ADC Practice Question — Ibuprofen and COX-2 inhibitors

Given this patient takes ramipril and frusemide, which additional risk must you consider if contemplating an NSAID?

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. After the extraction, you plan to prescribe analgesia. Given this patient takes ramipril and frusemide, which additional risk must you consider if contemplating an NSAID?

A. NSAIDs may cause hyperkalemia when combined with ramipril
B. There is no additional renal risk since the patient's kidney function has presumably been monitored by her GP
C. NSAIDs reduce the antihypertensive effect of ramipril, potentially causing a hypertensive crisis
D. Frusemide is nephrotoxic and adding an NSAID would compound the renal damage
E. The combination of NSAID + ACEI (ramipril) + diuretic (frusemide) significantly increases the risk of acute kidney injury — the 'triple whammy'

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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

According to TG, the risk of acute kidney injury is significantly increased when an NSAID is co-administered with an ACEI (or ARB) plus a diuretic — the 'triple whammy'. This patient on ramipril + frusemide must NOT be prescribed an NSAID. Paracetamol is the appropriate analgesic. This patient therefore has two independent reasons to avoid NSAIDs.

Source: Ch 5: Triple whammy — NSAID + ACEI + diuretic = acute kidney injury risk

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

Exam preparation FAQ

Should I memorise guidelines word-for-word for Ibuprofen and COX-2 inhibitors?

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

How are Ibuprofen and COX-2 inhibitors questions structured in the ADC written exam?

ADC Ibuprofen and COX-2 inhibitors questions present as clinical vignettes requiring management decisions. The correct answer is always traceable to a guideline source.

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Given this patient takes ramipril and frusemide, which additional risk must you consider if contemplating an NSAID?

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