Applying clinical knowledge and skill for MRCGP AKT

A 54-year-old man with type 2 diabetes has an HbA1c of 62 mmol/mol on maximum tolerated metformin. He has established atherosclerotic cardiovascular disease and a BMI of 33. eGFR is 74 mL/min/1.73m². Which is the most appropriate addition to his treatment?

1. A sulfonylurea Effective on HbA1c but the wrong tool here: hypoglycaemia, weight gain, and no cardiovascular outcome benefit in a patient with established vascular disease and obesity.
2. A DPP-4 inhibitor Weight-neutral and well tolerated but cardiovascular-neutral. Reasonable if the SGLT2 class were contraindicated; here it forgoes a proven outcome benefit.
3. An SGLT2 inhibitor correct Correct. With established atherosclerotic cardiovascular disease, an SGLT2 inhibitor is recommended alongside metformin irrespective of HbA1c, because the cardiovascular and renal outcome benefits are independent of glycaemic control.
4. Basal insulin Premature. Insulin is escalated to when oral options are exhausted or there is significant hyperglycaemia with catabolic features.
5. Pioglitazone Wrong. Cautioned or contraindicated with heart failure, causes weight gain and fluid retention, and raises fracture risk.

The point: Type 2 diabetes with established cardiovascular disease, heart failure or chronic kidney disease: add an SGLT2 inhibitor for the outcome benefit, not merely for the HbA1c. GLP-1 receptor agonists are the alternative where weight dominates.

Source: NICE NG28 — Type 2 diabetes in adults: management NICE · tier 1, national regulator or guidance

A 58-year-old man attends with a 4-week history of hoarseness. He is a current smoker with a 30-pack-year history and drinks 30 units of alcohol a week. He has no dysphagia and no neck lump. Examination of the mouth is unremarkable. What is the most appropriate action?

1. Prescribe a proton pump inhibitor for likely reflux laryngitis and review in 8 weeks Wrong as the primary plan. Reflux is a common cause of hoarseness, but treating empirically for two months in a heavy smoker delays a cancer diagnosis. A PPI can run alongside referral, not instead of it.
2. Prescribe a course of oral antibiotics Wrong. There is nothing to suggest bacterial infection, and four weeks of symptoms is not an acute laryngitis.
3. Advise voice rest and reassure Wrong. Reassurance without visualising the larynx in a high-risk patient is unsafe.
4. Request a chest radiograph and take no further action if normal Incomplete. A chest film is worth doing, because a left recurrent laryngeal nerve palsy from a lung tumour is a recognised cause, but a normal film does not exclude laryngeal cancer.
5. Refer on a suspected cancer pathway for laryngoscopy correct Correct. Persistent unexplained hoarseness beyond three weeks in an adult over 45 is a suspected head and neck cancer referral criterion, and his smoking and alcohol history compound the risk. He needs a look at the cords.

The point: Hoarseness beyond three weeks in an adult, particularly a smoker over 45, needs laryngoscopy. Other head and neck red flags: unexplained neck lump, persistent unilateral sore throat, unexplained mouth ulceration lasting more than three weeks.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 26-year-old woman is 6 weeks pregnant and has epilepsy controlled on sodium valproate 800 mg daily. She has been seizure-free for 4 years. She has just discovered the pregnancy and asks what to do about her medication. What is the most appropriate action?

1. Halve the dose immediately to reduce fetal exposure Wrong. Dose reduction without specialist input risks loss of seizure control, and the exposure during organogenesis has already occurred.
2. Stop the valproate today and start lamotrigine Wrong. Abrupt withdrawal risks seizures, which carry their own maternal and fetal risk, and cross-titration needs specialist supervision.
3. Do not stop the valproate abruptly; refer urgently to the specialist epilepsy service and start high-dose folic acid correct Correct. Valproate carries a high risk of major congenital malformation and neurodevelopmental harm, and should not be used in pregnancy, but stopping it abruptly at six weeks risks status epilepticus, and organogenesis is already well advanced. This needs an urgent specialist decision, not a unilateral one in general practice.
4. Advise termination of the pregnancy Wrong. That is not the doctor's decision to advise, and the risk, while real, is far from a certainty of harm. She needs accurate information and specialist counselling.
5. Continue the valproate unchanged and review after delivery Wrong. Doing nothing ignores a well-established teratogen and misses the chance for specialist input, screening and counselling.

The point: Valproate in women of childbearing potential requires the pregnancy prevention programme and should be avoided. Once a woman on valproate is already pregnant, do not stop it unilaterally: refer urgently, start 5 mg folic acid, and let the epilepsy service decide.

Source: MHRA — Valproate: pregnancy prevention programme; NICE NG217 Epilepsies NICE · tier 1, national regulator or guidance