ADC Practice Question — Combination analgesic therapy

Once the INR is managed and the extraction is eventually performed, what postprocedural pain management is most appropriate given that she is already taking maximum-dose paracetamol?

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. Li Wei, a 78-year-old woman, presents with a fractured upper left canine that requires extraction. Her medical history includes atrial fibrillation managed with warfarin, and she takes fluoxetine 20 mg daily for depression. She lives alone and mentions she has been taking Panadol Extra (paracetamol 500 mg + caffeine 65 mg) from the chemist for the pain, two tablets four times daily. Her INR from this morning is 4.1. Once the INR is managed and the extraction is eventually performed, what postprocedural pain management is most appropriate given that she is already taking maximum-dose paracetamol?

A. Switch to oxycodone 5 mg four-hourly as the sole analgesic
B. Add ibuprofen 400 mg three times daily since paracetamol alone is insufficient
C. Increase her paracetamol dose to 1.5 g four times daily for the first 48 hours post-extraction
D. Prescribe tramadol 50 mg four-hourly since it has fewer bleeding interactions than NSAIDs
E. Continue her current paracetamol regimen and add oxycodone 5 mg as required if pain is severe, with appropriate counselling

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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: E

Since the patient is already on maximum paracetamol and NSAIDs are contraindicated (warfarin + fluoxetine), oxycodone is the appropriate third-line option per TG. Oxycodone should be used in combination with non-opioid analgesics at the lowest dose. TG states tramadol is not recommended for dental pain, and it would risk serotonin toxicity with fluoxetine.

Source: Ch 5: Oxycodone preferred opioid; tramadol NOT recommended; avoid with SSRIs

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 are Combination analgesic therapy questions structured in the ADC written exam?

ADC Combination analgesic therapy questions present as clinical vignettes requiring management decisions. The correct answer is always traceable to a guideline source.

Should I memorise guidelines word-for-word for Combination analgesic therapy?

Focus on decision points — when the guideline says X vs Y. The exam tests application, not recitation.

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Once the INR is managed and the extraction is eventually performed, what postprocedural pain management is most appropriate given that she is already taking maximum-dose paracetamol?

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