General Practice & Chronic Disease

A 58-year-old man has a QRISK score of 14% over ten years and no history of cardiovascular disease. According to NICE, what should be offered?

• ANo treatment, since statins are only started for primary prevention when the ten-year risk is above 20%
• BAtorvastatin 80 mg daily, the dose used after a heart attack, since a higher dose gives more protection
• CAspirin 75 mg daily for primary prevention
• DAtorvastatin 20 mg daily for primary prevention, after discussing lifestyle changes✓

Answer: NICE recommends offering atorvastatin 20 mg for primary prevention when the ten-year QRISK is 10% or more, alongside lifestyle advice. Atorvastatin 80 mg is the secondary-prevention dose, and aspirin is not recommended for primary prevention.

A 64-year-old woman with type 2 diabetes has an HbA1c of 60 mmol/mol on maximum-dose metformin and has established cardiovascular disease. Which drug should be added?

• AA sulfonylurea such as gliclazide, which has the longest record of use in type 2 diabetes
• BPioglitazone, which improves insulin sensitivity in the liver and muscle
• CAn SGLT2 inhibitor with proven cardiovascular benefit✓
• DA DPP-4 inhibitor such as sitagliptin, which is weight-neutral and rarely causes hypoglycaemia

Answer: NICE recommends adding an SGLT2 inhibitor with proven cardiovascular benefit for people with type 2 diabetes and established cardiovascular disease, because it reduces cardiovascular events as well as glucose. The other options lower glucose without that benefit.

A 45-year-old woman has a two-month history of low mood, poor sleep and loss of interest, with no suicidal thoughts. PHQ-9 suggests moderate depression. What is the most appropriate first step?

• AAdvise her to rest and review in three months, since most episodes of depression resolve without any treatment
• BRefer urgently to the crisis team for assessment, since any diagnosis of depression requires same-day specialist input
• CStart a tricyclic antidepressant such as amitriptyline at a full therapeutic dose, since tricyclics are the most effective class for moderate depression
• DOffer a guided self-help or psychological intervention such as CBT, with an SSRI if she prefers or if therapy is unavailable✓

Answer: For less severe and moderate depression NICE recommends offering psychological interventions first, with an SSRI considered according to the person's preference. Tricyclics are not first line, crisis referral is for immediate risk, and delay is not treatment.

A 70-year-old man with COPD has had three exacerbations in the past year despite a long-acting muscarinic antagonist and a long-acting beta-agonist. His eosinophil count is raised. What is the next step?

• AAdd an inhaled corticosteroid to make triple therapy✓
• BStart long-term oral prednisolone at a low maintenance dose
• CAdd a short-acting beta-agonist to be used regularly four times a day
• DAdd oral theophylline

Answer: NICE recommends escalating to triple inhaled therapy (LAMA, LABA and ICS) for people with frequent exacerbations despite dual bronchodilation, particularly with asthmatic features or a raised eosinophil count. Long-term oral steroids are avoided, and regular SABA adds nothing.

A 35-year-old woman asks for advice about a first attack of migraine. Which lifestyle advice is most likely to reduce her attacks?

• ACutting out all dairy, wheat, chocolate and cheese regardless of whether they are triggers for her, since these foods cause migraine in everyone who is susceptible
• BKeeping a headache diary to identify triggers, regular meals and sleep, and limiting acute painkillers to fewer than ten to fifteen days a month✓
• CTaking a painkiller every morning before breakfast to prevent an attack starting, since regular analgesia keeps the pain threshold high
• DAvoiding all exercise and physical exertion, since a raised heart rate provokes migraine and rest is the only reliable way to keep attacks away

Answer: Identifying personal triggers, regular routine and avoiding medication overuse are the evidence-based basics. Daily painkillers cause medication-overuse headache, and blanket dietary exclusion has no evidence.

A 55-year-old man has a clinic blood pressure of 150/95 mmHg. What is the next step in diagnosis?

• AOffer ambulatory blood pressure monitoring (or home monitoring) to confirm the diagnosis✓
• BStart an antihypertensive immediately on the basis of the clinic reading
• CRequest an echocardiogram before making any diagnosis
• DRepeat the clinic reading in six months

Answer: NICE recommends confirming a clinic reading of 140/90 or above with ambulatory (or home) monitoring before diagnosing hypertension, because clinic readings overestimate the true blood pressure in many people.

A 30-year-old woman reports heavy menstrual bleeding with no other symptoms and a normal examination. She wants contraception too. What is the first-line treatment?

• AReferral for a hysterectomy as the definitive treatment
• BTranexamic acid taken during each period only
• CMefenamic acid taken during each period only
• DA levonorgestrel-releasing intrauterine system✓

Answer: NICE recommends the levonorgestrel IUS as first-line treatment for heavy menstrual bleeding when there is no structural cause, and it also provides contraception. Tranexamic or mefenamic acid are options for women who want to conceive or decline hormonal treatment.

A 72-year-old woman with osteoarthritis of the knee asks what she can do to reduce her pain. Which is the core NICE-recommended treatment?

• AGlucosamine and chondroitin supplements, which rebuild the cartilage over six to twelve months
• BLong-term oral opioids, titrated up until the pain is controlled
• CTherapeutic exercise and weight loss if overweight, with topical NSAID for the knee✓
• DIntra-articular steroid injections every month to keep the inflammation under control

Answer: Exercise, weight management and information are the core treatments for osteoarthritis, with topical NSAIDs recommended before oral ones for knee disease. Opioids are discouraged, glucosamine is not recommended, and steroid injections are for short-term relief only.