Set 1: For each patient, select the most appropriate safety-related action.
A. Stop valproate immediately without specialist advice
B. Start valproate because pregnancy safety rules only apply after conception
C. Do not start valproate in a new patient under 55 unless required specialist conditions are met and documented
D. Supply folic acid only and continue unchanged
E. Reassure that valproate has no reproductive risks in men
F. Switch to St John’s wort
G. Urgent specialist review because valproate has strict reproductive safety requirements
H. Advise that contraception is unnecessary if periods are regular
1. A 24-year-old woman takes sodium valproate for epilepsy. She is sexually active, not using reliable contraception and says she may want pregnancy within the next year. She has not had specialist review for over 18 months.
Which option is most appropriate?
2. A 32-year-old man with newly diagnosed epilepsy is being considered for sodium valproate. He is under 55 and has not tried alternative antiseizure medicines. The prescriber asks whether the new valproate restrictions matter for men.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate safety-related action.
A. Stop isotretinoin permanently without contacting the specialist
B. Assess mental health and sexual side effects, advise urgent specialist contact if serious or worsening symptoms occur
C. Start topiramate for migraine in pregnancy because migraine is not epilepsy
D. Reassure that pregnancy prevention is unnecessary with topiramate
E. Prescribe isotretinoin without contraception counselling
F. Use oral antibiotics instead of all acne treatments
G. Increase topiramate dose before conception
H. Ensure Pregnancy Prevention Programme requirements are met and arrange specialist review before continuing or starting topiramate if pregnancy is possible
3. A 29-year-old woman takes topiramate for migraine prevention. She is not using reliable contraception and says she and her partner may start trying for pregnancy soon. She asks for a repeat prescription.
Which option is most appropriate?
4. A 17-year-old taking isotretinoin for severe acne reports new low mood, loss of interest, erectile difficulties and feeling “not like himself”. His parent says symptoms have worsened since treatment started.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate action.
A. Stop the fluoroquinolone and seek urgent prescriber review because serious adverse effects are suspected
B. Continue ciprofloxacin and add a corticosteroid for tendon pain
C. Treat tendon pain with strenuous exercise
D. Reassure that nightmares are unrelated to medicines
E. Increase montelukast dose
F. Review montelukast urgently because neuropsychiatric adverse effects are possible
G. Add another fluoroquinolone
H. Report symptoms only if hospital admission occurs
5. A 67-year-old woman taking levofloxacin develops sudden Achilles tendon pain and tingling in both feet after 3 doses. She was prescribed it for a mild infection where alternatives were available.
Which option is most appropriate?
6. A 9-year-old child started montelukast 3 weeks ago. His parent reports new nightmares, agitation, aggression and low mood. There was no previous mental health history.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate safety concern or action.
A. Increase pregabalin because sedation means pain is uncontrolled
B. Supply pseudoephedrine because severe hypertension is not relevant
C. Review gabapentinoid and opioid combination urgently because of respiratory depression risk
D. Reassure because pregabalin cannot affect breathing
E. Avoid pseudoephedrine and seek suitable alternatives because of serious hypertension/cerebrovascular risk concerns
F. Add benzodiazepine to reduce opioid adverse effects
G. Ignore drowsiness if pain score improves
H. Supply two decongestants together for stronger effect
7. A 74-year-old man with COPD takes morphine modified-release and pregabalin. His wife reports increasing drowsiness, slower breathing and several episodes where he is difficult to wake.
Which option is most appropriate?
8. A 58-year-old woman asks for pseudoephedrine for nasal congestion. Her blood pressure today is 188/106 mmHg and she has a history of TIA.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate pharmacist action.
A. Report the suspected adverse drug reaction through the Yellow Card scheme and document appropriately
B. Ignore suspected adverse reactions to established medicines
C. Reassure because nitrofurantoin only affects the bladder
D. Stop all antibiotics permanently
E. Urgent review for possible nitrofurantoin-associated pulmonary or hepatic toxicity
F. Rechallenge with nitrofurantoin immediately
G. Report only if the reaction is definitely proven
H. Give particular attention to suspected adverse reactions because black triangle medicines are under additional monitoring
9. A 76-year-old woman has taken nitrofurantoin prophylaxis for recurrent UTI for 8 months. She now has persistent cough, breathlessness, fatigue and abnormal liver function tests.
Which option is most appropriate?
10. A patient starts a newly marketed medicine marked with a black triangle. Two weeks later they develop a suspected adverse reaction that is not listed clearly in the patient leaflet.
Which option is most appropriate?
Answers and Rationale
1. G
Valproate has strict reproductive safety requirements because of serious pregnancy-related risks. A woman of childbearing potential who is not using reliable contraception and may want pregnancy needs urgent specialist review, not abrupt unsupervised stopping.
2. C
Current MHRA safety measures apply to new male and female patients under 55. Valproate should not be newly started unless required specialist conditions are met, considered and documented.
3. H
Topiramate has a Pregnancy Prevention Programme because of risks if used during pregnancy. A patient who could become pregnant and is considering pregnancy needs specialist review and contraception/pregnancy-prevention discussion before continuation or initiation.
4. B
Isotretinoin safety measures include improved assessment and monitoring of mental health and sexual function. New or worsening mood or sexual symptoms should be taken seriously, with urgent specialist advice if severe or worsening.
5. A
Fluoroquinolones are associated with rare but potentially disabling or long-lasting adverse effects, including tendon injury and peripheral neuropathy. New tendon pain or neuropathic symptoms should prompt stopping and urgent prescriber review.
6. F
Montelukast can be associated with neuropsychiatric reactions, including sleep disturbance, agitation, aggression and mood changes. New behavioural or mood symptoms after starting treatment should trigger urgent review.
7. C
Gabapentinoids can increase respiratory depression risk, especially with opioids, respiratory disease and older age. Increasing drowsiness and slow breathing require urgent medicines review and clinical assessment.
8. E
Pseudoephedrine can raise blood pressure and has safety concerns in people with severe or uncontrolled hypertension or cerebrovascular risk. It should be avoided here and safer alternatives considered.
9. E
Long-term nitrofurantoin can rarely cause pulmonary and hepatic toxicity. Persistent cough, breathlessness, fatigue and abnormal liver function tests require urgent review of nitrofurantoin and clinical assessment.
10. H
Black triangle medicines are under additional monitoring. Suspected adverse reactions should be reported through Yellow Card, especially for new medicines, even if causality is not certain.
Here are 10 extended matching questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.