Using resources in the GPhC pre-registration exam
What is the best way to approach exam questions that include resources to help you answer the question?
Do you feel anxious and confused about how to tackle using resources during the GPhC exam? You should be glad to know that using an artefact or a resource is nothing new – actually, it is something you do in your everyday practice, whether you are a pre-registration (pre-reg) or provisionally registered (pro-reg) pharmacist.
Whatever sector of your practice, correctly finding and interpreting information in a resource or artefact is an important skill that guides and complements your knowledge and experience. It could be straightforward, eg looking up a dose, contraindications, adverse effects, drug interactions or complex task, for instance choosing the best treatment option in a guideline based on the patient history and other pertinent information. Whether you have a complex or straightforward task, it is important to develop a systematic approach at arriving at your decision. There are many ways of doing it, but whichever approach you choose is entirely up to you.
Here are some examples of using resources during the GPhC exam:
Question scenario 1: Blood and nutrition
A 60-year-old man weighing 60kg is due to commence treatment with desferrioxamine mesilate for established chronic iron overload. He has a ferritin level of 1900nanogram/mL.
Which one of the following is the most appropriate daily dose for this man?
Resource: Summary of product characteristics (smpc) for desferrioxamine mesilate
A: 1500mg/day
B: 2100mg/day
C: 3300mg/day
D: 3600mg/day
E: 5400mg/day
Click here for the comments and answer
First of all, read the full scenario fully and note the key pertinent information and be clear of what is being asked. In this case, it’s a dose for a 60kg man with a ferritin level of 1900ng/mL for chronic iron overload. Now you need to decide where on the smpc you are going to locate the information. It’s not good enough trying to go through the whole smpc as you’ve only got limited time to answer the question. Your previous practice with smpc should come in handy here as you would know that you would find doses under ‘Posology and method of administration’. We would advise using the table of contents and going straight to section 4.2 posology and method of administration. Next you need to locate the correct indication, which is ‘chronic iron overload’. Now go to the section on ‘dose’ and locate a dose related to a ferritin level of 1900ng (ie less than 2000ng/mL). The dose is 25 mg/kg/day. Calculate your daily dose as 60kgx25mg/kg/day = 1500mg/day.
Correct answer is A.
Reference: Hospira UK Limited (2001). Desferrioxamine mesilate smpc.
Question scenario 2: Cardiovascular system
Mr J is a 56-year-old white British man. He has a clinic blood pressure (BP) of 141/91mmHg and his subsequent average day-time Ambulatory Blood Pressure Monitoring (ABPM) reading is 136/86mmHg. His 10-year cardiovascular risk has been calculated to be 20%.
What is the best next step in managing hypertension in this man?
A: Amlodipine
B: Indapamide
C: Lifestyle measures only
D: Spironolactone
E: Ramipril
Click here for the comments and answer
This is a complex scenario because it requires piecing a lot of information together. As before, you should read the scenario fully and extract important information and be clear of what is being asked. The underpinning knowledge required here includes diagnosing hypertension and correct application of guidelines. Being familiar already with the hypertension treatment guidelines should help you to navigate to the right information quickly. Start off at ‘clinic BP’ and locate where your patient falls. The clinic BP falls between 140/90 to 179/119 mmHg. Then look under ABPM or HBPM and note that your patient falls under 135/85 to 149/94 mmHg (Stage 1 hypertension). Next, match information in the next box with pertinent information from your patient history. The patient has a 10-year CVD risk of greater than 10% (ie 20%) so he requires treatment in addition to lifestyle measures. Go to the next chart ‘choice of antihypertensive drug, monitoring treatment and BP targets’ and select a treatment that matches your patient. Patient aged 55 or over, so a calcium channel blocker (CCB) such as amlodipine is the best option.
Correct answer is A.
Question scenario 3: Endocrine system
A 50-year-old man weighing 80kg has attended the GP practice for a medical review. He suffers from type 2 diabetes and hypertension. He is taking the following regular drugs; atorvastatin tablets 20mg 1OD, neutral protamine Hagedorn (NPH) insulin 10 units BD, metformin m/r tablets 1000mg 1BD and ramipril capsules 10mg 1OD. His current measured HbA1c is 75 mmol/mol (9.0%). You have discussed blood glucose control with the patient and a decision has been made to change NPH insulin to Lantus.
What dose of Lantus would you most recommend?
Resource: Lantus (insulin glargine) smpc
A: 10 units BD
B: 14 units OD
C: 14-16 units OD
D: 16 units OD
E: 20 units OD
Click here for the comments and answer
Being familiar with the structure of the smpc will help you quickly locate the information you need. The question requires a dose for Lantus for a patient being changed from neutral protamine Hagedorn (NPH). Go onto section ‘4.2 Posology and method of administration’. Select the most relevant piece of information to read, in this case, it’s ‘switch from twice daily NPH insulin to Lantus’. Read off the reduction in basal insulin, ie 20-30% during the first weeks of treatment. For 20 units daily, reduction of 20% to 30% = 20 units - (4 units to 6 units) = 14 units to 16 units per day.
Correct answer is C.
Question scenario 4: Genitourinary system
A 26-year-old woman weighing 71kg presents at the GP practice for emergency contraception. She completed a course of rifampicin five weeks ago. She had unprotected sexual intercourse (UPSI) 16 hours ago. She is NOT on any form of contraception. You ascertain that the woman is most likely to ovulate in three days’ time. You have a Patient Group Direction available at the pharmacy for the supply of levonorgestrel (LNG) and ulipristal acetate (UPA). You have advised the woman that a copper intra-uterine device will need to be fitted.
What advice or treatment regarding emergency contraception is most appropriate?
A: 1x levonorgestrel 1.5mg stat
B: 1x ulipristal 30mg stat
C: 2x levonorgestrel 1.5mg
D: 2x ulipristal 30mg
E: Advise that woman that oral hormonal contraception is contraindicated
Click here for the comments and answer
You should identify key pertinent information from the scenario to help you apply the guidelines correctly. You should also have the underpinning knowledge on drug interactions related to emergency contraception. The key information for this woman includes weight (71kg), significance of prior use of rifampicin, time since UPSI (16hrs) and ovulation timing (in three days’ time). Go on the decision-making algorithm on page 14 of the resource, ‘Last UPSI <96 hours="" ago?’="YES," ‘upsi="" likely="" to="" have="" taken="" place="" ≤5="" days="" prior="" to="" the="" estimated="" day="" of="" ovulation’="‘Yes" or="" unknown’.="" also,="" the="" woman="" weighs="" more="" than="" 70kg.="" from="" here,="" select="" ‘ulipristal="" +="" start="" contraception="" in="" 5="" days’="" as="" the="" best="" option.="" the="" enzyme="" inducer="" was="" stopped="" more="" than="" four="" weeks="" ago="" so="" assume="" no="">
Correct answer is B.
Reference: FSRH (2019). Emergency Contraception.
Question scenario 5: High risk drugs
A 40-year-old woman weighing 70kg has attended hospital for chemotherapy treatment. She is receiving trastuzumab (Herceptin) infusion for metastatic breast cancer once per week every Monday at 9am. She has attended the appointment today, Tuesday at 9am, which is eight days after the last dose.
What is the best course of action?
Resource: smpc for trastuzumab (Herceptin)
A: Give 140mg now (Tuesday) and 140mg every Tuesday
B: Give 280mg now (Tuesday) and 140mg every Tuesday
C: Give 280mg now (Tuesday) and 280mg every Tuesday
D: Give 420mg now (Tuesday) and 420mg every Tuesday
E: Give 560mg now (Tuesday) and 420mg every Tuesday
Click here for the comments and answer
You should read the scenario fully to understand what you are being asked to do. A knowledge of the structure of the smpc would work to your advantage and save you time. The key information for this patient includes weight (70kg-needed to calculate the dose), indication (metastatic breast cancer-required so that you can locate the correct dose) and dosing schedule (weekly) and missed or delayed dose information (one day late as it is eight days after last dose).
Decide the section of the smpc that you are going to read based on what has been asked. In this instance, you are being asked to calculate a dose and the action to take for a delayed or missed dose. Go onto section ‘4.2 Posology and method of administration’. Next go to ‘Metastatic breast cancer’ and read off ‘Maintenance dose’ under weekly schedule as 2 mg/kg body weight. For a 70kg woman, this is 140mg every Monday. Read off the recommendation given further down the section under ‘missed doses’. The patient has missed less than one week, the guidance recommends 2 mg/kg now and seven days later according to the weekly schedule.
The correct answer is A.
Reference: Roche products limited (2019): Trastuzumab smpc.
Top tips
From the scenarios above, our advice is as follows:
- Be familiar with the relevant resources or artefacts that are most likely to be used during the GPhC exam and how they can be used quickly to get to the required information.
- Practise accessing and navigating through the various sections of these resources thoroughly.
- Read and understand the scenario fully before attempting to tackle it.
- Note down the key information in the scenario and work systematically to piece together your answer.
- Be alert to potential tricks, eg looking up under the wrong indication, wrong route of administration or wrong dose schedule.
Luso Kumwenda, MSc Community Pharmacy (Cardiff), B Pharm Hons (Zimbabwe), Independent Prescriber, MRPharms, Mentor at UKBPA & RPS.
Prof David R. Katerere, PhD Pharmaceutical Science (Strathclyde), Tshwane University of Technology.
Disclaimer: The views in this article are our own and do not represent the views of any organisations we are associated with.
Provisionally registered pharmacists, pre-registration trainees and those resitting the exam are likely to receive another update from the GPhC shortly, detailing the date – or dates – for the online exam, the regulator told C+D yesterday (November 18).
