 5 days later with spontaneous bruising. His INR is checked and it is 4.5. Of note, he has a
past history of epilepsy, depression, homelessness and substance misuse. Out of the list below, which
drug is most likely to have caused the bruising?
A. Rifampicin
B. St John's Wort
C. Heroin
D. Sodium valproate
E. Lamotrigine
ANSWER:
D. Sodium valproate
EXPLANATION:
Sodium valproate is an enzyme INhibitor so can INcrease warfarin levels if used concurrently
Given the patient's past medical history, he could be taking any of the above drugs however the question
is testing whether you know which drug is an enzyme inhibitor.
 Rifampicin is an enzyme inducer.

 St John's Wort is an enzyme inducer.
 Heroin (diamorphine) is neither an enzyme inducer nor an inhibitor.
 Lamotrigine is neither an enzyme inducer nor an inhibitor
Q-93
You are working in general practice. Your next patient is a 72-year-old gentleman who has attended for
review of his recent blood results. You had previously been concerned regarding a raised plasma glucose
measurement, so you provided him with lifestyle advice and advised further blood tests in 8 weeks time.
He reports making some changes to his diet, and choosing to walk to the local shops rather than driving.
His past medical history includes coeliac disease, chronic kidney disease and osteoarthritis.
His blood results are as follows (fasting sample):
Hb 146 g/L Male: (135-180) Female: (115 - 160)

Platelets 235 * 109/L (150 - 400)
WBC 7.0 * 109/L (4.0 - 11.0)
Na+ 139 mmol/L (135 - 145)
K+ 4.4 mmol/L (3.5 - 5.0)
Urea 10.4 mmol/L (2.0 - 7.0)
Creatinine 216 µmol/L (55 - 120)
eGFR 28 ml/minute
CRP <5 mg/L (< 5)
Plasma glucose 7.3 mol/L (<6 mmol/L)
HbA1c 54 mmol/mol
What is the most appropriate intervention in view of this man's HbA1c?

A. No intervention required
B. Lifestyle advice
C. DESMOND training
D. Metformin
E. Sitagliptin
ANSWER:
E. Sitagliptin
EXPLANATION:
For type 2 diabetics requiring treatment, metformin is contraindicated in those with eGFR < 30
This gentleman's blood results indicates that he has type 2 diabetes mellitus - his blood glucose
measurements have been raised on two separate occasions, and his HbA1c measurement is >48
mmol/mol, despite already being given lifestyle advice. He therefore requires treatment with medication.
In this patient, the most appropriate treatment option is sitagliptin, an example of a dipeptidyl peptidase
4 (DPP-4) inhibitor. This is due to his eGFR being <30ml/minute, meaning that metformin is
contraindicated.
In this case, the patient has already been provided with lifestyle advice, which he seems to have taken on
board. His HbA1c has remained raised, which indicates he requires treatment with medication.
DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) is an NHS course
designed to educate those with type 2 diabetes and their families, which helps patients to identify their
own health risks and to set their own goals. Whilst this may be useful in the ongoing management of his
type 2 diabetes, it does not outweigh the need for medication in this case.
Q-94
A 46 year old patient is on quadruple therapy (rifampicin, isoniazid, ethambutol and pyrizinamide) for a
confirmed diagnosis of pulmonary tuberculosis. He also has a history of depression for which he takes
sertaline. He later presents complaining that his vision has deteriorated, more specifically colours appear
less vivid. Which medicationis most likely to be responsible?
A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyrizinamide
E. Sertaline
ANSWER:
C. Ethambutol
EXPLANATION:
Ethambutol is associated with optic neuropathy and development of colour blindness. It should be
discontinued if these symptoms develop. In clinical practice pyridoxine (vitamin B6) is given concurrently
with ethambutol to try to prevent these side effects.
Please see Q-20 for Tuberculosis: Drug Side Effects and Mechanism of Action
Q-95
A 2-year-old girl is brought for review due to a barking cough which is worse at night. A diagnosis of croup
is suspected. The girl weighs 10kg.
The recommended dose of dexamethasone for croup is 150mcg/kg.
What is the correct volume of dexamethasone 2mg/5ml solution to give as a stat dose?
_______ ml
ANSWER:
3.75
EXPLANATION:
The recommended dose for this child = 150mcg/kg * 10kg = 1,500mcg or 1.5mg
The correct volume is therefore ( 1.5 / 2 ) * 5 = 3.75 ml
The October 2011 AKT feedback stated: 'We regularly test candidates' ability to calculate drug doses, for
example where the drugs need to be given in mg/kg. A worrying number of candidates were apparently
unable to correctly perform a relatively simple calculation regarding a drug dose for a child, and this poses
concerns about patient safety. '
Q-96
A 54-year-old woman with a long history of rheumatoid arthritis is reviewed in clinic complaining of
shortness of breath. Oxygen saturations are 92% on room air with spirometry showing a restrictive
pattern associated with a reduced transfer factor. Which one of the following drugs is most likely to be
responsible?
A. Depomederone
B. Hydroxychloroquine
C. Methotrexate
D. Ciclosporin
E. Celecoxib
ANSWER:
C. Methotrexate
EXPLANATION:
Methotrexate may cause lung fibrosis
This has patient has pulmonary fibrosis which may be caused by methotrexate. Other anti-rheumatoid
drugs such as sulfasalazine and gold may also cause pulmonary fibrosis
DRUGS CAUSING LUNG FIBROSIS
Causes
 amiodarone
 cytotoxic agents: busulphan, bleomycin
 anti-rheumatoid drugs: methotrexate, sulfasalazine
 nitrofurantoin
 ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide)
Q-97
A 64-year-old man is diagnosed as being hypertensive. He is known to suffer from chronic heart failure
secondary to alcoholic cardiomyopathy (NYHA class I). Which one of the following medications is
contraindicated?
A. Lisinopril
B. Indapamide
C. Verapamil
D. Bisoprolol
E. Doxazosin
ANSWER:
C. Verapamil
EXPLANATION:
Please see Q-13 for Prescribing in Patients with Heart Failure
Q-98
Which one of the following statements regarding digoxin is correct?
A. Toxicity can occur in patients with digoxin levels in the therapeutic range
B. Hyponatraemia predisposes to digoxin toxicity
C. Haemodialysis is the treatment of choice for digoxin toxicity
D. It has a short half-life
E. It has negative inotropic properties
ANSWER:
A. Toxicity can occur in patients with digoxin levels in the therapeutic range
EXPLANATION:
Please see Q-7 for Digoxin and Digoxin Toxicity
Q-99
Which one of the following calcium channel blockers is most likely to precipitate pulmonary oedema in a
patient with known chronic heart failure?
A. Amlodipine
B. Diltiazem
C. Felodipine
D. Verapamil
E. Nifedipine
ANSWER:
D. Verapamil
EXPLANATION:
Verapamil is the most highly negatively inotropic calcium channel blocker
Please see Q-60 for Calcium Channel Blockers
Q-100
You receive a discharge summary for Ms Liu, a 60-year-old lady, who has had an acute surgical admission
with pancreatitis. The summary notes that it was thought to be drug-related. Her past medical history
includes atrial fibrillation and type 2 diabetes. Her regular medications are bisoprolol, apixaban,
metformin, sitagliptin, and atorvastatin. She also takes an over-the-counter vitamin D supplement.
Which of her medications might have caused this presentation and should be reported by Yellow Card?
A. Bisoprolol
B. Apixaban
C. Metformin
D. Sitagliptin
E. Vitamin D
ANSWER:
D. Sitagliptin
EXPLANATION:
A rare, but important, side effect of DPP4-inhibitors is pancreatitis
Bisoprolol, apixaban and vitamin D do not cause pancreatitis.
Metformin does not cause pancreatitis. It can increase the risk of lactic acidosis however and should be
stopped in cases where there is risk of this; this would include serious illness such as pancreatitis.
Sitagliptin is the correct answer; DPP4-inhibitors have been shown to cause acute pancreatitis and should
be stopped if it is suspected and reported by Yellow Card.
Q-101
Which one of the following drugs used in the management of tuberculosis is most associated with
peripheral neuropathy?
A. Rifampicin
B. Pyrazinamide
C. Ethambutol
D. Streptomycin
E. Isoniazid
ANSWER:
E. Isoniazid
EXPLANATION:
Isoniazid causes peripheral neuropathy
Q-102
An 85-year-old gentleman with a past medical history of atrial fibrillation has been commenced on
amiodarone. As his GP, which of the following tests should be performed?
A. CXR every 6 months

B. CXR, TFTS, LFTS every 6 months
C. TFTs, LFTs every 6 months
D. ECG, CXR every 6 months
E. TFTS, LFTS, potassium every 6 months
ANSWER:
C. TFTs, LFTs every 6 months
EXPLANATION:
Amiodarone is a class III antiarrhythmic medication. It can affect many body systems, including the
thyroid, liver and lungs.
Current recommendations include liver and thyroid function tests on a 6 monthly basis. Chest x-rays should
be performed prior to starting amiodarone treatment, however they do not need to be performed
routinely post treatment unless patients develop respiratory signs or symptoms.
AMIODARONE: ADVERSE EFFECTS

Adverse effects of amiodarone use
 thyroid dysfunction: both hypothyroidism and hyper-thyroidism
 corneal deposits
 pulmonary fibrosis/pneumonitis
 liver fibrosis/hepatitis
 peripheral neuropathy, myopathy
 photosensitivity
 'slate-grey' appearance
 thrombophlebitis and injection site reactions
 bradycardia
 lengths QT interval
Important drug interactions of amiodarone include:
 decreased metabolism of warfarin, therefore increased INR
 increased digoxin levels
Q-103
A 24-year-old woman presents following a sudden, acute onset of pain at the back of the ankle whilst
jogging, during which she heard a cracking sound. Which one of the following medications may have
contributed to this injury?
A. Metronidazole
B. Nitrofurantoin
C. Fluconazole
D. Ciprofloxacin
E. Terbinafine
ANSWER:
D. Ciprofloxacin
EXPLANATION:
Ciprofloxacin may lead to tendinopathy
This patient has classical signs of Achilles tendon rupture. Tendon damage is a well documented
complication of quinolone therapy. It appears to be an idiosyncratic reaction, with the actual median
duration of treatment being 8 days before problems occur
QUINOLONES
Quinolones are a group of antibiotics which work by inhibiting DNA synthesis and are bactericidal in nature.
Examples include:
 ciprofloxacin
 levofloxacin
Mechanism of action
 inhibit topoisomerase II (DNA gyrase) and topoisomerase IV
Mechanism of resistance
 mutations to DNA gyrase, efflux pumps which reduce intracellular quinolone concentration
Adverse effects
 lower seizure threshold in patients with epilepsy
 tendon damage (including rupture) - the risk is increased in patients also taking steroids
 cartilage damage has been demonstrated in animal models and for this reason quinolones are generally
avoided (but not necessarily contraindicated) in children
 lengthens QT interval
Contraindications
 Quinolones should generally be avoided in women who are pregnant or breastfeeding
 avoid in G6PD
Q-104
Which one of the following statements regarding metformin is true?
A. Should be stopped in a patient admitted with a myocardial infarction

B. Hypoglycaemia is a recognised adverse effect
C. May cause a metabolic alkalosis
D. May aggravate necrobiosis lipoidica diabeticorum
E. Increases vitamin B12 absorption
ANSWER:
A. Should be stopped in a patient admitted with a myocardial infarction
EXPLANATION:
Metformin should be stopped following a myocardial infarction due to the risk of lactic acidosis. It may be
introduced at a later date. Diabetic control may be achieved through the use of a insulin/dextrose infusion
(e.g. the DIGAMI regime)
Q-105
A 58-year-old man who is taking lithium for bipolar disorder presents for review. During routine
examination he found to be hypertensive with a blood pressure of 166/82 mmHg. This is confirmed with
two separate readings. Urine dipstick is negative and renal function is normal. What is the most
appropriate medication to start?
A. Amlodipine
B. Ramipril
C. Losartan
D. Bendroflumethiazide
E. Doxazosin
ANSWER:
A. Amlodipine
EXPLANATION:
Diuretics, ACE-inhibitors and angiotensin II receptor antagonists may cause lithium toxicity. The BNF
advises that neurotoxicity may be increased when lithium is given with diltiazem or verapamil but there is
no significant interaction with amlodipine. Alpha-blockers are not listed as interacting with lithium but
they would not be first-line treatment for hypertension.
The NICE hypertension guidelines suggest amlodipine wouldn't be a bad first choice, even if we ignore his
lithium treatment.
Please see Q-39 for Lithium Toxicity

Q-106
A 39-year-old heroin user, Jack, comes to the surgery and requests methadone. He has previously used
methadone last year at 30mg once a day. Jack is currently using the same amount of heroin that he used
last year and so wants to restart on the 30mg methadone, as he thinks that dose will help control
withdrawal symptoms from heroin. You've never prescribed methadone before and do not feel confident
in doing so. What is the most appropriate course of action?
A. Prescribe methadone at 30mg once a day and monitor the patient closely
B. Prescribe methadone at 10mg once a day and gradually titrate up to control withdrawal symptoms
C. Ask the patient to provide evidence of heroin use before prescribing methadone
D. Not prescribe methadone
E. Test the patient for opioid use before prescribing methadone
ANSWER:
D. Not prescribe methadone
EXPLANATION:
The initiating prescriber must be experienced and competent because of the dangers associated with
methadone and should not feel coerced to prescribe because of the patient. As you have not prescribed
methadone before and do not feel confident to do so it would be unsafe for you to prescribe this drug.
Before prescribing methadone opioid dependence should first be confirmed by history, examination and
toxicology screening using urine or oral fluid swabs. Prescribing methadone involves the multidisciplinary
team and ideally, the patient's drug team or local drug worker should be contacted as well as the
pharmacist.
Only after these steps should methadone be prescribed, starting at a low dose and titrating upwards.
Methadone is typically taken once daily. The standard concentration is 1mg/ml oral solution; higher
concentrations are available but rarely used. The starting dose of methadone should be between 10 mg
and 30 mg daily, depending on the amount of heroin, the length and method of use or other opioids being
used.
Q-107
Each of the following drugs are known to inhibit cytochrome P450, except:
A. Ketoconazole
B. Ciprofloxacin
C. Erythromycin
D. Clopidogrel
E. Amiodarone
ANSWER:
D. Clopidogrel
EXPLANATION:
Q-108
A 49-year-old female comes to see you as for the last five months she has been having erratic periods,
troublesome hot flushes and emotional lability. She wishes to try hormone replacement therapy (HRT)
and has no contraindications. There is a family history of unprovoked DVT in this patient's mother but she
has never been affected.
What is the most suitable preparation of HRT for this patient?
A. Oral combined continuous HRT

B. Oral oestrogen only HRT
C. Transdermal oestrogen only HRT
D. Transdermal combined sequential preparation
E. Levonorgestrel releasing intrauterine device
ANSWER:
D. Transdermal combined sequential preparation
EXPLANATION:
The answer here is a transdermal, combined sequential preparation of HRT. This patient has erratic
periods; she, therefore, has an intact uterus and will need oestrogen with progesterone to protect the
endometrium. This rules out any form of oestrogen-only HRT.
Using a Mirena coil (levonorgestrel-releasing uterine device) is unlikely to help with the emotional lability
and hot flushes associated with menopause. Using it alone, without an oestrogen component is not an
option for this patient. This patient is aged 49 and still having periods: therefore a sequential preparation
is more suitable rather than continuous, which is used after cessation of menses.
With the family history of unprovoked DVT, a transdermal preparation may be indicated as this method of
absorption reduces significantly the risks of venous thromboembolism associated with HRT.
(AKT feedback report Jan 2017)
Please see Q-59 for Hormone Replacement Therapy: Indications
Q-109
A 59-year-old man with a history of type 2 diabetes mellitus and benign prostatic hypertrophy develops
urinary retention associated with acute renal failure. Which one of the following drugs should be
discontinued?
A. Gliclazide
B. Paroxetine
C. Atenolol
D. Metformin
E. Finasteride
ANSWER:
D. Metformin
EXPLANATION:
As the patient has developed acute renal failure metformin should be stopped due to the risk of lactic
acidosis. In the long term paroxetine may also need to be stopped as SSRIs can contribute to urinary
retention.
Q-110
Which one of the following is least recognised as a side-effect of sildenafil?
A. Blue discolouration of vision

B. Abnormal liver function tests
C. Flushing
D. Nasal congestion
E. Non-arteritic anterior ischaemic optic neuropathy
ANSWER:
B. Abnormal liver function tests
EXPLANATION:
Q-111
What is the most appropriate time to take blood samples for therapeutic monitoring of lithium levels?
A. At any time
B. Immediately before next dose
C. 4 hours after last dose
D. 6 hours after last dose
E. 12 hours after last dose
ANSWER:
E. 12 hours after last dose
EXPLANATION:
THERAPEUTIC DRUG MONITORING

Lithium
 range = 0.4 - 1.0 mmol/l
 take 12 hrs post-dose
Ciclosporin
 trough levels immediately before dose
Digoxin
 at least 6 hrs post-dose
Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should
be checked if:
 adjustment of phenytoin dose
 suspected toxicity
 detection of non-adherence to the prescribed medication
Q-112
A 52-year-old female consults her GP asking about hormone replacement therapy (HRT). What is the most
compelling indication for starting HRT?
A. Prevention of ischaemic heart disease

B. Prevention of osteoporosis
C. Reversal of vaginal atrophy
D. Control of vasomotor symptoms such as flushing
E. Prevention of Alzheimer's disease
ANSWER:
D. Control of vasomotor symptoms such as flushing
EXPLANATION:
Main indication for HRT: control of vasomotor symptoms
Please see Q-59 for Hormone Replacement Therapy: Indications
Q-113
You receive a request to prescribe isotretinoin for a 19-year-old man. Two months ago you referred him to
dermatology as he had scarring acne vulgaris. The medication request asks you to prescribe 500mcg/kg
daily given as one dose. He currently weighs 72kg.
Isotretinoin is available in 5mg and 20mg capsules. What is the most appropriate dose to prescribe?
_____ mg
ANSWER:
35
EXPLANATION:
Some judgement is required here. The dose should be 500mcg/kg = 0.5mg/kg * 72kg = 36mg.
There are however no 1mg tablets available. This figure should therefore be rounded to 35mg.
Q-114
What is the most appropriate dose of adrenaline to give during a cardiac arrest?
A. 1ml 1:100,000 IV
B. 10ml 1:1,000 IV
C. 0.5ml 1:1,000 IM
D. 1ml 1:10,000 IV
E. 10ml 1:10,000 IV
ANSWER:
E. 10ml 1:10,000 IV
EXPLANATION:
 anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
 cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
10ml of the 1:10,000 preparation contains 1mg of adrenaline.
From the BNF:

Adrenaline (epinephrine) 1 in 10 000 (100 micrograms/mL) is recommended in a dose of 1 mg (10 mL) by
intravenous injection repeated every 3-5 minutes if necessary
Please see Q-80 for Adrenaline
Q-115
Which one of the following investigations is essential prior to starting anti-tuberculosis therapy?
A. Liver functions tests

B. Urine for acid-fast bacilli
C. Vitamin B6 level
D. Blood glucose
E. Full blood count
ANSWER:
A. Liver function tests
EXPLANATION:
The British Thoracic Society have published guidelines on the management of tuberculosis. Liver functions
tests should be checked in all cases and monitored throughout treatment. Visual acuity and renal function
should also be checked prior to starting ethambutol
Q-116
You perform a medication review on a 35-year-old female patient. She has been taking methotrexate for
rheumatoid arthritis (RA) for the past 5 years. She takes 7.5mg once a week and folic acid 5mg once a
week. Her RA is very stable at this dose and she has not had a flare for the duration of her treatment.
Which statement below is correct?

A. She requires blood monitoring every 3 months
B. She should be advised to take the folic acid on the same day as the methotrexate
C. RA is not associated with an increased risk of infection
D. Her risk of malignancy is the same as the general population
E. Her risk of cardiovascular disease is the same as the general population
ANSWER:
A. She requires blood monitoring every 3 months
EXPLANATION:
A patient on long-term methotrexate requires maintenance blood monitoring every 3 months
Folic acid is routinely co-prescribed with methotrexate in order to reduce adverse effects and toxicity (folic
acid is usually taken on a 'non-methotrexate' day). Therefore, option 2 is wrong.
Once stable on methotrexate patients require blood tests at least every 12 weeks. Therefore, option 1 is
correct.
RA is associated with an approximate doubling of the risk of infection; chest infection and generalized
sepsis are particular risks. Therefore, option 3 is wrong.
RA itself predisposes to lymphoproliferative diseases (particularly lymphoma). Therefore, option 4 is

incorrect.
People with RA are at increased risk of CVD compared with the general population. Therefore, option 5 is
wrong.
Please see Q-16-18 for Drug Monitoring
Q-117
A 45-year-old lady attends for a routine medication review. She is known to suffer from asthma and
frequent migraines. Which of the following medications should be prescribed by brand name only?
A. Amoxicillin
B. Theophylline
C. Prednisolone
D. Sumatriptan
E. Salbutamol
ANSWER:
B. Theophylline
EXPLANATION:
Theophylline should be prescribed by brand name only. This is because theophylline has a narrow
therapeutic index and the modified-release preparations have different release characteristics. Therefore,
patient's should be prescribed the same brand to ensure their symptoms remain controlled.

Q-118
A 50-year-old female with a background of osteoarthritis and psoriasis, was recently diagnosed with type
2 diabetes. She is know to be averse to taking medications, but after a period of diet control alone, her
HbA1c had increased to 59mmol/mol. Following discussions, she was started on standard-release
metformin at a dose of 500mg twice per day, to be taken with meals.
After two weeks of trying metformin, she complained of intolerable side effects, including nausea and
diarrhoea.
What is the most appropriate next step in management?
A. Stop metformin, and encourage lifestyle measures alone

B. Reduce the dose of metformin to 500mg once per day
C. Continue the current dose of metformin, and prescribe loperamide for her diarrhoea
D. Increase the dose of metformin to 500mg three times per day
E. Switch to a modified release metformin 500mg once per day
ANSWER:
E. Switch to a modified release metformin 500mg once per day
EXPLANATION:
If metformin is not tolerated due to GI side-effects, try a modified-release formulation before switching to
a second-line agent
1) This option is incorrect. The patient's HbA1c had already increased with lifestyle measures alone, and
thus continuing this would be unlikely to prove effective.
2) This option is incorrect. A dose of 500mg OD of metformin is likely to be sub-therapeutic, and side
effects may still continue.
3) This option is incorrect. Adding loperamide may well reduce the patient's diarrhoea, however, this is not
an appropriate longterm management option.
4) This option is incorrect. Although increasing the dose to 500mg three times per day is appropriate for
management of this patient's diabetes, it does not address the fact that she has developed intolerable side
effects.
5) This option is correct. Switching to a modified release preparation is often effective in reducing
unwanted side effects. It should be started at 500mg once per day, and increased every 10-15 days on the
basis of blood glucose measurements.

Q-119-121
A. U&E, LFT
B. TFT, LFT
C. TFT, U&E
D. LFT
E. FBC, U&E
F. FBC, LFT, U&E
G. U&E
H. Plasma glucose
I. ECG
commenced
Q-119
Methotrexate
ANSWER:
F. FBC, LFT, U&E
Q-120
Levetiracetam
ANSWER:
J. No routine monitoring required61%
Q-121
Amiodarone
ANSWER:
B. TFT, LFT
Q-122
name?
A. Paroxetine
B. Clozapine
C. Lofepramine
D. Carbamazepine
E. Sumatriptan
ANSWER:
D. Carbamazepine
EXPLANATION:
Q-123
A 67-year-old man with a history of atrial fibrillation and ischaemic heart disease presents with symptoms
consistent with a chest infection. His current medication includes amiodarone, warfarin and simvastatin.
Which one of the following antibiotics is it most important to avoid if possible?
A. Trimethoprim
B. Co-amoxiclav
C. Cefaclor
D. Levofloxacin
E. Erythromycin
ANSWER:
E. Erythromycin
EXPLANATION:
Erythromycin may potentially interact with amiodarone, warfarin and simvastatin. Levofloxacin reacts to
a lesser extent with both amiodarone and warfarin.
MACROLIDES
Erythromycin was the first macrolide used clinically. Newer examples include clarithromycin and
azithromycin.
Macrolides act by inhibiting bacterial protein synthesis by blocking translocation. If pushed to give an answer
they are bacteriostatic in nature, but in reality this depends on the dose and type of organism being treated.
Mechanism of resistance
 post-transcriptional methylation of the 23S bacterial ribosomal RNA
Adverse effects
 gastrointestinal side-effects are common. Nausea is less common with clarithromycin than erythromycin
 cholestatic jaundice: risk may be reduced if erythromycin stearate is used
 P450 inhibitor (see below)
 azithromycin is associated with hearing loss and tinnitus
Common interactions
 statins should be stopped whilst taking a course of macrolides. Macrolides inhibit the cytochrome P450
isoenzyme CYP3A4 that metabolises statins. Taking macrolides concurrently with statins significantly
increases the risk of myopathy and rhabdomyolysis.
Q-124
Which one of the following side-effects is least recognised in patients taking ciclosporin?
A. Hypokalaemia
B. Hyperplasia of the gum
C. Hypertension
D. Tremor
E. Excessive hair growth
ANSWER:
A. Hypokalaemia
EXPLANATION:
Ciclosporin side-effects: everything is increased - fluid, BP, K+, hair, gums, glucose
Hyperkalaemia rather than hypokalaemia is seen with ciclosporin use
Please see Q-51 for Ciclosporin
Q-125
A 42-year-old man comes to see you complaining of tinnitus for the last few weeks but now reports
hearing loss. He suffers from chronic obstructive pulmonary disease. He currently uses a salbutamol
inhaler when required, azithromycin, beclometasone-formoterol (Fostair) inhaler, tiotropium inhaler and
glycopyrronium bromide.
On examination, the Rinne test is positive bilaterally (air conduction greater than bone conduction) but
hearing is significantly reduced on both sides. This is worse on the left. Weber test lateralises to the right.
Otoscopy is normal.
You suspect a sensorineural hearing loss and refer the patient urgently to see an Ear, Nose and Throat
(ENT) specialist.
Which of his medication may be causing his current symptoms and should be stopped?
A. Salbutamol
B. Azithromycin
C. Tiotropium
D. Glycopyrronium
E. Beclometasone-formoterol
ANSWER:
B. Azithromycin
EXPLANATION:
Azithromycin is associated with hearing loss and tinnitus
Of the medication listed, azithromycin is ototoxic and can cause sensorineural hearing loss. The first
symptom of this is usually tinnitus and patients should be instructed to stop this medication immediately if
these symptoms occur owing to the risk of irreversible hearing damage. The hearing loss will improve in
the majority of cases.
The most common side effects listed in the British National Formulary (BNF) for salbutamol and
beclometasone-formoterol include arrhythmias, headaches, dizziness, nausea, palpitations, tremor and
hypokalaemia (with high doses).
The most common side effects for tiotropium and glycopyrronium include arrhythmias, cough, headaches,
dry mouth and nausea.
Please see Q-123 for Macrolides
Q-126
Each one of the following is associated with carbon monoxide poisoning, except:
A. Cardiac arrhythmias
B. Chorea
C. Confusion
D. Blue skin and mucosae
E. Hyperpyrexia
ANSWER:
D. Blue skin and mucosae
EXPLANATION:
Carbon monoxide poisoning is associated with pink skin and mucosae
Please see Q-65 for Carbon Monoxide Poisoning
Q-127
A 25-year-old woman is diagnosed with a urinary tract infection. She has a past history of epilepsy and is
currently taking sodium valproate. Which one of the following antibiotics should be avoided if possible?
A. Co-amoxiclav
B. Nitrofurantoin
C. Cefixime
D. Trimethoprim
E. Ciprofloxacin
ANSWER:
E. Ciprofloxacin
EXPLANATION:
Ciprofloxacin lowers the seizure threshold
Whilst many antibiotics can lower the seizure threshold, this effect is seen particularly with quinolones.
The BNF advises that quinolones 'should be used with caution in patients with a history of epilepsy, or
conditions that predispose to seizures'
Please see Q-103 for Quinolones

Q-128
What is the most appropriate time to take blood samples for therapeutic monitoring of digoxin levels?
A. At any time
B. At least 6 hours after last dose
C. At least 2 hours after last dose
D. Immediately after last dose
E. At least 4 hours after last dose
ANSWER:
B. At least 6 hours after last dose
EXPLANATION:
Please see Q-111 for Therapeutic Drug Monitoring
Q-129
Concurrent use of which one of the following would make combined oral contraceptive pill less effective?
A. Fluconazole
B. Sodium valproate
C. Allopurinol
D. Isoniazid
E. Carbamazepine
ANSWER:
E. Carbamazepine
EXPLANATION:
Q-130
A 45-year-old man with a history of epilepsy and psychiatric problems is admitted to the Emergency
Department with confusion following a seizure earlier in the day. On examination he is noted to have a
coarse tremor, blood pressure = 134/86 mmHg, pulse = 84/min regular and temperature = 36.7ºC. What is
the most likely diagnosis?
A. Carbamazepine overdose
B. Lithium toxicity
C. Benzodiazepine toxicity
D. Tricyclic overdose
E. Neuroleptic malignant syndrome
ANSWER:
B. Lithium toxicity
EXPLANATION:
Please see Q-39 for Lithium Toxicity
Q-131
You review an 82-year-old woman who takes digoxin for atrial fibrillation. Which one of the following
factors is most likely to predispose her to develop digoxin toxicity?
A. Concurrent sodium valproate use

B. Liver impairment
C. Concurrent clarithromycin use
D. Hypokalaemia
E. Hypocalcaemia
Hypokalaemia predisposes patients to digoxin toxicity
ANSWER:
D. Hypokalaemia
EXPLANATION:
Q-132
A 57-year-old man is having a CT scan with intravenous contrast as part of their work-up. They have a
history of hypertension, type 2 diabetes mellitus and depression. Their current medication list is as
follows:
Amlodipine 10mg od
Metformin 1g bd
Simvastatin 20mg on
Citalopram 20mg od
Based on BNF guidance, what is the most appropriate advice to given regarding his metformin therapy?
A. No need to stop metformin

B. Stop 48 hours before the scan and restart after 48 hours
C. Discontinue on the day of the scan and restart after 24 hours
D. Discontinue on the day of the scan and restart after 48 hours
E. Discontinue on the day of the scan and restart after 5 days
ANSWER:
D. Discontinue on the day of the scan and restart after 48 hours
EXPLANATION:
Iodine-containing x-ray contrast media - metformin should be discontinued on the day of the procedure
and for 48 hours thereafter
Q-133
One of your patients develops a photosensitive rash after starting a newly licensed medication. You
decide to complete a Yellow Card. Who is responsible for collating and assessing the Yellow Card reports?
A. Medicines and Healthcare products Regulatory Agency (MHRA)

B. British National Formulary (BNF)
C. Local Clinical Commissioning Group (CCG)
D. Commission on Human Medicines (CHM)
E. National Patient Safety Agency (NPSA)
ANSWER:
A. Medicines and Healthcare products Regulatory Agency (MHRA)
EXPLANATION:
Please see Q-41 for Yellow Card Scheme
Q-134
Which of the following combination of symptoms is most consistent with digoxin toxicity?
A. Nausea + tinnitus
B. Gynaecomastia + blue vision
C. Headache + diarrhoea
D. Nausea + yellow / green vision
E. Diarrhoea + tinnitus
ANSWER:
D. Nausea + yellow / green vision
EXPLANATION:
Digoxin may cause yellow-green vision
Gynaecomastia may occur with prolonged digoxin use but is not a sign of toxicity in itself. Diarrhoea is less
common than nausea / vomiting in digoxin toxicity.
Q-135
You review a 60-year-old patient who is known to have chronic obstructive pulmonary disease and
epilepsy. Her seizure control has recently worsened. Which one of the following drugs is most likely to
worsen seizure control?
A. Tiotropium (inhaled)
B. Sertraline
C. Clarithromycin
D. Carbocisteine
E. Aminophylline
ANSWER:
E. Aminophylline
EXPLANATION:
Please see Q-47 for Prescribing in Patients with Epilepsy
Q-136
A 65-year-old man presents to your clinic with lethargy and leg swelling. You organise some bloods which
show the following:
Na+ 138 mmol/l

K+ 5.6 mmol/l
Urea 19.3 mmol/l
Creatinine 299 µmol/l
His renal function six months ago was normal. Which one of his regular medications is it most important
to stop straight away?
A. Ibuprofen
B. Warfarin
C. Paracetamol
D. Diazepam
E. Atenolol
ANSWER:
A. Ibuprofen
EXPLANATION:
NSAIDs such as ibuprofen can significantly worsen renal impairment and must be avoided in patients with
acute kidney injury or chronic kidney disease.
Q-137
Which one of the following side-effects is most associated with the use of verapamil?
A. Dyspepsia
B. Myalgia
C. Gingival hyperplasia
D. Constipation
E. Ankle oedema
All of the above side-effects may occur but constipation is the most common.
ANSWER:
D. Constipation
EXPLANATION:
Q-138
Which one of the following medications used in the management of hyperlipidaemia is most likely to
cause flushing?
A. Bezafibrate
B. Ezetimibe
C. Nicotinic acid
D. Atorvastatin
E. Cholestyramine
ANSWER:
C. Nicotinic acid
EXPLANATION:
HYPERLIPIDAEMIA: MECHANISM OF ACTION AND ADVERSE EFFECTS
The following table compares the side-effects of drugs used in hyperlipidaemia:
Drugs Mechanism of action Adverse effects

Statins HMG CoA reductase inhibitors Myositis, deranged LFTs
Ezetimibe Decreases cholesterol absorption in the small intestine Headache
Nicotinic acid Decreases hepatic VLDL secretion Flushing, myositis
Fibrates Agonist of PPAR-alpha therefore increases lipoprotein Myositis, pruritus,
lipase expression cholestasis
Cholestyramine Decreases bile acid reabsorption in the small intestine, GI side-effects
upregulating the amount of cholesterol that is
converted to bile acid
Q-139-141
Theme: Side-effects of diabetes mellitus drugs
A. Metformin
B. Acarbose
C. Glimepiride
D. Nateglinide
E. Pioglitazone
F. Diazoxide
G. Repaglinide
Select the drug most likely to cause each one of the following side-effects
Q-139
Syndrome of inappropriate ADH secretion
ANSWER:
C. Glimepiride
Q-140
Lactic acidosis
ANSWER:
A. Metformin
Q-141
Fluid retention
ANSWER:
E. Pioglitazone
Q-142
A 65-year-old male patient attends their GP for a routine medication review. Their current regular
medications are ramipril and amlodipine for hypertension, bisoprolol and digoxin for atrial fibrillation,
atorvastatin for hypercholesterolemia and PRN paracetamol for osteoarthritis. The GP decides to alter one
of the patients medications.
A week following starting this altered medication, the patient presents to the emergency department with
palpitations, nausea & vomiting, lethargy and disturbances to their colour vision. You perform an ECG and
note a AV nodal block.
Which of the following new medications is most likely to have precipitated this event?
A. Pravastatin
B. Bendroflumethiazide
C. Bisoprolol
D. Losartan
E. Co-codamol
ANSWER:
B. Bendroflumethiazide
EXPLANATION:
Thiazides may cause precipitation of digoxin toxicity
This patient has presented to the emergency department with symptoms of digoxin toxicity.
Whilst the patients presenting complaint of palpitations, nausea & vomiting and lethargy are non-specific,
the clue is in the ECG you request. AV nodal block with the given history is pathognomonic of digoxin
toxicity.
Pravastatin is not known to interact with digoxin.
Bendroflumethiazide may interact with digoxin to precipitate toxicity. As hypokalemia may also cause
digoxin toxicity, other diuretics may also precipitate toxicity.
Losartan is not known to interact with digoxin.
Co-codamol is unlikely to precipitate digoxin toxicity.
Q-143
Concurrent use of which one of the following would make the combined oral contraceptive pill less
effective?
A. Fluconazole
B. Cimetidine
C. St John's Wort
D. Fluoxetine
E. Isoniazid
ANSWER:
C. St John's Wort
EXPLANATION:
St John's Wort is an enzyme inducer and can reduce the effectiveness of the combined oral contraceptive
pill
St John's Wort is an inducers of the P450 enzyme system in the liver. This results in the combined oral
contraceptive pill being metabolised faster and hence may reduce effectiveness.
Q-144
A 22-year-old man consults you as he and his housemate have been feeling generally unwell for the past
few weeks. Which one of the following is the most common feature of carbon monoxide poisoning?
A. Hyperpyrexia
B. Nausea
C. Cherry red skin
D. Confusion
E. Headache
ANSWER:
E. Headache
EXPLANATION:
Carbon monoxide poisoning - most common feature = headache
Cherry red skin is a sign of severe toxicity and is usually seen post-mortem
Please see Q-65 for Carbon Monoxide Poisoning
Q-145
Your next patient is a 34-year-old man who is known to have an alcohol problem. He has drunk around
100 units per week for the past five years. He regularly misses meals and smokes 20 cigarettes per day.
What vitamin supplementation, if any, should you recommend?
A. Oral vitamin B compound

B. Oral thiamine
C. Oral vitamin B compound + multivitamins
D. No supplementation is advised. Give standard dietary advice
E. Oral thiamine + vitamin D
ANSWER:
B. Oral thiamine
EXPLANATION:
Whilst vitamin B compound is widely prescribed it is not recommended in recent guidelines, for example
SIGN.
Please see Q-22 for Alcohol – Problem Drinking: Management
Q-146
Which one of the following adverse effects is most likely to be seen in patients taking ciclosporin?
A. Hypertension
B. Hypokalaemia
C. Alopecia
D. Dehydration
E. Atrophy of the gums
ANSWER:
A. Hypertension
EXPLANATION:
Ciclosporin side-effects: everything is increased - fluid, BP, K+, hair, gums, glucose
Please see Q-51 for Ciclosporin
Q-147
Which one of the following is least recognised in patients taking amiodarone?
A. Pulmonary fibrosis
B. Corneal deposits
C. Peripheral neuropathy
D. Hyperthyroidism
E. Gynaecomastia
ANSWER:
E. Gynaecomastia
EXPLANATION:
Drug causes of gynaecomastia include spironolactone (the most common drug cause), cimetidine and
digoxin
Please see Q-102 for Amiodarone: Side Effects
Q-148
A 62-year-old man is commenced on finasteride for symptoms of bladder outflow obstruction. Which one
of the following adverse effects is most associated with this treatment?
A. Alopecia
B. Gynaecomastia
C. Prostate cancer
D. Increased levels of serum prostate specific antigen
E. Postural hypotension
ANSWER:
B. Gynaecomastia
EXPLANATION:
FINASTERIDE
Finasteride is an inhibitor of 5 alpha-reductase, an enzyme which metabolises testosterone into
dihydrotestosterone.
Indications
 benign prostatic hyperplasia
 male-pattern baldness
Adverse effects
 impotence
 decrease libido
 ejaculation disorders
 gynaecomastia and breast tenderness
Finasteride causes decreased levels of serum prostate-specific antigen
Q-149
You are doing a medication review for a woman who is prescribed the combined oral contraceptive pill
(COCP). Which one of the following would NOT decrease the effectiveness of the COCP?
A. Rifampicin
B. Sodium valproate
C. Carbamazepine
D. St John's Wort
E. Phenytoin
ANSWER:
B. Sodium valproate
EXPLANATION:
Sodium valproate is an P450 inhibitor
Q-150
A 54-year-old man with hypertension is reviewed in clinic. He complains that over the past two months he
has developed ankle swelling. Which one of the following drugs is most likely to be responsible?
A. Perindopril
B. Amlodipine
C. Doxazosin
D. Moxonidine
E. Losartan
ANSWER:
B. Amlodipine
EXPLANATION:
Calcium channel blockers - side-effects: headache, flushing, ankle oedema
Q-151
Patients taking amiodarone are at an increased risk of thyroid dysfunction. What problems may long-term
amiodarone use cause?
A. Thyrotoxicosis
B. Hypothyroidism
C. Hypothyroidism + thyroid cancer
D. Hypothyroidism + thyrotoxicosis + thyroid cancer
E. Hypothyroidism + thyrotoxicosis
ANSWER:
E. Hypothyroidism + thyrotoxicosis
EXPLANATION:
Please see Q-6 for Amiodarone and the Thyroid Gland
Q-152
Thrombocytopenia is associated with each of the following drugs except:
A. Abciximab
B. Quinine
C. Warfarin
D. Penicillin
E. Sodium valproate
ANSWER:
C. Warfarin
EXPLANATION:
Please see Q-73 for Drug-Induced Thrombocytopenia
Q-153
You are doing a medication review on a patient with chronic kidney disease who is prescribed metformin.
At what creatinine value do NICE recommend stopping metformin?
A. > 110 µmol/l

B. > 120 µmol/l
C. > 130 µmol/l
D. > 140 µmol/l
E. > 150 µmol/l
ANSWER:
E. > 150 µmol/l
EXPLANATION:
NICE recommend that the dose of metformin should be reviewed if the creatinine is > 130 micromol/l (or
eGFR < 45 ml/min) and stopped if the creatinine is > 150 micromol/l (or eGFR < 30 ml/min)
Q-154
You are doing a medication review on a 64-year-old man with a history of cerebrovascular disease (having
had a stroke 3 years ago), depression and knee osteoarthritis. His medication list is as follows:
clopidogrel 75mg od
simvastatin 20mg on
amlodipine 5mg od
ramipril 10mg od
diclofenac 50mg prn
sertaline 50mg od
What is the most appropriate change to make to his medications?

A. Switch sertaline to citalopram
B. Switch diclofenac for an alternative NSAID
C. Add aspirin
D. Reduce the dose of simvastatin
E. Switch clopidogrel to aspirin
ANSWER:
B. Switch diclofenac for an alternative NSAID
EXPLANATION:
Diclofenac is now contraindicated with any form of cardiovascular disease
DICLOFENAC
The MHRA updated it's guidance on diclofenac in June 2013 after a Europe-wide of review of cardiovascular
safety.
Whilst it has long been known that NSAIDs may be linked to an increased risk of cardiovascular events the
evidence base has now become much clearer. Diclofenac appears to be associated with a significantly
increased risk of cardiovascular events compared with other NSAIDs.
It is therefore advised that diclofenac is contraindicated in patients with the following:

 ischaemic heart disease
 peripheral arterial disease
 cerebrovascular disease
 congestive heart failure (New York Heart Association classification II-IV)
Patients should be switched from diclofenac to other NSAIDs such as naproxen or ibuprofen. This advice
does not apply to topical diclofenac.
Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the
NSAIDs.
Q-155
Which of the following drugs is considered most likely to precipitate an attack of acute intermittent
porphyria?
A. Morphine
B. Aspirin
C. Atenolol
D. Metformin
E. Oral contraceptive pill
ANSWER:
E. Oral contraceptive pill
EXPLANATION:
ACUTE INTERMITTENT PORPHYRIA: DRUGS
Acute intermittent porphyria (AIP) is an autosomal dominant condition caused by a defect in
porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. It characteristically presents
with abdominal and neuropsychiatric symptoms in 20-40 year olds. AIP is more common in females (5:1)
Drugs which may precipitate attack

 barbiturates
 halothane
 benzodiazepines
 alcohol
 oral contraceptive pill
 sulphonamides
Drugs considered safe to use

 paracetamol
 aspirin
 codeine
 morphine
 chlorpromazine
 beta-blockers
 penicillin
 metformin
Q-156
What are the main indications for the use alpha blockers?
A. Urinary incontinence + postural hypotension

B. Migraine prophylaxis + urinary incontinence
C. Hypertension + benign prostatic hyperplasia
D. Hypertension + heart failure
E. Postural hypotension + benign prostatic hyperplasia
ANSWER:
C. Hypertension + benign prostatic hyperplasia
EXPLANATION:
ALPHA BLOCKERS
Alpha blockers are used in the management of benign prostatic hyperplasia and hypertension. Examples
include doxazosin and tamsulosin.
Side-effects
 postural hypotension
 drowsiness
 dyspnoea
 cough
Caution should be exercised in patients who are having cataract surgery due to the risk of intra-operative
floppy iris syndrome
Q-157
A 57-year-old man with a history of ischaemic heart disease is keen to try sildenafil for erectile
dysfunction. Which one of the following medications may contraindicate its use?
A. Nebivolol
B. Losartan
C. Nicorandil
D. Nifedipine
E. Ramipril
ANSWER:
C. Nicorandil
EXPLANATION:
Nicorandil has a nitrate component as well as being a potassium channel activator
Q-158
A 76 year old lady visits your surgery with ankle swelling over the last 2 weeks. The swelling is bilateral,
with pitting oedema to the mid-shin. She had a change to her medication 2 weeks ago. What medication is
most likely to have caused this?
A. Amlodipine
B. Bisoprolol
C. Bendroflumethiazide
D. Clopidogrel
E. Ramipril
ANSWER:
A. Amlodipine
EXPLANATION:
Bendroflumethiazide does not cause ankle oedema, and it's most likely side-effects are postural
hypotension and electrolyte disturbances, especially hypokalaemia.
Beta blockers like bisoprolol are not associated with ankle oedema. They can cause peripheral coldness
due to vasoconstriction, hypotension and bronchospasm.
Clopidogrel likewise isn't associated with ankle oedema. It can cause gastrointestinal symptoms or
occasionally bleeding disorders.
ACE inhibitors like ramipril are known to cause hypotension, renal dysfunction and a dry cough.They are
not known to cause ankle oedema.
Amlodipine is a calcium channel blocker which commonly causes ankle oedema which tends to be only
partially responsive to diuretics. They can also cause other side-effects associated with vasodilatation such
as flushing and headaches.
References: BNF
Q-159
You are consulting with a 55-year-old gentleman who has erectile dysfunction. After a long discussion, he
decides he would like to start some medication and you prescribe sildenafil a phosphodiesterase inhibitor
(PDE-5). He mentions that he had a friend who used that but then had a very painful experience when he
had an erection that wouldn't go down and he had to go to the hospital.
What concurrent condition would put a patient at risk of priapism if he took this medication?
A. Peyronie's disease
B. Diabetes
C. Rheumatoid arthritis
D. Sickle-cell disease
E. Unstable angina
ANSWER:
D. Sickle cell disease
EXPLANATION:
Prescribe PDE-5 inhibitors with caution to men with sickle cell disease as they are at risk of priaprism
Priapism is the presence of a persistent and painful erection and can require urgent referral to hospital for
treatment.
PDE-5 inhibitors should be used with caution in those with a predisposition to priapism (for example in
sickle-cell disease, multiple myeloma, or leukaemia). Therefore, option 4 is correct.
Peyronie's disease is when the penis is curved. PDE-5 inhibitors should also be used with caution in men
with Peyronie's disease and other anatomical abnormalities of the penis but it does not cause a
predisposition to priapism. Therefore, option 1 is incorrect.
Diabetes does not predispose to priapism but it is a risk factor for erectile dysfunction. Therefore, option 2
is wrong.
Unstable angina would be a contraindication to a PDE-5 but would not predispose to priapism. Therefore,
option 5 is wrong.
Rheumatoid arthritis does not predispose to priapism. Therefore, option 3 is incorrect.

Q-160
You review a 57-year-old man with chronic kidney disease stage 3. Which one of the following drugs is it
safe to prescribe given his degree of renal impairment?
A. Tetracycline
B. Metformin
C. Warfarin
D. Nitrofurantoin
E. Lithium
ANSWER:
C. Warfarin
EXPLANATION:
Tetracycline, metformin, nitrofurantoin and lithium should be avoided in severe renal failure. Warfarin in
constrast may be well tolerated although patients may require closer monitoring.
Q-161
A 70-year-old man who takes warfarin for atrial fibrillation is found to have an INR of 6.2. Which of the
following drugs is he most likely to have recently taken?
A. Ciprofloxacin
B. Flucloxacillin
C. St John's Wort
D. Carbamazepine
E. Aspirin
ANSWER:
A. Ciprofloxacin
EXPLANATION:
Ciprofloxacin is a P450 enzyme inhibitor
Ciprofloxacin is a known inhibitor of the P450 system and hence may cause an increase in INR.
Q-162
A 26-year-old female is commenced on carbamazepine for focal impaired awareness seizures. She has no
previous medical history of note and consumes a moderate amount of alcohol. Three months later she is
admitted due to series of seizures and carbamazepine levels are noted to be subtherapeutic. A pill-count
reveals the patient is fully compliant. What is the most likely explanation?
A. Auto-inhibition of liver enzymes
B. Prescription of omeprazole
C. Prescription of fluoxetine
D. Auto-induction of liver enzymes
E. Alcohol binge
ANSWER:
D. Auto-induction of liver enzymes
EXPLANATION:
Carbamazepine is an inducer of the P450 system. This in turn increases the metabolism of carbamazepine
itself - auto-induction
Q-163
Which one of the following features is least associated with ecstasy poisoning?
A. Rhabdomyolysis
B. Hyperthermia
C. Ataxia
D. Hypertension
E. Hypernatraemia
ANSWER:
E. Hypernatraemia
EXPLANATION:
Hyponatraemia may be seen secondary to water intoxication
Please see Q-72 for Ecstasy Poisoning
Q-164
A 54-year-old obese man presents with lethargy and polyuria. A fasting blood sugar is requested:
Fasting glucose 8.4 mmol/l
He is given dietary advice and a decision is made to start metformin. What is the most appropriate
prescription?
A. Metformin 500mg od with food for 5 days then metformin 500mg bd for 5 days then metformin
500mg tds for 20 days then review
B. Metformin 500mg tds with food
C. Metformin 500mg od with food for 14 days then metformin 500mg bd for 14 days then review
D. Metformin 1g tds with food
E. Metformin 500mg tds taken at least 1 hour before meals
ANSWER:
C. Metformin 500mg od with food for 14 days then metformin 500mg bd for 14 days then review
EXPLANATION:
Metformin should be titrated slowly, leave at least 1 week before increasing dose
Gastrointestinal side-effects are more likely to occur if metformin is not slowly titrated up. The BNF
advises leaving at least 1 week before increasing the dose.
Q-165
Mr Cunningham, a 58-year-old patient who has recently been diagnosed with type 2 diabetes, presents
with a few days of tingling in his hands and feet, and twitching in his muscles all over. His other past
medical history includes hypertension, hiatus hernia, cholecystectomy, and seborrhoeic dermatitis. His
medications include metformin and atorvastatin (recently commenced), amlodipine, omeprazole, and
ketoconazole shampoo. You suspect his new symptoms may be due to hypocalcaemia and request a bone
profile amongst other tests. His calcium level comes back normal however.
Which of the following conditions is the most likely cause of his symptoms?
A. Motor neurone disease (MND)

B. Hypomagnesaemia
C. Peripheral neuropathy
D. Anxiety
E. Contact allergy to ketoconazole
ANSWER:
B. Hypomagnesaemia
EXPLANATION:
Hypomagnesaemia can present with similar symptoms to hypocalcaemia
Motor neurone disease: incorrect answer, MND can present with muscle twitching, but wouldn't fit with
the peripheral paraesthesia and is not the most likely diagnosis.
Hypomagnesaemia: correct answer. Hypomagnesaemia presents similarly to hypocalcaemia, and this

patient has some risk factors for this - long term proton pump inhibitor therapy, and diabetes (osmotic
diuresis).
Peripheral neuropathy: incorrect answer, although this is a possible complication of diabetes and can
present with peripheral sensory changes, this would tend to be of less acute onset and not in keeping with
the muscle twitching felt all over.
Anxiety: incorrect answer. Hyperventilation may occur with panic attacks which can cause tingling in the
extremities but would not cause muscle twitching.
Contact allergy to ketoconazole: incorrect answer. Contact allergy might cause localised skin irritation but
not muscle twitching.
Please see Q-1 for Hypomagnesaemia
Q-166
A 54-year-old female is being investigated for a macrocytic anaemia. Bloods test reveal a low vitamin B12
level. Which one of the following medications may be contributing to this?
B. Digoxin
C. Amiodarone
D. Sodium valproate
E. Metformin
ANSWER:
E. Metformin
EXPLANATION:
Q-167-169
A. U&E, LFT
B. TFT, LFT
C. TFT, U&E
D. LFT
E. FBC, U&E
F. FBC, LFT
G. U&E
H. Calcium
I. ECG
commenced
Q-167
Perindopril
ANSWER:
G. U&E
Q-168
Sodium valproate during the first 6 months of therapy
ANSWER:
D. LFT
Q-169
Pioglitazone
ANSWER:
D. LFT
Q-170
You see a 45-year-old type one diabetic patient who has come to see you about his erections. They have
slowly been getting worse over the last 6 months. You review his medications and discuss some treatment
options. He has no other past medical history.
On your recommendation, he decides to try phosphodiesterase (PDE-5) inhibitor and you prescribe
sildenafil.
What should you advise this man about taking a PDE-5 inhibitor?
A. Lifestyle modification will not help his erections

B. He will need to take the medication daily
C. Of the available PDE-5 inhibitors, this patient can only get sildenafil on an NHS prescription
D. Sexual stimulation is required to facilitate an erection
E. He must take sildenafil at least 6 hours before sexual activity
ANSWER:
D. Sexual stimulation is required to facilitate an erection
EXPLANATION:
PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection
PDE-5 inhibitors are the first-line treatment for erectile dysfunction if there are no contraindications to
their use.
The most common organic cause of erectile dysfunction (ED) is vasculogenic causes such as cardiovascular
disease (CVD). Therefore, the same risk factors and lifestyle factors apply as for CVD. Erectile dysfunction
usually responds well to a combination of lifestyle changes and drug treatment. Therefore, option 1 is
incorrect. Advise, where applicable, that he should lose weight (important), stop smoking, reduce alcohol
consumption, and increase exercise. Lifestyle changes and risk factor modification must precede or
accompany treatment.
Generic sildenafil can be prescribed without restriction on the NHS. Furthermore, for certain medical
conditions (such as diabetes) there are other PDE-5 inhibitors which can be prescribed on the NHS.
Therefore, option 3 is incorrect.
For most men, as-required treatment with a PDE-5 inhibitor is suitable. The frequency of treatment will
need to be considered on an individual basis. Therefore, option 2 is incorrect.
Sildenafil only needs to be taken 1 hour before sexual activity and requires sexual stimulation in order to
facilitate an erection.
Therefore, option 4 is correct and option 5 is incorrect.
Q-171
A 67-year-old woman is noted to have corneal opacities during a routine opticians appointment. These are
not affecting her vision. Which one of the following drugs is most likely to be the cause?
A. Amiodarone
B. Sodium valproate
C. Methotrexate
D. Frusemide
E. Digoxin
ANSWER:
A. Amiodarone
EXPLANATION:
Amiodarone therapy can result in both corneal opacities and optic neuritis.
DRUGS CAUSING OCULAR PROBLEMS

Cataracts
 steroids
Corneal opacities
 amiodarone
 indomethacin
Optic neuritis
 ethambutol
 amiodarone
 metronidazole
Retinopathy
 chloroquine, quinine
Sildenafil can cause both blue discolouration and non-arteritic anterior ischaemic neuropathy
Q-172-174
Theme: Side-effects of anti-anginals
A. Anal ulceration
B. Reduced seizure threshold
C. Hyponatraemia
D. Thrombocytopaenia
E. Constipation
F. Drug-induced lupus
G. Tachycardia
H. QT interval prolongation
I. Sleep disturbances
For each one of the following drugs choose the side-effect which it is characteristically associated with:
Q-172
Verapamil
ANSWER:
Constipation
Q-173
Atenolol
ANSWER:
Sleep disturbances
Q-174
Isosorbide mononitrate
ANSWER:
Tachycardia
SIDE-EFFECTS OF COMMON DRUGS: ANTI-ANGINALS
to treat angina
Drug Side-effect
Calcium channel blockers • Headache
• Flushing
• Ankle oedema
Verapamil also commonly causes constipation

Beta-blockers • Bronchospasm (especially in asthmatics)
• Fatigue
Drug Side-effect
• Cold peripheries
• Sleep disturbances
Nitrates • Headache
• Postural hypotension
• Tachycardia
Nicorandil • Headache
• Flushing
• Anal ulceration
Q-175
Cara is 33 years old and has recently joined your practice. She has a diagnosis of bipolar disease and has
been on lithium for four years, with no complications. How often, according to NICE guidelines, should
Cara's renal function be monitored?
A. Every 6 months for a year then every 12 months

B. Every 6 months
C. Every 3 months
D. Every 12 months
E. Every 24 months
ANSWER:
B. Every 6 months
EXPLANATION:
Once established on treatment patients who are taking lithium should have their renal function monitored
every 6 months.
The following paragraph is from the NICE guidelines 2014 - Bipolar disorder: the assessment and
management of bipolar disorder in adults, children and young people in primary and secondary care
'Measure the person's weight or BMI and arrange tests for urea and electrolytes including calcium,
estimated glomerular filtration rate (eGFR) and thyroid function every 6 months, and more often if there is
evidence of impaired renal or thyroid function, raised calcium levels or an increase in mood symptoms that
might be related to impaired thyroid function.'
References
NICE Guidelines 'Bipolar disorder: the assessment and management of bipolar disorder in adults, children
and young people in primary and secondary care' 2014
https://www.nice.org.uk/guidance/cg185
Q-176
A 28-year-old woman who is an intravenous heroin user comes for review. Which one of the following
complications is most likely to occur as a result of her drug use?
A. Seizures
B. Osteoporosis
C. Peptic ulcer disease
D. Schizophrenia
E. Venous thromboembolism
ANSWER:
E. Venous thromboembolism
EXPLANATION:
Q-177
One of your elderly patients is admitted to hospital with digoxin toxicity. Which one of her other
medications is most likely to have precipitated this?
A. Doxycycline
B. Aspirin
C. Diltiazem
D. Atorvastatin
E. Bisoprolol
ANSWER:
C. Diltiazem
EXPLANATION:
Diltiazem may cause precipitation of digoxin toxicity
The calcium channel blockers diltiazem and verapamil both increase serum digoxin levels.
Q-178
Each one of the following is seen in amiodarone therapy, except:
A. Hyperthyroidism
B. Liver cirrhosis
C. Hypokalaemia
D. Hypothyroidism
E. Pulmonary fibrosis
ANSWER:
C. Hypokalaemia
EXPLANATION:
Please see Q-102 for Amiodarone: Adverse Effects
Q-179
Each one of the following is a feature of organophosphate poisoning, except:
A. Defecation
B. Mydriasis
C. Salivation
D. Lacrimation
E. Urination
ANSWER:
B. Mydriasis
EXPLANATION:
ORGANOPHOSPHATE INSECTICIDE POISONING
One of the effects of organophosphate poisoning is inhibition of acetylcholinesterase leading to upregulation
of nicotinic and muscarinic cholinergic neurotransmission. In warfare, sarin gas is a highly toxic synthetic
organophosphorus compound that has similar effects.
Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)

 Salivation
 Lacrimation
 Urination
 Defecation/diarrhoea
 cardiovascular: hypotension, bradycardia
 also: small pupils, muscle fasciculation
Management
 atropine
 the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

PASSMEDICINE MCQs-PHARMACOLOGY

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PHARMACOLOGY MCQs

Which of his medications should you stop?

Features may be similar to hypocalcaemia:

Features of opioid misuse

Complications of opioid misuse

Emergency management of opioid overdose

Harm reduction interventions may include

Management of opioid dependence

Thyroid stimulating hormone (TSH) 0.2 mU/L

Which of the following is most likely to be responsible for these results?

AMIODARONE AND THE THYROID GLAND

Amiodarone may be continued if this is desirable

AIT type 1 AIT type 2

Sildenafil can cause blue-tinted vision or cyanopsia.

DIGOXIN AND DIGOXIN TOXICITY

PRESCRIBING IN PREGNANT PATIENTS

PHOSPHODIESTERASE TYPE V INHIBITORS

The blue pill, Viagra (sildenafil), causes blue discolouration of vision

What is the most likely diagnosis?

Malignant hyperthermia occurs in susceptible individuals exposed to halogenated volatile anaesthetics

A. Switch to pioglitazone 15mg od

Please see Q-11 for Metformin

PRESCRIBING IN PATIENTS WITH HEART FAILURE

Tamoxifen is typically used for 5 years following removal of the tumour.

Drug Main monitoring parameters Details of monitoring

Drug Main monitoring parameters Details of monitoring

Drug Main monitoring parameters Details of monitoring

Drug Main monitoring parameters Details of monitoring

A. Increase dose ramipril

Double the dose of lansoprazole. Incorrect, no indication for this.

Increase dose bisoprolol. Incorrect. No indication for increasing bisoprolol here.

SIDE-EFFECTS OF COMMON DRUGS: DIABETES DRUGS

Drug Most common side effects

TUBERCULOSIS: DRUG SIDE-EFFECTS AND MECHANISM OF ACTION

ALCOHOL - PROBLEM DRINKING: MANAGEMENT

A. Methyldopa for hypertension

Please see Q-8 for Prescribing in Pregnant Patients

A. Sildenafil is contraindicated due to a diagnosis of macular degeneration

Option 1 is incorrect as macular degeneration is not a contraindication for prescribing sildenafil.

Option 4 is incorrect as hypertension is not a contraindication for prescribing sildenafil.

Option 5 is incorrect as diabetes is not a contraindication for prescribing sildenafil.

Please see Q-9 for Phosphodiesterase Type V Inhibitors

Drugs which should be prescribed by brand

Orlistat 120mg tds

Which one of her medications must be stopped straight away?

Please see Q-8 for Prescribing in Pregnant Patients

Please see Q-8 for Prescribing in Pregnant Patients

DRUG CAUSES OF URTICARIA

Please see Q-9 for Phosphodiesterase Type V Inhibitors

A. Newly licensed medicine

Denotes a preparation that is less suitable to prescribe

Newly licensed medicines

Paracetamol does not interact with SSRIs or insulin.

Cannabis is not known to interact with SSRIs.

Cheese interacts with monoamine oxidase inhibitors but not SSRIs.

A. Mefloquine may be safely prescribed

The following advice is therefore given:

What do the current guidelines recommend?

Toxicity may be precipitated by: