ADC Practice Question — Cardiovascular disease — anticoagulants and antiplatelets

You are concerned about a potential drug interaction…

Pharmacology questions in the ADC written exam test applied prescribing decisions, not rote recall of drug names. This exam-level vignette tests your ability to work through clinical details and arrive at the correct management.

Mrs. Fatima Al-Rashid, a 75-year-old woman, presents for a routine dental check-up. She takes warfarin for atrial fibrillation. During examination, you discover a mobile, tender lower incisor (tooth 41) that she wishes to have removed. She also mentions she has been applying miconazole oral gel for oral thrush diagnosed by her GP last week. Her other medications include ramipril 5 mg and frusemide 20 mg daily. Her INR from 3 days ago was 2.6, but she does not have a more recent result. You are concerned about a potential drug interaction in this patient. Which combination poses the greatest risk?

A. Miconazole oral gel and warfarin, as miconazole inhibits warfarin metabolism and can significantly increase the INR
B. Frusemide and warfarin causing excessive anticoagulation through protein-binding displacement
C. Ramipril and warfarin causing an increased risk of angioedema
D. Ramipril and frusemide causing excessive hypotension during the dental procedure
E. Miconazole and ramipril causing acute kidney injury

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Sources cited

Therapeutic Guidelines v4 Odell's 3rd & 4th Ed IADT 2020 Code of Conduct CMS (Evans) Infection Control + more

Show the answer and cited explanation

Correct answer: A

Miconazole (including oral gel formulation) inhibits CYP2C9, the primary enzyme responsible for warfarin metabolism, and can significantly increase the INR, placing the patient at elevated bleeding risk. This is a well-documented drug interaction. The TG guidance on drug interactions and warfarin management emphasise the importance of considering all medications that affect anticoagulation. This makes the 3-day-old INR even less reliable.

Source: Ch 23: Drug interactions affecting warfarin — miconazole increases INR

Remy's study tip — For pharmacology vignettes, read the patient’s medical history and allergies BEFORE looking at the drug options.

Exam preparation FAQ

How should I prepare for Pharmacology & Therapeutics in the ADC exam?

Build competence across all topics. The exam tests application of guidelines to clinical scenarios, not memorisation.

How do I approach an unfamiliar Cardiovascular disease — anticoagulants and antiplatelets vignette?

Extract key clinical data from the stem before reading options. There are usually 3–4 critical variables that determine the correct answer.

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