PLAB 1 UK Clinical Guidelines & Prescribing Safety — Questions and Answers
Question 1: According to NICE guidelines, what is the first-line antihypertensive for a 65-year-old Caucasian man with no other comorbidities?
- ACE inhibitor (e.g., ramipril)
- Calcium channel blocker (e.g., amlodipine) (Correct answer)
- Thiazide-like diuretic (e.g., indapamide)
- Beta-blocker (e.g., atenolol)
Correct answer: Calcium channel blocker (e.g., amlodipine)
NICE hypertension guidelines (NG136): for patients aged 55 or over, or people of any age who are Black British/African/Caribbean, the first-line treatment is a calcium channel blocker (CCB). For under-55 non-Black patients, an ACE inhibitor or ARB is first line. At 65, a CCB is recommended.
Question 2: According to NICE guidelines (NG28), which of the following patients with type 2 diabetes should be started on metformin as first-line therapy?
- A patient with eGFR 25 ml/min/1.73m²
- A patient with no contraindications to metformin and HbA1c above the agreed target (Correct answer)
- A patient with recurrent hypoglycaemia on other agents
- A patient with type 1 diabetes
Correct answer: A patient with no contraindications to metformin and HbA1c above the agreed target
NICE recommends metformin as first-line pharmacological therapy for type 2 diabetes in patients who have no contraindications (renal impairment eGFR<30, hepatic failure, alcohol excess) and whose HbA1c is above their agreed target after lifestyle modification. It does not cause hypoglycaemia and aids weight neutrality.
Question 3: According to the BNF and NICE, what is the recommended first-line treatment for uncomplicated lower urinary tract infection (UTI) in a non-pregnant woman?
- Co-amoxiclav for 7 days
- Nitrofurantoin for 3 days (if eGFR >45) or trimethoprim for 3 days (Correct answer)
- Ciprofloxacin for 5 days
- Amoxicillin for 5 days
Correct answer: Nitrofurantoin for 3 days (if eGFR >45) or trimethoprim for 3 days
PHE/NICE guidelines recommend nitrofurantoin (3 days, if eGFR >45) or trimethoprim (3 days, if low local resistance) as first-line for uncomplicated lower UTI in women. Ciprofloxacin should be reserved for complicated UTIs or resistant organisms to preserve its effectiveness.
Question 4: A 72-year-old man has an acute exacerbation of COPD. Arterial blood gas shows: pH 7.29, PaCO2 8.5 kPa, PaO2 7.0 kPa, HCO3 26 mmol/L. His oxygen saturations are 82% on air. What is the target oxygen saturation for this patient according to BTS guidelines?
- 98–100%
- 88–92% (Correct answer)
- 94–98%
- 96–98%
Correct answer: 88–92%
BTS guidelines for COPD exacerbation recommend a target SpO2 of 88–92% for patients at risk of hypercapnic respiratory failure (type 2 respiratory failure, as shown here by elevated PaCO2). High-flow oxygen can suppress the hypoxic ventilatory drive in these patients, worsening CO2 retention.
Question 5: According to NICE stroke guidelines, which antiplatelet regimen should be started within 24 hours of a confirmed ischaemic stroke (not thrombolysed)?
- Clopidogrel 75mg daily for life
- Dual antiplatelet therapy: aspirin 300mg for 2 weeks, then clopidogrel 75mg monotherapy (Correct answer)
- Anticoagulation with apixaban immediately
- Aspirin 75mg indefinitely
Correct answer: Dual antiplatelet therapy: aspirin 300mg for 2 weeks, then clopidogrel 75mg monotherapy
NICE NG128: After ischaemic stroke, start aspirin 300mg immediately (if haemorrhage excluded), continue for 2 weeks, then switch to clopidogrel 75mg monotherapy for long-term secondary prevention. NICE (2023) updated guidance recommends clopidogrel as first-line long-term antiplatelet over aspirin.
Question 6: A 55-year-old man has had a myocardial infarction. According to NICE guidelines (NG185), which combination of medications should he be prescribed for secondary prevention?
- Aspirin alone
- Aspirin + P2Y12 inhibitor (e.g., ticagrelor) + high-intensity statin + ACE inhibitor + beta-blocker (Correct answer)
- Warfarin + statin + beta-blocker
- Clopidogrel + statin only
Correct answer: Aspirin + P2Y12 inhibitor (e.g., ticagrelor) + high-intensity statin + ACE inhibitor + beta-blocker
Post-MI secondary prevention (NICE NG185): dual antiplatelet (aspirin + ticagrelor/clopidogrel/prasugrel for 12 months), high-intensity statin (atorvastatin 80mg), ACE inhibitor (or ARB if intolerant), and beta-blocker. All four classes are indicated unless contraindicated.
PLAB 1 UK Clinical Guidelines & Prescribing Safety
According to NICE guidelines, what is the first-line antihypertensive for a 65-year-old Caucasian man with no other comorbidities?