Prescribing & Prescribing Assessment | Bradford VTS

Bradford VTS · Clinical Skills

Prescribing & Prescribing Assessment

Because handing someone a piece of paper with the wrong drug on it is frowned upon — in both real life and the exam.

High-yield tips for AKT & SCA For Trainees, Trainers & TPDs Knowledge not found elsewhere

By Dr Ramesh Mehay & Sabah Malik | Last updated: April 2026

Prescribing is one of the most powerful — and most dangerous — things you do as a GP. Every day you write dozens of decisions that will follow patients home. This page covers safe prescribing principles, the cytochrome P450 system, QT interval, practical medication management, prescribing pearls by specialty, and everything you need to know about the MRCGP Prescribing Assessment.

📥 Downloads

Prescribing Handouts & Resources

Handouts, summaries, and teaching extras — ready when you are. Includes prescribing tutorials, medication review frameworks, error analyses, opioid conversion charts, and more.

path: PRESCRIBING

🌐 Web Resources

A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best prescribing pearls are not hiding in the official documents.

📘 Core Clinical Guidance

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BNF Online

The prescriber's bible. Doses, interactions, cautions — all in one place. Bookmark it.

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NICE CKS

Clinical Knowledge Summaries — first-line GP guidance including prescribing decisions for common conditions.

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Shared Care Guidelines (SWY APC)

South & West Yorkshire guidelines for shared care prescribing — drugs initiated in secondary care but monitored in GP.

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CredibleMeds / AZCERT

The definitive resource for QT-prolonging drugs. Check any drug before co-prescribing with other QT-prolongers.

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MDCalc — Corrected QT (QTc)

Calculate the corrected QT interval online. Essential when assessing QT prolongation risk in practice.

🎓 GP Training Resources

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RCGP — Prescribing Assessment

Official RCGP page for the mandatory ST3 prescribing assessment, with all supporting documents and spreadsheets.

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BVTS Videos on Prescribing

Bradford VTS YouTube playlist covering prescribing topics including OSCEs — practical and exam-focused.

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MHRA Yellow Card Scheme

Report suspected adverse drug reactions. Every GP must know how and when to report. AKT favourite.

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SIGN — Polypharmacy & Realistic Prescribing

Excellent Scottish guidance on managing polypharmacy, deprescribing, and medication review — highly practical.

🎯 Exam & Revision Resources

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BBC — How Did We Mess Up Antibiotics?

A fascinating listen on antibiotic prescribing and AMR. Excellent for SCA conversations about antibiotics and patient expectations.

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NICE Patient Decision Aids

Shared decision-making tools — including statins with Cates diagrams. Excellent for SCA shared decision-making practice.

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PrescQIPP

NHS prescribing quality improvement resource — bulletins on cost-effective prescribing, generics, and medicines optimisation.

⚡ Quick Summary — One-Minute Recall

If you've got 60 seconds before a tutorial, a clinic, or a mild existential crisis about prescribing — start here.

⚡ The Ten Things Every GP Trainee Must Know About Prescribing

Always prescribe generically (except inhalers — prescribe by brand)
CYP450 inducers speed up drug metabolism (SCRAP GPS); inhibitors slow it down (SICKFACES.COM G)
QTc prolongation: worry if increase >10 msec; dangerous if >20 msec
High-risk interactions: warfarin, lithium, digoxin, methotrexate, theophylline
Never write "as directed" on a prescription — always spell out the dose
Metformin: stop if eGFR <30; caution if eGFR <45 (lactic acidosis risk)
NSAIDs: naproxen safer than ibuprofen; never use diclofenac routinely; avoid in IHD/CVD
All ST3 trainees must complete the MRCGP Prescribing Assessment — a review of 50 retrospective prescriptions
Deprescribe in polypharmacy — stopping medication can be as therapeutic as starting it
Yellow Card: report suspected adverse drug reactions to the MHRA — anyone can report, not just doctors

✅ Safe Prescribing Core

Check allergies before prescribing
Check interactions (BNF Appendix 1)
Check renal/hepatic function for appropriate drugs
Document indication in records
Give appropriate safety-netting advice

🚨 Never Miss These

Prescribing in pregnancy without checking safety
NSAIDs in heart failure or eGFR <30
ACEi/ARBs in pregnancy (teratogenic)
Methotrexate weekly — not daily (fatal errors have occurred)
Warfarin + NSAIDs = major bleed risk

💡 Quick Wins

Use BNF interactions checker — it's free and fast
Amber drugs need secondary care initiation and GP monitoring
Max 2 months' supply for routine repeats
Add monitoring reminders to the patient record
Sick day rules: stop metformin, ACEi/ARB, NSAIDs if dehydrated/unwell

💡 Why This Matters in GP

The Scale of the Problem

Prescribing errors are one of the leading causes of preventable patient harm in the NHS. Studies suggest that around 1 in 20 prescriptions in UK general practice contains an error or suboptimal choice — not always dangerous, but always preventable.

The PRACtICe study found that prescribing errors occur in 4.9% of all GP prescriptions, with around 0.2% being potentially serious.

Why Trainees Struggle

Speed — feeling pressure to prescribe quickly
Unfamiliarity with local formularies and Amber drug rules
Confusion about generic vs brand names
Not routinely checking interactions
Not thinking about the patient's whole drug list
Repeating hospital prescriptions without reviewing them

💡 The Bigger Picture

Prescribing is not just a clinical skill — it's a consultation skill. How you explain a new medication, explore patient concerns about side effects, share decisions about starting or stopping treatment, and safety-net appropriately are all assessed in the SCA. A technically correct prescription issued without shared decision-making is a near-fail in the exam — and a missed opportunity in real life.

📚 Core Knowledge

The foundations of safe GP prescribing — from writing a prescription to managing repeat medication systems.

🛡️ Safe Prescribing Principles

General Principles

Prescribe generically where possible (but brand for inhalers)
Avoid combined products unless specifically needed
Avoid liquid medicines for adults — they are very expensive
Avoid orodispersible formulations — more expensive without clear benefit
Avoid dietary supplements as first line — use dietitian referral pathway
Limit OTC items — can the patient buy it themselves?
Issue electronically wherever possible — handwritten = more errors
Don't give "a pill for every ill" — ask if medication is truly needed

NHS Cost-Saving Defaults

No bath emollients or shower gels — use plain emollient
No branded erectile dysfunction treatment — generics are pennies
Avoid liothyronine unless initiated by secondary care
Only prescribe licensed colecalciferol — avoid unlicensed versions
Use only low-cost pen needles and glucose test strips
Avoid liquid/suspension for adults unless truly unable to swallow tablets (e.g. nitrofurantoin suspension ≈ £500 vs tablets at pence)
No glucosamine on NHS
No nicotinic acid or omega fish oils routinely

✍️ Writing a Prescription

🚨 Never Write "As Directed"

Writing "ASD" or "as directed" on a prescription is dangerous and unacceptable. Always spell out the dose, frequency, and duration precisely. The patient needs to know — and so does the pharmacist.

Key Writing Rules

Liquid medicines — write the dose in mg. Let the pharmacist work out the mls. E.g. "Amoxicillin 250mg TDS" — the pharmacist calculates the volume.
Dose — spell out every element: drug name, dose, form, frequency, duration, quantity
Abbreviations — avoid abbreviations that cause errors (OD vs QDS; mcg not μg — μ can be misread as m, giving 1000× the intended dose)
Decimal points — never use trailing zeros (1.0mg → write 1mg); always use leading zeros (0.5mg, never .5mg)
Controlled drugs — quantity must be in words AND figures

📦 Supply Rules at a Glance

Situation	Maximum Supply	Notes
Standard repeat prescription	2 months (56–62 days)	Standard rule for most medications
Travelling / long absence	3 months (NHS)	E.g. cruise ship workers, oil rig, overseas posting
Controlled drugs (schedule 2/3)	30 days	Legal maximum for most CDs
High-risk or monitoring drugs	Clinician discretion	Consider shorter supply until monitoring confirmed
Dosette tray prescriptions	28 days (4 trays)	Issue 7 × 4 trays; adjust if weekly issue needed

🧬 The Cytochrome P450 System

The liver's enzyme system — the source of half of all prescribing interactions in general practice. Once you understand it, a lot of drug interactions start to make sense.

What Is It?

The cytochrome P450 (CYP450) system is the liver's main enzyme system for metabolising drugs and foreign chemicals. It is named because it is found in cell membranes (CYTO = cell), contains a haem pigment (CHROME + P), and absorbs light at 450nm.

Its functions include: producing cholesterol and natural steroids; detoxifying foreign chemicals; and metabolising drugs so they don't linger in the body indefinitely.

Think of it as the body's own processing plant for drugs. When the plant runs faster or slower, drug levels change — sometimes dangerously.

🔴 Inducers — Speed Up Metabolism

Inducers increase the rate of drug metabolism by 2–3× over 1 week. The drug being metabolised is cleared faster, so it may become ineffective.

Clinical consequence: A patient on warfarin who starts rifampicin will have reduced anticoagulation — their INR will fall and they may clot.

🧠 Mnemonic: SCRAP GPS

Sulphonylureas

Carbamazepine

Rifampicin

Alcohol (chronic)

Phenytoin

Griseofulvin

Phenobarbital

St John's Wort

🟡 Inhibitors — Slow Down Metabolism

Inhibitors decrease the rate of drug metabolism by 2–3×. The drug being metabolised persists longer, so its effect is enhanced — and potentially toxic.

Clinical consequence: A patient on warfarin who starts metronidazole will have enhanced anticoagulation — their INR will rise and they may bleed.

🧠 Mnemonic: SICKFACES.COM G

Sodium valproate

Isoniazid

Cimetidine

Ketoconazole

Fluconazole

Alcohol (binge)

Chloramphenicol

Erythromycin

Sulfonamides

Ciprofloxacin

Omeprazole

Metronidazole

Grapefruit juice

Drugs That Interact With CYP450 Inducers/Inhibitors

These are the drugs whose levels are changed when inducers or inhibitors are co-prescribed. They are the drugs at risk:

Warfarin COCP Corticosteroids Tricyclic antidepressants Statins Theophylline Pethidine Ciclosporin Tamoxifen

🍊 Grapefruit Juice — The Classic AKT Topic

Grapefruit juice inhibits CYP3A4 in the gut wall. This increases absorption of many drugs — statins, calcium channel blockers, certain antihistamines, immunosuppressants. The effect is dose-dependent (more juice = more inhibition) and can last several days with regular consumption. Other citrus juices do not have this effect.

🔬 A Real-World CYP450 Scenario Worth Remembering

A patient with breast cancer on tamoxifen comes to you with depression. You consider prescribing an antidepressant. Do not prescribe paroxetine or fluoxetine — they are strong CYP2D6 inhibitors that reduce conversion of tamoxifen to its active metabolite, reducing its anti-cancer effect and increasing risk of cancer recurrence. Use citalopram or venlafaxine instead.

💓 QT Interval & QT Prolongation

One of the most important prescribing safety topics in GP — and a reliable AKT favourite. Know this cold.

What Is the QT Interval?

The QT interval is the time from the start of the Q wave to the end of the T wave on ECG. It represents the time taken for ventricular depolarisation and repolarisation.

During repolarisation there is a relative refractory period — if an electrical stimulus arrives during this window, premature ventricular depolarisation can occur, leading to dangerous arrhythmias, most notably Torsades de Pointes (TdP).

This is why we watch the QT interval so carefully with certain drugs.

Normal & Abnormal Values

Sex	QTc Normal	Prolonged
Men	<440 msec	>440 msec
Women	<470 msec	>470 msec

Always correct the QT for heart rate — use Bazett's formula (QTc = QT/√RR). If heart rate <60 or >100 bpm, use Fridericia's formula instead as Bazett's becomes inaccurate at extremes.

Calculate QTc online at MDCalc →

How Much Should I Worry?

QTc Increase	Risk Level	Action Required
≤10 msec increase	Mild/Low	Usually safe. BUT be careful when combining multiple mildly prolonging drugs — the cumulative effect can push into moderate range.
10–20 msec increase	Moderate	Clinically significant. Assess risk vs benefit. Consider dose reduction or switching to alternative. Monitor with repeat ECG.
>20 msec increase	High/Dangerous	Act now. Stop the offending drug if possible. Switch to an alternative. Arrange urgent ECG and monitoring. Refer if needed.

Common QT-Prolonging Drugs in GP (Moderate Effect)

Drug Class	Examples
Antibiotics	Erythromycin, clarithromycin, azithromycin, ciprofloxacin
Antidepressants	Citalopram, escitalopram, clomipramine, quetiapine
Anti-emetics	Ondansetron
Antifungals	Fluconazole
Antipsychotics	Haloperidol, chlorpromazine, risperidone, amisulpride, levomepromazine, zuclopenthixol
Addiction treatment	Methadone (especially >100mg/day), lofexidine
Cardiac	Amiodarone, sotalol, flecainide
Other	Hydroxyzine, hydroxychloroquine, tolterodine, quinine, sildenafil

💡 QT Prolongation — Non-Drug Causes (Don't Forget)

Electrolyte imbalances — especially hypokalaemia, hypomagnesaemia, hypocalcaemia
Ischaemic cardiac disease or post-cardiac arrest
Hypothermia
Raised intracranial pressure
Congenital long QT syndrome — 1 in 2000; leading cause of sudden cardiac death in young people; often asymptomatic until first event

🚨 QT Prolongation — Practical Red Flags

Patient on methadone >100mg/day — high QT prolongation risk; request baseline ECG
Co-prescribing two or more QT-prolonging drugs — even mild QT drugs can combine dangerously
Elderly patient on antipsychotic + macrolide antibiotic — classic dangerous combination
Patient on citalopram 40mg + azithromycin — both moderate QT prolongers
Any new palpitations, syncope, or presyncope in patients on QT-prolonging drugs — check ECG urgently

💎 Prescribing Pearls by Specialty

High-yield prescribing tips from across the clinical spectrum — the kind your trainer knows but might not think to mention.

⚠️ High-Interaction Drugs — Extra Caution When Co-Prescribing

Whenever a patient is already on one of the following, check for interactions carefully before adding any new medication. These have narrow therapeutic windows, complex pharmacokinetics, or serious consequences if levels shift:

Gentamicin Warfarin Lithium Digoxin Theophylline Methotrexate Phenytoin Insulin Ciclosporin

💊 Analgesia & NSAIDs+

🥇 First Principle

Follow the WHO pain ladder. Start with paracetamol. Then add a weak opioid (e.g. codeine). Then strong opioids. Don't prescribe randomly — work up the ladder systematically.

NSAID Summary

NSAID	Key Points	Use?
Naproxen	Best GI safety profile of non-selective NSAIDs. Stronger than ibuprofen.	First Choice
Ibuprofen	Weaker anti-inflammatory. Fewer side effects than naproxen. Less powerful for inflammatory conditions.	Second Choice
Diclofenac	High GI ulcer and cardiovascular risk. Avoid routinely in primary care.	Avoid
Etoricoxib / Celecoxib (COX-2)	Fewer GI events. Do NOT prescribe in IHD, PVD, CVD, or CHF grade 2–3. Etoricoxib licensed for acute gout.	Selective Use
NSAID gels (Ibugel, Voltarol)	Consider before oral NSAIDs in musculoskeletal conditions — far safer profile.	Consider First

⚠️ NSAID + PPI Rule

Give a PPI with NSAIDs if: patient is aged ≥65 OR has high-risk factors (history of gastric/duodenal ulcers, GI bleeding, on blood thinners, aspirin 300mg, prednisolone, or SSRIs). Yes — SSRIs increase GI bleed risk too.

💡 Non-Opioid Adjuvants

Consider amitriptyline (neuropathic / musculoskeletal). Avoid gabapentinoids (gabapentin, pregabalin) where possible — high misuse potential, increasingly controlled. If you do use them, titrate up slowly and taper down slowly to avoid withdrawal seizures.

Individual NSAID Profiles — A Brief Rundown

NSAID	Key Clinical Note
Ibuprofen	Fewer side effects than other non-selective NSAIDs but weaker anti-inflammatory. Not ideal where inflammation is prominent. Dexibuprofen is the active enantiomer — similar profile.
Naproxen	First-choice non-selective NSAID. Good efficacy with lower GI incidence than most — better than ibuprofen for inflammatory conditions.
Ketoprofen	Similar efficacy to ibuprofen but more side effects. Dexketoprofen licensed for short-term mild-to-moderate pain only.
Etodolac	Comparable to naproxen in efficacy. Licensed for osteoarthritis and rheumatoid arthritis.
Indometacin	Efficacy equal to or greater than naproxen, but high incidence of side effects including headache, dizziness, and GI disturbance.
Mefenamic acid	Minor anti-inflammatory properties. Occasionally causes diarrhoea and haemolytic anaemia — stop if these occur.
Meloxicam	Licensed for short-term osteoarthritis pain relief and long-term treatment of rheumatoid arthritis and ankylosing spondylitis.
Nabumetone	Comparable effect to naproxen.
Piroxicam	As effective as naproxen. Once-daily dosing. However, more GI side effects than most NSAIDs and more frequent serious skin reactions — use with caution.
Tolfenamic acid	Licensed specifically for acute migraine treatment.
Diclofenac	High cardiovascular and GI risk. Avoid routinely in primary care — use naproxen instead.

🌶️ Capsaicin — Use Sparingly

When prescribing or advising capsaicin cream for musculoskeletal or neuropathic pain: use only a small amount rubbed into the skin. A large blob does not mean more effect — it just means chilli-like burning that won't help the pain and will irritate the patient.

🚫 Do Not Prescribe Diazepam for Back Pain

Despite its historical use, diazepam is not recommended for low back pain (NICE NG59). It provides minimal benefit for musculoskeletal pain and carries significant risks of dependence, sedation, and falls — especially in older patients. Refer to NICE guidance on low back pain for evidence-based management.

❤️ Cardiovascular Prescribing+

After starting an ACEi or ARB — check U&Es and eGFR 2 weeks later. Stop or reduce dose if eGFR falls >25% or creatinine rises >30%.
Verapamil + diltiazem — never co-prescribe. Combined negative chronotropic effect → profound bradycardia. Mnemonic: VD (don't combine V and D).
Reduce diuretics in elderly patients during summer — risk of dehydration and AKI.
Know the features of digoxin toxicity: nausea, vomiting, yellow/green visual disturbance, bradycardia. Monitor serum levels.
Beta-blockers are contraindicated in asthma — even "cardioselective" ones carry risk.
For palliative heart failure breathlessness: low dose oral morphine (5mg MR BD or 2.5–5mg PRN). If eGFR <50, consider oxycodone instead. Keep total daily dose below 30mg morphine equivalent — higher doses associated with increased mortality in this context.

🧠 Mental Health Prescribing+

Antidepressants take 4–6 weeks to work. Tell patients clearly. Encourage them to persevere for at least 4 weeks before judging.
Do NOT over-emphasise possible worsening of mood when starting SSRIs. If you over-egg this, the nocebo effect makes it more likely to happen.
Tapering SSRIs — always reduce slowly when stopping. Abrupt cessation causes discontinuation syndrome (dizziness, flu-like symptoms, electrical sensations).
Paroxetine or fluoxetine + tamoxifen — contraindicated. Use citalopram or venlafaxine instead (see CYP450 section).
Lithium — know the toxicity features: coarse tremor, confusion, ataxia, vomiting, diarrhoea, seizures. Monitor serum levels every 3–6 months. NSAIDs and diuretics raise lithium levels → toxicity.
Propranolol — if patient has significant suicidal risk, prescribe with caution and in limited quantities. Propranolol overdose is associated with increasing mortality — always consider whether ongoing prescription is appropriate.
Do not prescribe benzodiazepines (diazepam, lorazepam) or Z-drugs (zopiclone, zolpidem) for insomnia or anxiety without careful consideration. Regular use for more than 2 weeks renders them ineffective for sleep and creates dependency.

🌿 Dermatology Prescribing+

Topical Steroid Strengths

Strength	Examples	Use
Mild	Hydrocortisone 1%	Face, flexures, children, mild eczema
Mild/Moderate	Clobetasone butyrate (Eumovate)	Moderate eczema, short-term use
Moderate	Mometasone (Elocon), Beclomethasone valerate 0.025%	Non-facial eczema, psoriasis
Potent	Clobetasol propionate (Dermovate)	Severe eczema, psoriasis — limited areas only

Limit topical steroids to 2 weeks maximum for most uses — long-term use causes skin atrophy, telangiectasia, and striae.
Ointments penetrate better than creams — use ointments where you need efficacy; creams where patients prefer cosmesis.
Always explain to patients that long-term unsupervised steroid use will damage the skin.

🫁 Respiratory Prescribing+

Never prescribe beta-blockers in asthma — even "cardioselective" drugs (bisoprolol, atenolol) carry bronchospasm risk.
When stopping oral steroids prescribed for more than 2 weeks — always taper down. Never stop abruptly. Risk of adrenal crisis increases with: 4+ weeks of steroids; repeated short courses; high-dose inhaled steroids; multiple steroid preparations.
Adrenal crisis risk persists for up to 12 months after stopping regular steroids. Patients must carry a Steroid Emergency Card.
Always prescribe inhalers by brand name — different inhalers have different dose delivery; the generic is not interchangeable.
Nasal steroid sprays should not be prescribed long-term without review — prolonged use damages the nasal mucosa.

👴 Elderly Prescribing & Polypharmacy+

✅ Core Principle

In elderly patients — especially those who are frail — consider deprescribing at every medication review. Stopping medication can be as beneficial as starting it. The goal is medicines optimisation, not maximisation.

Strong evidence that stopping psychotropic drugs (including opioids) reduces falls. A psychotropic medication approximately doubles fall risk.
Nitrofurantoin — long-term use (>6 months) is associated with pulmonary toxicity. Review regularly. Avoid for prophylaxis in very frail patients.
Overactive bladder medications (antimuscarinics) can cause dizziness, confusion, blurred vision in elderly — consider stopping if these features develop.
Reduce diuretics in summer to prevent dehydration and AKI.
Sick day rules: stop metformin, ACEi/ARB, NSAIDs when dehydrated or acutely unwell — document this advice every time you prescribe these drugs.
STOPP/START criteria — use these when reviewing polypharmacy in elderly patients. Commonly tested in AKT.

🤰 Prescribing in Pregnancy & Breastfeeding+

🚨 Drugs to Avoid in Pregnancy (Key Examples)

ACEi and ARBs — teratogenic; cause renal malformations, oligohydramnios, neonatal renal failure
NSAIDs — avoid especially in third trimester; premature closure of ductus arteriosus
Statins — discontinue during pregnancy; cholesterol required for fetal development
Methotrexate — highly teratogenic; stop at least 3 months before conception in both sexes
Sodium valproate — major teratogen; neural tube defects; requires Pregnancy Prevention Programme
Tetracyclines — affect bone and tooth development; avoid in pregnancy and under 12s
Warfarin — teratogenic in first trimester; use LMWH instead in pregnancy

✅ Drugs Generally Safe in Pregnancy

Paracetamol (first choice analgesic), penicillins, cephalosporins, erythromycin (not clarithromycin), metformin (for GDM — supervised use), low-dose aspirin (from 12 weeks in pre-eclampsia prevention), folic acid 400 micrograms daily (or 5mg if high risk).

💉 Palliative Care Prescribing+

If pain is not controlled — increase the 24-hour opioid dose by one third. E.g. MST 30mg BD → 40mg BD.
Breakthrough dose = one-sixth of the total daily opioid dose. Always update this when you increase the regular dose.
When starting a syringe driver — do NOT remove an existing opioid patch. Continue it and change as scheduled. Add any increase to the driver and update the PRN dose calculation.
Not all pain is opioid-responsive. If opioid dose increases are not helping — consider an adjuvant. Bone pain from metastases responds better to NSAIDs than opioids.
Know opioid toxicity signs: confusion, hallucinations, picking at invisible things in mid-air, myoclonic jerks. Usually caused by too-rapid dose escalation or renal impairment.
Levomepromazine is an excellent anti-emetic in palliative care — covers many receptor types, long half-life. Oral/SC dose for nausea: 2.5–6.25mg. The 25mg tablets cut into quarters are considerably cheaper than 6mg tablets.

🦠 Antibiotic Prescribing & AMR+

Follow local antibiotic guidelines — these vary by area and are updated regularly. Always check your local formulary.
The COCP is only reliably affected by the rifampicin family (rifampicin, rifabutin). Most common antibiotics (amoxicillin, trimethoprim, erythromycin) do NOT reduce pill efficacy unless the patient develops severe vomiting or diarrhoea.
If a patient on the COCP has severe vomiting or diarrhoea (from any cause including antibiotics or orlistat) — advise condom use during the illness and for 7 days after.
Enzyme-inducing drugs (rifampicin, some anti-epileptics, St John's Wort, HIV medications) DO reduce COCP efficacy — dose adjustment or alternative contraception required.
Long-term nitrofurantoin prophylaxis — consider pulmonary toxicity risk. Avoid for more than 6 months without review.
Antibiotic stewardship: explore back-up/delayed prescriptions for mild infections. Safety-net clearly and explain the reasoning — this is prime SCA territory.

👶 Prescribing in Children+

⚖️ Weight Estimation in Children

Age 1–10 years:
Weight (kg) = (Age in years + 4) × 2

Under 1 year:
3 months ≈ 6kg | 6 months ≈ 8kg | 9 months ≈ 9kg

Always calculate doses by weight in children — never use adult doses
Avoid tetracyclines under 12 (dental and bone effects)
Avoid aspirin under 16 (risk of Reye's syndrome)
Always use the BNFC (BNF for Children) — regular BNF does not cover paediatric doses
Eye drops drain down the nasolacrimal duct — eye ointment (e.g. chloramphenicol ointment) gives better contact time than drops

🍼 Infant Formula Feeding Volumes — A Guide for GP Consultations

Useful reference when advising parents concerned about whether their baby is feeding adequately:

Age	Volume per Feed	Frequency
Newborn / first few weeks	45–90 ml (1.5–3 oz)	Every 2–3 hours
2 months	120–150 ml (4–5 oz)	Every 3–4 hours
4 months	120–180 ml (4–6 oz)	Per feed as needed
6 months	180–230 ml (6–8 oz)	About 4–5 times a day

Volumes increase as the baby grows. Always reassure parents that demand feeding is appropriate and brief fluctuations in intake are normal. If concerned about weight gain, weigh and plot on centile chart.

🔗 Dependency-Prone & High-Risk Drug Groups+

⚠️ The Four High-Dependency Drug Groups

Opioids — including tramadol. High abuse potential. Avoid in under-65s except for specific indications.
Gabapentinoids — gabapentin and pregabalin. Class C controlled drugs. Black market value. Titrate up and taper down (seizure risk on abrupt withdrawal).
Benzodiazepines — diazepam, lorazepam, temazepam. High addiction potential. Avoid for insomnia or anxiety as a long-term solution.
Z-drugs — zopiclone, zolpidem. Stop working after 2 weeks of regular use. Significant dependency and cognitive effects, especially in elderly.

Starting any of these drugs, even at age 65, means an expected 15+ years of use. Many patients describe significant life improvement when gradually withdrawn after years of dependency. Discuss alternatives, coping strategies, and non-pharmacological approaches before prescribing.

🩸 Haematology & Endocrine Prescribing+

Haematology

💊 Ferrous Fumarate / Ferrous Sulphate or Folic Acid — Give a 3–4 Month Course

Iron stores take time to replenish after the haemoglobin normalises. A 3–4 month course is needed to fully restore iron stores. Do not repeat blood tests until the 3-month mark — there is no point checking sooner. The course is the treatment; premature blood testing leads to unnecessary review and patient anxiety.

Same principle applies to folic acid supplementation where stores need rebuilding.

Endocrine

🦋 Levothyroxine — Be Guided by the TSH

When deciding whether to increase, decrease, or maintain the levothyroxine dose, use the TSH as your primary guide. Do not adjust dose based on symptoms alone — the TSH is your objective measure of thyroid hormone adequacy. Target TSH is typically 0.4–2.5 mU/L for most adults, though a slightly higher target may be appropriate in the elderly or in those with cardiac disease (per BNF).

Recheck TSH 6–8 weeks after any dose change (takes time for the pituitary to reflect the new steady state)
Once stable, annual TSH monitoring is usually sufficient
Liothyronine (T3) should NOT be initiated in primary care — secondary care only, in rare cases

🚨 Red Flags & High-Risk Prescribing Scenarios

The prescribing errors and scenarios that can cause serious patient harm. Know these by heart.

🚨

Methotrexate prescribed daily instead of weekly. This error has killed patients. Methotrexate for inflammatory conditions is a WEEKLY drug. Always document clearly on the prescription and patient record. The most common fatal prescribing error in UK primary care.

🚨

NSAIDs in heart failure or severe CKD (eGFR <30). NSAIDs cause sodium and water retention, worsen heart failure, and can precipitate AKI. Absolutely avoid.

🚨

ACEi or ARB in pregnancy. Teratogenic at all stages of pregnancy. Causes renal dysgenesis, oligohydramnios, and neonatal renal failure. Switch to alternative antihypertensive (labetalol, nifedipine, methyldopa) before conception where possible.

🚨

Sodium valproate in women of childbearing potential without a Pregnancy Prevention Programme. Valproate causes neural tube defects and neurodevelopmental problems. Must be on the MHRA Pregnancy Prevention Programme. Annual acknowledgement form required.

🚨

Co-prescribing warfarin with NSAIDs, antibiotics, or enzyme-inducing drugs without monitoring INR. Warfarin has a narrow therapeutic index. Any new drug can destabilise INR. Always warn patient and arrange INR check.

🚨

Lithium + NSAIDs or diuretics. NSAIDs and diuretics reduce renal clearance of lithium, causing toxic accumulation. Monitor lithium levels urgently if either is added.

🚨

Continuing sick-day risk drugs when patient is dehydrated or acutely unwell. Metformin (lactic acidosis), ACEi/ARB (AKI), NSAIDs (AKI) — all must be stopped when patient is dehydrated. Document sick day advice every time you prescribe these.

🚨

QT-prolonging drugs in a patient already on QT-prolonging drugs. Additive QT prolongation can cause Torsades de Pointes and sudden death. Always check CredibleMeds before adding any new drug with QT-prolonging potential.

🚨

Beta-blockers in asthma. Even "cardioselective" beta-blockers can precipitate fatal bronchospasm in asthma. Always check respiratory history before prescribing.

🚨

Prescribing by brand name for inhalers but generically for everything else — and getting it the wrong way around. Inhalers MUST be prescribed by brand (device matters for dose delivery). Everything else should be generic.

⚠️ Common Pitfalls & Trainee Traps

The mistakes trainees make most often. Some are embarrassing. Some are dangerous. All are avoidable once you know about them.

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Accepting hospital discharge prescriptions without reviewing them. Hospitals frequently start medications that are not appropriate long-term, miss interactions with existing drugs, or forget to include monitoring requirements. Never just put a discharge medication onto the repeat template without reviewing it carefully.

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Not checking the whole drug list before prescribing. A trainee who prescribes a new drug without checking the rest of the patient's medications is making one of the most dangerous prescribing errors possible. Every new prescription needs a quick interaction check.

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Giving 3 months of a drug on first prescription. When starting a new medication, give a shorter supply initially — 4–6 weeks is often appropriate — to review efficacy and tolerability before committing to larger quantities.

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Forgetting to document the indication in the patient record. If you don't document why you prescribed it, no-one (including future you) will know. This also makes medication reviews much harder and risks the drug being continued indefinitely without reason.

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Prescribing lansoprazole 30mg indefinitely without stepping down. Many patients are started on 30mg during an acute episode and stay on it forever. Step down to 15mg — or consider stopping — once the acute indication has resolved.

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Not giving sick day rules advice when prescribing metformin, ACEi/ARB, or NSAIDs. Patients on these drugs need to know to stop them temporarily if they become acutely unwell or dehydrated. This advice must be given and documented every time.

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Prescribing gabapentinoids too readily. Gabapentin and pregabalin are Class C controlled drugs with high misuse and black market potential. Avoid starting them unless there is a clear, NICE-supported indication. If already prescribed by a hospital, review whether continuation is appropriate.

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Using the word "as directed" (ASD) on prescriptions. This is unsafe and unacceptable. Always spell out dose, frequency, and duration explicitly. If you find yourself writing ASD — stop and write it out properly.

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Not recognising when a patient's symptom is a drug side effect. Tiredness, cough, ankle swelling, confusion, falls, GI upset — all can be drug side effects. Before adding a new drug to treat a symptom, always ask: "Could this be caused by a drug they're already on?"

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Not thinking about steroid emergency cards. Patients on long-term or high-dose steroids need a Steroid Emergency Card. In a crisis, they may be unable to communicate their steroid dependency — this card can save their life.

🧠 Memory Aids & Cheat Sheets

The frameworks and mnemonics that make prescribing easier to remember under pressure.

💊 ONE STOP — Safe Prescribing Checklist

One system at a time — review whole list

No allergies missed

EGFR / renal function checked

Sick day rules given if needed

Therapeutic indication documented

Optimise dose (not maximum, not minimum — right)

Patient counselled and agrees

🔁 AIMS — Medication Review Framework

Adherence — is the patient actually taking it?

Indication — is it still needed?

Monitoring — are checks up to date?

Side effects — any problems to address?

⚗️ CYP450 Inducers — SCRAP GPS

Sulphonylureas

Carbamazepine

Rifampicin

Alcohol (chronic)

Phenytoin

Griseofulvin

Phenobarbital

St John's Wort

⚗️ CYP450 Inhibitors — SICKFACES.COM G

Sodium valproate

Isoniazid

Cimetidine

Ketoconazole

Fluconazole

Alcohol (binge)

Chloramphenicol

Erythromycin

Sulfonamides

Ciprofloxacin

Omeprazole

Metronidazole

Grapefruit juice

⚡ High-Risk Drug Interactions — Quick Reference
Drug 1	Drug 2	Risk & Action
Warfarin	Metronidazole / fluconazole / erythromycin	INR rises → bleed risk — monitor INR within a week
Lithium	NSAIDs / diuretics / ACEi	Lithium toxicity — check lithium level urgently
Methotrexate	NSAIDs / trimethoprim / penicillin	Methotrexate toxicity — avoid combination
COCP	Rifampicin / enzyme inducers / St John's Wort	Reduced contraceptive efficacy — additional contraception needed
Tamoxifen	Paroxetine / fluoxetine	Reduced tamoxifen efficacy — use citalopram or venlafaxine instead
Theophylline	Ciprofloxacin / erythromycin	Theophylline toxicity — monitor levels; reduce dose
Digoxin	Amiodarone / verapamil	Digoxin toxicity — reduce digoxin dose; monitor levels
Verapamil	Diltiazem / beta-blockers	Profound bradycardia / heart block — avoid combination

💬 Insider Pearls — What Trainees & Trainers Have Learned the Hard Way

Insights drawn from national research into GP trainee prescribing, real medico-legal cases, RCGP examiner feedback, and the accumulated wisdom of educators who have reviewed thousands of GP trainee prescriptions. The things nobody puts in a textbook.

📊 The Stats That Every Trainee Should See Once

Your Error Rate Is Probably Higher Than You Think

National research on GP trainee prescribing (the REVISiT study, BJGP Open 2022) found a prescribing error rate of 8.9% among GP trainees in their final year — almost double the 5% error rate in qualified GPs. The suboptimal prescribing rate was 35%.

When over 1,700 trainees completed the national prescribing assessment pilot:

98.4% found at least one instance of suboptimal prescribing
71.5% found at least one actual prescribing error
The mean number of suboptimal prescribing instances was 24 per trainee
More than half of trainers said the assessment highlighted gaps they had not previously noticed
90% of trainees said it changed their prescribing practice

This is not a criticism — it is a baseline. The point is that prescribing habits form early, errors are common, and systematic review genuinely improves safety.

The Drugs Most Likely to Cause Preventable Harm

Research on preventable drug-related hospital admissions in UK general practice (Avery et al., BJGP 2014) identifies the same culprits consistently. Just four classes account for over half of all preventable admissions:

Antiplatelet agents Diuretics NSAIDs Anticoagulants

Adding opioids, beta-blockers, RAAS drugs, diabetes drugs, digoxin, and corticosteroids gets to 75% of all preventable admissions.

💡 Why This Matters for Trainees

These are also the drugs most commonly tested in the AKT and most likely to generate errors in the MRCGP prescribing assessment. They deserve the most careful prescribing and the most consistent monitoring. Not the flashy new drugs — the ones you write dozens of times a week.

🔍 Where GP Trainees Actually Go Wrong — The Research Evidence

🚨 The Error That Nobody Expects: Eye Drops and Ear Drops

The REVISiT study found that prescriptions for eye, ear, and topical external preparations had one of the highest error rates of any drug category — over 75% of those prescriptions were associated with a prescribing problem. Not the complex polypharmacy reviews. The topical ointments. The ear drops.

Common issues: wrong concentration, wrong frequency, no specified duration, wrong formulation (drops vs ointment). Eye ointment is usually better than drops for conditions like conjunctivitis because it stays in contact longer — drops drain down the nasolacrimal duct. Check the concentration every time you prescribe a topical. It sounds trivial. The research says it isn't.

💡 Liquid Medicines in Adults: Expensive, Error-Prone, Usually Unnecessary

Oral liquid preparations had a prescribing error rate of 35% and a suboptimal prescribing rate of 31% in the national trainee review — the highest rates of any oral drug category. The most common issue: prescribing liquids for patients who can take tablets.

The rule is simple: if a patient is eating food, they can usually swallow a tablet. Liquid nitrofurantoin costs around £500; the tablets cost pence. Liquid medicines are also harder to dose accurately and more prone to prescribing errors. Reserve them for patients with a genuine swallowing or absorption problem — and document why.

🚨 The Drop-Down Menu Problem — A Real and Recurring UK GP Error

MDDUS medico-legal cases and InnovAiT teaching cases both document a recurring error: the wrong drug or wrong strength is selected from a drop-down menu on EMIS or SystmOne. Real examples that have reached medico-legal proceedings:

Methotrexate instead of metoclopramide — a doctor typed "met" and selected the first option. The patient developed severe toxicity. Both drugs begin with the same letters; the system offered no warning.
Oramorph 100mg/5ml selected instead of 10mg/5ml — 10 times the intended dose. The higher strength appeared first in the pick list. The pharmacist dispensed it without querying. Nurses administered it.
Procyclidine instead of prochlorperazine — prescribed for nausea. Same strength, same form. Wrong drug entirely. No alert triggered.

The habit to build: after making a selection from a drop-down, always read back what appeared in the prescription field — drug name, strength, and form — before confirming. It takes three seconds. These errors do not take three seconds to explain to a coroner.

🔄 The Hospital-to-GP Transition — Why Prescribing Feels Different

What Changes When You Move to GP

GP trainees consistently report that prescribing in primary care feels harder than it did in hospital — and research confirms their prescribing error rate is genuinely higher. Here is why the context is so different:

Hospital Prescribing	GP Prescribing
Acute episodes, short courses	Long-term chronic conditions, years of medication
Usually one problem at a time	Multiple comorbidities and polypharmacy are the norm
Pharmacist checks every drug chart before dispensing	You are the primary safety check — the pharmacist is reactive
Patient observed continuously in hospital	Patient goes home — safety-netting is your only safeguard
Drug chart reflects what's being given now	Repeat template may not reflect hospital-initiated changes
Specialist available for queries immediately	Most decisions made independently, in 10–12 minutes
Clear drug charts, structured drug rounds	Drop-down menus, pick lists, system-level decisions

✅ Your Most Underused Prescribing Resource: The Practice Pharmacist

Most GP practices now employ a clinical pharmacist. Research consistently shows that pharmacist-led medication review significantly reduces prescribing errors and improves medicines safety. Use them actively — not just when something has gone wrong. Ask them to look over your prescriptions when you're unsure. They know the local formulary, the interactions database, and the Amber drug rules better than anyone in the building.

🔥 AKT Insider Intelligence — Straight From RCGP Examiner Feedback

📋 The Same Prescribing Themes Keep Appearing in AKT Examiner Reports

The RCGP AKT core group publishes feedback after every sitting. In the three most recent AKT reports (AKTs 48, 49, and 50, covering 2023–2024), improving quality, safety and prescribing was flagged as a recurring area of difficulty in all three. Specific areas identified:

Common side effects of long-term medications — candidates consistently do not know the side effect profiles of drugs used in chronic disease management well enough. Revise this from the BNF, not from memory.
Controlled drug prescribing rules — what must appear on the prescription, maximum supply, how to write the quantity. This comes up repeatedly. Check the BNF Appendix on prescribing controlled drugs.
Drug monitoring requirements — which bloods, at what intervals, for which drugs. Not knowing when to recheck U&Es after starting an ACEi costs marks every sitting.
Interpretation of borderline blood results — candidates overlook results that are not clearly abnormal. The AKT specifically tests whether you notice a borderline value and act appropriately.

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AKT trap — nearly a third of all questions have a prescribing component. RCGP examiners state explicitly: "Nearly one third of questions can have a significant therapeutic component such as drug monitoring, adverse effects or interactions." Trainees who treat prescribing as a small topic are systematically under-revising one of the largest domains in the exam.

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AKT trap — the "do nothing" answer. Examiners note that candidates find it hard to choose "no investigation, no prescription, no referral" as the correct answer — even when it clearly is. If the scenario describes a self-limiting condition in a well patient, the correct answer may be reassurance and safety-netting. Resisting the urge to over-investigate and over-prescribe is tested deliberately.

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AKT trap — dose calculation reality check. RCGP examiners warn that candidates regularly submit dose calculation answers that are clearly incompatible with real life. A decimal point in the wrong place can give a dose 10 or 100 times too high. Always ask: is this volume physically reasonable? Could a patient actually be given this? If not — you've made an error.

💡 Things Trainees Wish They'd Known at the Start of ST3

✅ Habits That Protect You

Download the BNF app to your phone — it's free for NHS staff. The interaction checker, monitoring requirements, and side effect profiles are all in there. Use it. Trainees who check interactions routinely make fewer errors.
Subscribe to MHRA Drug Safety Update emails. They arrive monthly. They contain real safety alerts for real drugs you prescribe. Most trainees never read them. The ones who do catch things others miss.
When signing repeat prescription requests, look at the whole list. Not just the item being requested. Hospital letters add things; patients accumulate drugs. You may be the only person doing this check for months.
Verify the drop-down selection before confirming. Read the drug name, strength, and formulation back after selecting — every time.
Always document the indication for any drug you add to the repeat template. Future you — and the next prescriber — will need to know why it was started.

⚠️ What Nobody Tells You

Hospital discharge medications are often wrong. What was appropriate for a post-surgical inpatient is often not appropriate at home indefinitely. Never add a discharge drug to the repeat template without reviewing whether it still makes sense for this patient in primary care.
Suboptimal prescribing is not the same as an error — but it still matters. Most of the 24 average instances found per trainee in the national assessment were suboptimal, not technically erroneous. That means good-but-could-be-better choices. The assessment catches these too.
Adherence is underestimated. If a condition isn't responding to apparently adequate treatment, always ask honestly: "Are you actually taking it?" before escalating doses. Non-adherence is one of the most common causes of apparent treatment failure in GP.
Your prescribing habits form early and are hard to break. The patterns you establish in ST3 are the ones you carry into your career. The prescribing assessment exists precisely because early habits matter.
Asking for help is not weakness — it's the right prescribing behaviour. When uncertain about an interaction, dose, or indication: ask the pharmacist, check the BNF, call the MDO. Every one of those contacts is safer than guessing.

📋 Making the Most of the MRCGP Prescribing Assessment — Practical Wisdom

Before You Start

Run the computer search early. EMIS and SystmOne built-in searches sometimes fail depending on how your user account is configured. Don't discover this in your last fortnight of ST3. Give yourself time to troubleshoot or switch to the manual method (reviewing consultations backwards and entering data by hand).
Get the prescribing manual and read it before you review your prescriptions. This is the framework you'll use to classify what you find. Trainees who use it as they review — rather than as an afterthought — get significantly more from the process.
Don't pre-select "safe" prescriptions. The assessment is formative. Picking prescriptions you know are correct defeats the purpose and may trigger a request to repeat it.

During the Review

Be honest. If something looks suboptimal, flag it. The mean suboptimal prescribing rate in the national pilot was 40.6% — nearly half of all prescriptions reviewed. There is no stigma in finding things to improve. That is precisely the point.
Don't just identify the error — explore why it happened. Was it time pressure? Uncertainty about the guideline? Following a hospital letter without checking? Understanding the root cause is what generates meaningful PDP entries. Examiners explicitly look for this in the reflection form.
Look for good prescribing too. The assessment asks you to identify examples of high-quality prescribing, not just problems. Every trainee in the national pilot had at least one example highlighted. These are worth noting — they tell you what your strengths are.

After the Review

Convert findings into specific, actionable PDP entries. "Improve my prescribing" is not a PDP entry. "Review BNF monitoring requirements for methotrexate, amiodarone, and lithium — check against my current practice by [date]" is.
Discuss honestly with your trainer. More than half of trainers in the national evaluation said the assessment revealed gaps they were previously unaware of. Your trainer may learn something too. That's not embarrassing — it's what the assessment is designed to do.
Don't treat it as done once the form is submitted. The changes you make to your prescribing habits in the weeks after the assessment are the most valuable part. Trainees who engage with the findings and actively change their practice are the ones who report real benefit.

✅ One More Thing Worth Knowing

The RCGP prescribing assessment FAQ specifically notes: if a trainee reviews 50 prescriptions and finds no errors and no suboptimal prescribing, this is unusual enough to raise a concern. It has never happened in the data collected to date. This is not a pressure to invent problems — it is reassurance that finding things is completely normal and expected. The question is not whether you'll find something to learn. It's how honestly and usefully you engage with it.

💬 "What I Wish I Knew" — Synthesised From Trainee Experience

What trainees who passed consistently say

Prescribing is a communication task, not just a clinical task. You are being marked on how you explain it, not just what you prescribed.
Safety beats perfection. A safe, slightly generic answer scores more than a risky "clever" prescription that misses a contraindication.
Mentioning monitoring is easy marks. It is one of the most commonly forgotten things — and one of the easiest to add.
Deprescribing is hidden gold. Especially in elderly and polypharmacy cases. Most candidates never think to stop drugs.
Never assume the examiner knows what you're thinking. Say everything important out loud. Your reasoning. Your safety checks. Your monitoring plan.
The BNF alone is not enough. Knowing the drug is not the same as knowing how to explain it simply to a worried patient.

The mental test that protects you in clinic and in exams

🧠 "Would I Defend This?"

Before signing or recommending any prescription, ask yourself: "Would I be comfortable defending this decision to a colleague, a trainer, or a coroner?" If the answer is uncertain — check it, verify it, or ask. This single mental habit prevents most serious prescribing errors.

✅ Default Mindset for Every Prescription

Correct drug for this diagnosis
Safe for this patient (APRIL check)
Correct dose for renal/hepatic function
Explained clearly and simply
Monitoring plan stated
Safety-net given

⚠️ The High-Yield Prescribing Pitfall Clusters — From Trainee Reports

QT Prolongation Traps

SSRIs + antipsychotics (citalopram + quetiapine)
Adding macrolides to existing QT-prolonging drugs
Methadone at high doses (>100mg/day)

Renal Function Traps

Metformin — stop if eGFR <30
NSAIDs in CKD — avoid
DOAC dosing — eGFR-dependent adjustments
Nitrofurantoin — ineffective if eGFR <45

Elderly Prescribing Traps

Falls risk drugs — opioids, benzodiazepines, antihypertensives
Anticholinergic burden — confusion, falls, urinary retention
Sedatives — double the falls risk
Not considering stopping drugs when reviewing

Pregnancy & Controlled Drug Traps

Forgetting to ask pregnancy status before prescribing
Not adjusting medication for known pregnancy
Controlled drugs — not discussing monitoring or dependence risk
Valproate in women of childbearing age — PPP requirement

📓 Practical Prescribing Habits From Trainees Who Thrived

Build a Personal Formulary Early

Trainees consistently report that creating a personal formulary file in ST1 makes prescribing faster and safer throughout training. For each common condition, note:

First-line drug, typical dose, duration
Key cautions and contraindications
One or two alternatives
Monitoring requirements

Cover at minimum: UTI, LRTI, asthma step-up, COPD, hypertension, T2DM, contraception, HRT, depression, analgesia. Update from NICE CKS and BNF regularly. Get it signed off by your trainer.

The "Guide → Local → Senior" Rule

When unsure what to prescribe, follow this order every time:

Check NICE CKS or BNF. This is your primary safety check — not memory, not habit.
Check the local formulary. Your ICB may have local first-line choices that differ from national guidance (for cost or resistance reasons). Know where to find it.
Ask your trainer or a senior colleague. This is not weakness — it is the correct professional behaviour. RCGP and GMC both emphasise prescribing within your competence.

✅ Normalising Uncertainty With Patients

"Because I'm still in my supervised training stage, I like to double-check plans for more complex situations. I'll step out briefly and discuss this with my supervising GP — then I'll come back and explain the final plan."

This phrase — endorsed by forums and GP educators — demonstrates safety awareness and professional transparency without undermining the patient's confidence.

The Desk Prescribing Checklist — Adapted From Trainee Consensus

Many trainees keep a short physical or digital checklist to run through before finalising any prescription. This is what repeatedly comes up in GP training forums and educator resources:

Right drug for this indication, guideline-concordant?
Right patient — allergies, pregnancy, age, renal/liver function?
Right dose, route, frequency, duration?

Interactions checked — especially anticoagulants, methotrexate, lithium?
Monitoring and review plan documented?
Drop-down selection verified on screen before confirming?

This checklist takes 20–30 seconds. It catches the errors that cause the most harm — the ones made quickly, automatically, and without thought.

💡 Learning While Prescribing — The "Questions List" Habit

Keep a running list of prescribing questions that come up during clinic — e.g. "When would I choose a DOAC over warfarin here?", "When would I use mirabegron instead of an antimuscarinic?" — and go through them in tutorials. Trainees who do this consistently report it is far more efficient than random reading, and it produces PDP entries that are genuine rather than invented. The RCGP explicitly endorses this type of focused reflection over scattered reading.

🔄 Repeat Prescriptions & Medication Reviews

Managing a repeat prescription system well is one of the most important — and most underestimated — patient safety activities in general practice.

When to Add a Drug to the Repeat Template

✅ Add to Repeat If

Medication for a chronic disease
Discharged from hospital for long-term use
Specialist letter recommends ongoing prescription
Emollients if used regularly
Pain relief / antidepressants / antipsychotics (with appropriate review dates)

❌ Do NOT Add If

Acute prescription not intended for long-term use
High-risk drug without confirmed monitoring plan
Drug never reviewed since hospital discharge
Drug without clear documented indication
Patient asking repeatedly for acute medications — question why

The 4 Aims of a Repeat Prescription System

Reduce prescription request burden for regular medications — systems must be efficient without sacrificing safety.
Ensure disease control targets are optimised to patient tolerance — review isn't just about issuing, it's about effectiveness.
Consolidate CDM (Chronic Disease Medication) annual reviews — ideally all chronic disease reviews happen together to reduce fragmentation.
Set review dates correctly — medication review dates on the repeat template should match or fall just after the recall dates to avoid gaps in monitoring.

💡 Admin Tip — Check the Medication Review Date First

When an admin team member receives a repeat prescription request: first check the medication review date. If within date → issue. If overdue → book patient for review. If completely out of medication → use a prescription request route to cover the gap while booking the review. Never just issue indefinitely without review.

What a Medication Review Should Cover

Domain	What to Review
Indication	Is each drug still needed? Has the original problem resolved?
Effectiveness	Is the drug working? Has HbA1c / BP / lipid target been reached?
Safety	Any interactions? Contraindications with new drugs/conditions?
Adherence	Is the patient taking it? Any barriers? Side effects causing non-adherence?
Dose optimisation	Is the dose appropriate? Could it be reduced? Has it been titrated?
Monitoring	Are required blood tests/ECG/BP measurements up to date?
Polypharmacy	Is everything truly necessary? What can be safely stopped?
Cost	Is a generic available? Are branded versions being prescribed unnecessarily?

Drugs That Need Monitoring — Do Not Forget

⚠️ Monitoring-Dependent Drugs

Antipsychotics — FBC, lipids, glucose, LFTs, weight, BP, ECG
NOACs (apixaban, rivaroxaban, dabigatran) — FBC, U&Es, LFTs annually
Methotrexate — FBC + LFTs every 3 months (haematotoxicity)
Lithium — serum level + TFTs + U&Es every 6 months
Amiodarone — TFTs, LFTs, CXR every 6 months
Amber drugs — see amber list; each has specific monitoring requirements
ACEi/ARBs — U&Es + eGFR 2 weeks after starting/dose change
Statins — LFTs before starting; repeat if symptomatic

📋 Amber Drug Scheme

Amber drugs are drugs that are initiated by a specialist but monitored and continued by the GP under a shared care agreement.

Examples: azathioprine, methotrexate, hydroxychloroquine, leflunomide, lithium, methylphenidate, atomoxetine, ciclosporin, tacrolimus, and more.

Key rule: before accepting shared care, make sure you have received the shared care agreement, understand the monitoring requirements, and have written guidance from the specialist.

🧠 Glycaemic Targets in Special Circumstances

🧠 Dementia — Relaxed HbA1c Target

NICE NG28 (2022) does not give a fixed target for dementia but explicitly recommends considering a relaxed HbA1c target on a case-by-case basis for older or frail patients — particularly where:

Tight control poses a high risk of hypoglycaemia (falls, injury, unrecognised episodes)
Life expectancy means longer-term risk reduction benefits are unlikely
Intensive management is inappropriate given comorbidities

Practical target: In clinical practice, a relaxed HbA1c of approximately 58–70 mmol/mol is commonly used for patients with dementia or significant frailty — always set and reviewed individually. Prioritise avoidance of hypoglycaemia over tight control.

🕯️ End of Life Care — Glycaemic Aim

For patients with a terminal illness or life expectancy under 1 year, HbA1c targets are no longer the primary concern. The glycaemic aim shifts to:

Avoid hypoglycaemia — unwell patients cannot recognise or manage hypos safely
Avoid symptomatic hyperglycaemia — thirst, polyuria, poor wound healing, infections all reduce quality of life

Deprescribe glucose-lowering agents where appropriate. Review the medication list with palliative care or a specialist. Many patients can safely come off metformin, SGLT2 inhibitors, and sulphonylureas at end of life — this reduces pill burden and monitoring demands.

🟡 Amber Drugs — Shared Care Prescribing

Amber drugs are medications initiated in secondary care but continued or monitored in primary care under a shared care agreement. When asked to prescribe or continue an amber drug, ensure you have received a shared care protocol, understand the monitoring requirements, and have written guidance from the initiating specialist. The list below is from the Hull and East Yorkshire shared care formulary — use your local ICB formulary for current guidance.

Drug	Indication
Acamprosate	Alcohol relapse prevention
Alzheimer's medications (donepezil, rivastigmine, galantamine, memantine)	Mild-to-moderate dementia in Alzheimer's disease
Apomorphine	Parkinson's disease
Atomoxetine	ADHD
Azathioprine / 6-mercaptopurine	Immunosuppression; inflammatory bowel disease
Ciclosporin	Immunosuppression (post-transplant and other indications)
Cinacalcet	Secondary hyperparathyroidism in end-stage renal disease
Denosumab	Osteoporotic fracture prevention (postmenopausal women)
Dexamfetamine / Lisdexamfetamine / Methylphenidate	ADHD
Erythropoietin	Renal anaemia
Fulvestrant	Breast cancer
Guanfacine	ADHD (specialist-initiated)
Hydroxychloroquine	DMARD; immunosuppression (RA, SLE)
Leflunomide	Rheumatoid arthritis (DMARD)
Lithium	Bipolar disorder; recurrent depression
Melatonin	Sleep disorders (specialist-initiated only)
Methotrexate	Immunosuppression (RA, psoriasis, IBD)
Modafinil	Narcolepsy
Mycophenolate mofetil	Immunosuppression (post-transplant)
Naltrexone	Alcohol relapse prevention; opioid dependence
Penicillamine	Rheumatoid arthritis (DMARD)
Raloxifene / Tamoxifen	Breast cancer chemoprevention
Riluzole	Amyotrophic lateral sclerosis (MND)
Sirolimus / Tacrolimus	Immunosuppressant post-transplant
Sodium aurothiomalate (gold injection)	Rheumatoid arthritis (DMARD)
Sulphasalazine	DMARD; inflammatory bowel disease
Testosterone	Male hypogonadism; menopausal symptoms in women
Verapamil	Cluster headaches (specialist-initiated)

🔑 Before Prescribing or Continuing an Amber Drug

Confirm a valid shared care agreement is in place and on file
Understand which monitoring tasks are your responsibility vs the specialist's
Know what to do with abnormal results — and who to escalate to
Do not prescribe amber drugs initiated by secondary care unless you have received written instructions and accepted the shared care responsibilities

❓ FAQ — Quick Answers

Do I have to prescribe generically?

For most drugs yes — it saves NHS money and is standard practice. The main exception is inhalers (different devices deliver different doses; the generic device may not be the same) and some modified-release formulations where bioavailability varies between brands.

When can I prescribe controlled drugs?

As a GP trainee, you can prescribe controlled drugs once provisionally registered with the GMC. Maximum supply is typically 30 days (schedule 2 and 3). Prescriptions must be handwritten or from an approved computer system and include quantity in words and figures.

What is a Yellow Card and when should I submit one?

The MHRA Yellow Card is the UK's system for reporting suspected adverse drug reactions. Anyone can report — patients, pharmacists, nurses, doctors. You MUST report ALL suspected ADRs to black triangle (▼) drugs regardless of severity. For established drugs, report serious ADRs.

What is an Amber drug?

Amber drugs are initiated by a specialist but monitored and continued by the GP under a shared care agreement. You must have the shared care agreement before accepting responsibility. Examples: methotrexate, azathioprine, lithium, methylphenidate.

When do I involve the MHRA / report something?

Report via Yellow Card if you suspect any adverse drug reaction, especially for new black triangle drugs (all ADRs), serious reactions (any drug), and rare reactions. Drug safety alerts from MHRA should be acted on promptly — check your inbox and the CAS (Central Alerting System).

What commonly comes up on prescribing in the AKT?

CYP450 interactions (very common), QT prolongation, specific drug monitoring requirements, prescribing in pregnancy/renal impairment, STOPP/START criteria, controlled drug prescribing rules, Yellow Card reporting, and the pharmacology of common GP drugs (metformin, SSRIs, statins, warfarin, insulin).

🏫 For Trainers — Teaching Prescribing

Ideas, frameworks, and discussion prompts for trainers covering prescribing in tutorials.

🧠 Common Trainee Blind Spots in Prescribing

Accepting hospital discharge medications uncritically
Not checking the interaction profile of a new drug
Prescribing a drug for a symptom that is itself a drug side effect
Not considering deprescribing as a therapeutic option
Failing to document the indication for a newly added repeat medication
Not giving or documenting sick day rule advice

💬 Tutorial Discussion Prompts

"Tell me about the last new repeat medication you added. What was your thought process?"
"What is the pharmacology of [drug they prescribed this week]?"
"Walk me through how you'd counsel a patient starting metformin."
"What would you do if a patient on lithium came to you with a UTI needing antibiotics?"
"Let's review five of your last prescriptions together — what would you do differently?"
"What does deprescribing mean? Can you give me an example from your list?"

📋 Tutorial Ideas for Prescribing

Prescription writing exercise — give trainee 5–6 scenarios and ask them to write out the full prescription. Review for completeness and accuracy.
Medication review exercise — pull up a real patient (or anonymised case) with polypharmacy and review together: what to stop, what to monitor, what's missing.
Drug interaction challenge — give trainee a scenario with a new drug to prescribe and ask them to identify any interactions first.
MRCGP Prescribing Assessment tutorial — review the trainee's spreadsheet together, discuss any errors found, and identify PDP entries.
Role-play — trainee explains a new statin to a trainer playing a concerned patient who has "read terrible things online." Assess ICE exploration, explanation quality, and safety-netting.

🔥 AKT High-Yield Tips

Prescribing is tested in nearly a third of all AKT questions. This section covers the highest-yield areas, revision tables, trap patterns, and a practical study plan.

📋 4-Step AKT Prescribing Study Plan

Build a "Top 30" prescribing list. Create a table of 30 core GP conditions. For each, write: first-line drug(s), starting dose, titration, key interactions, monitoring requirements, pregnancy/renal considerations. Use NICE CKS and BNF only — not memory.
Use questions to drive reading, not vice versa. Do mixed AKT questions from a question bank. For every prescribing question you get wrong or guessed, read the BNF/CKS section and add/update your table. Questions reveal gaps; reading fills them.
Focus time on safety questions. Set aside specific sessions for "improving quality, safety and prescribing" domain questions — monitoring frequencies, shared care, interactions, errors. These feature in every AKT and are frequently cited in RCGP examiner feedback.
Mini-mock on prescribing in the last 4–6 weeks. Do 100–150 prescribing-heavy questions (mix of clinical and admin domains) under timed conditions to build speed and sharpen pattern recognition.

💡 What RCGP Examiners Say Repeatedly

In AKT feedback reports across three consecutive sittings, the same prescribing themes appear: drug monitoring requirements, common side effects of chronic disease medications, controlled drug prescribing rules, and antimicrobial stewardship. Nearly one third of all AKT questions have a significant therapeutic component. This is not a small topic.

🎯 AKT Prescribing Trap Patterns

Pattern	Typical Question Style	What Is Being Tested
Interacting antibiotic	Patient on warfarin for AF needs antibiotic for LRTI; options include a macrolide	Recognising increased INR/QT risk and choosing a safer agent (e.g. amoxicillin instead of clarithromycin)
Wrong dose or frequency	Child analgesia or inhaler — multiple plausible regimens given	Matching exact BNF frequency and maximum dose; not relying on memory
High-risk drug monitoring	Patient on methotrexate develops sore throat and mouth ulcers	Knowing when to stop the drug, request urgent FBC, and refer — not just reassure
Duplicate therapy	New drug added to prescription that overlaps existing treatment class	Recognising duplication and rationalising — e.g. two ACEi equivalents, two SSRI-type agents
Renal dosing	Elderly patient with CKD offered usual dose of DOAC or antibiotic	Adjusting dose or switching drug based on eGFR; knowing exact thresholds
"Do nothing" answer	Self-limiting viral illness in a well patient; multiple treatment options listed	Recognising when not to prescribe is the correct answer — examiners note candidates find this hardest
Dose calculation	Volume to administer for a given dose and concentration	Arithmetic accuracy with a reality check — answers that are clearly incompatible with real-world volumes are common errors

📊 Core Conditions — AKT Prescribing Revision Table

Verified against NICE guidelines and BNF. Always cross-check doses with BNF/NICE CKS before prescribing. This table is for revision orientation only.

Condition	First-Line Drug(s)	Key Monitoring / Safety	AKT Trap
Hypertension (uncomplicated)	ACEi or ARB if <55 years and not of Black African/Caribbean ethnicity; CCB (e.g. amlodipine) if ≥55 years or Black ethnicity. Add second agent from other class if needed; then thiazide-like diuretic (e.g. indapamide)	Baseline U&Es and eGFR; repeat 2 weeks after starting ACEi/ARB or after dose change; watch for potassium rise; CCBs can cause ankle oedema	Wrong first-line by age/ethnicity; missing renal check after ACEi/ARB; ignoring hyperkalaemia
AF — stroke prevention	DOAC (e.g. apixaban) usually preferred over warfarin. Anticoagulate if CHA₂DS₂-VASc ≥2 (men) or ≥3 (women); consider at score of 1 in men	Renal function at baseline and at least annually (more often in CKD or elderly); bleeding risk assessment (HAS-BLED); check for interacting drugs	Choosing aspirin alone for AF stroke prevention; wrong DOAC dose in CKD or age; forgetting renal monitoring
T2DM (no major comorbidities)	Metformin first-line if tolerated. Add SGLT2 inhibitor or other agents based on CV/renal status and HbA1c. Lifestyle always	eGFR before and during metformin use; stop if eGFR <30, caution if <45; B12 with long-term metformin; SGLT2i: genital infections, DKA risk — document sick day rules advice	Continuing metformin at very low eGFR; starting SGLT2i without explaining DKA/genital infection risk and sick day rules
Heart failure (reduced EF)	Four pillars: ACEi/ARB (or ARNI), beta-blocker, MRA, SGLT2 inhibitor	U&Es, eGFR, K+ after dose changes; monitor for cough (ACEi), angio-oedema, renal decline; BP and HR	Not uptitrating because of mild asymptomatic BP drop; missing need for renal/potassium monitoring; using NSAID in HF
Asthma (adults)	SABA reliever + low-dose ICS add-on. Then LABA (in combination inhaler). Step up according to control. MART/SMART regimens per BTS/SIGN and NICE guidance	Inhaler technique review at every visit; adherence; exacerbation action plan; steroid card if frequent oral steroids	Prescribing LABA without ICS; excess SABA without stepping up controller; no safety-net on worsening breathlessness; beta-blocker in asthma
COPD	SABA or SAMA for initial relief. Escalate to LABA/LAMA ± ICS depending on symptoms, exacerbation history, and blood eosinophil count. Smoking cessation and vaccines are non-pharmacological essentials	Check inhaler technique; assess exacerbation frequency; oxygen only with target saturation documentation in CO₂ retainers	Using ICS without LABA; giving oxygen without documented target saturations (CO₂ retention risk); not addressing smoking cessation

⚠️ High-Risk Medications — Exam-Sensitive Monitoring

Drug	Key Points	Monitoring / Errors Examiners Like
Methotrexate	Weekly dosing only — usually 2.5 mg tablets (to reduce confusion). Folic acid co-prescribed (usually 5 mg weekly on a different day). Daily dosing has caused patient deaths	FBC, U&Es, LFTs regularly. Stop and refer urgently with sore throat, mouth ulcers, bruising, dyspnoea, or rash. Daily dosing = serious, AKT-tested error
Lithium	Narrow therapeutic index. Interactions: NSAIDs, ACEi, diuretics raise lithium levels → toxicity. Toxicity signs: coarse tremor, confusion, ataxia, diarrhoea	Serum lithium level, eGFR, TFTs, calcium. More frequent when starting or changing dose. Stop and seek urgent advice if toxicity suspected
Warfarin	Many interactions: macrolides, fluconazole, metronidazole, NSAIDs, alcohol changes, other anticoagulants. Vitamin K-dependent. Wide INR variation with diet	INR at set intervals; urgent check if bleeding or interacting drug started; educate on diet and alcohol. Failure to monitor INR is a top cause of serious error
DOACs (apixaban, rivaroxaban, dabigatran)	Dose depends on indication, age, weight, renal function. Avoid in severe renal failure. Adjust dose around surgery. No routine monitoring of drug level but renal monitoring essential	eGFR at least annually; more often in older patients or CKD. Wrong dose for eGFR/age is a frequent AKT trap
Sodium valproate (women of childbearing potential)	Highly teratogenic — neural tube defects, neurodevelopmental problems. Must be on MHRA Pregnancy Prevention Programme. Annual specialist review required. Avoid as first-line where possible in females who may conceive	Contraception documented; annual acknowledgement form; LFTs. Using valproate without PPP = serious clinical and AKT error
Strong opioids	Shortest duration, lowest effective dose. Avoid for chronic non-cancer pain without specialist input. Do not combine with other sedatives. Constipation prophylaxis always required	Review regularly for sedation, falls risk, constipation. Dose conversion errors and duplication (patch + oral) are classic exam scenarios. Driving implications must be discussed
Amiodarone	TFTs, LFTs, CXR every 6 months. Causes both hyper- AND hypothyroidism. Multiple interactions. Photosensitivity	Monitoring failure is commonly tested. Not reducing warfarin dose when starting amiodarone = classic error

🦠 Common Infections — Antimicrobial Stewardship (AKT Frequent Topic)

Always cross-check local antibiotic formulary. The AKT tests principles of stewardship and appropriate duration — not memorisation of specific doses.

Infection	Likely First-Line	Typical Pitfalls	Safety / AKT Angle
Uncomplicated UTI (non-pregnant woman)	Nitrofurantoin MR or trimethoprim (depending on local resistance and contraindications). Typical course 3–7 days per local/NICE guidance	Too long duration; nitrofurantoin in poor eGFR (ineffective and potentially harmful if eGFR <45); repeated empiric courses without urine culture	Renal function check; antimicrobial stewardship; recurrent UTI work-up
UTI in pregnancy	Nitrofurantoin (avoid near term — risk of neonatal haemolysis), or cefalexin. Avoid trimethoprim in first trimester (folate antagonist). Treat asymptomatic bacteriuria in pregnancy	Using contraindicated agents; missing asymptomatic bacteriuria screening in pregnancy; using nitrofurantoin at term	Pregnancy drug safety; choice of agent; asymptomatic bacteriuria awareness
Sore throat / tonsillitis	Usually no antibiotics. If indicated (high FeverPAIN or Centor score, severe or immunocompromised): phenoxymethylpenicillin	Amoxicillin in suspected glandular fever (causes maculopapular rash); automatic antibiotics for likely viral URTI	Stewardship; patient expectation management; recognising glandular fever
LRTI / CAP (community-treated)	Amoxicillin or doxycycline depending on severity and allergy. Duration: 5 days for most community-treated CAP per current NICE guidance	Over-treating viral bronchitis; excessively long courses (10–14 days); wrong agent when patient on warfarin (macrolide raises INR)	CURB-65 risk stratification; antibiotic choice; hospital vs community decision

🚨 Classic Prescribing Error Examples — AKT and GP Training

⚠️ Errors That Kill Marks (And Patients)

Methotrexate daily instead of weekly — the most consistently cited fatal prescribing error in UK primary care. 2.5 mg tablets are used specifically to reduce this risk.
Colchicine without maximum course limit — for acute gout, maximum is 6 mg per course (BNF). Not stating this risks toxicity.
Potent steroid cream in children — using Dermovate on a child's face, or prescribing high-frequency topical steroids without limiting duration.
"Triple whammy" interaction — NSAIDs + ACEi + diuretic together = high risk of AKI, especially in the elderly or when dehydrated.
Tramadol + SSRIs — serotonin syndrome risk. Tramadol is serotonergic. Combining with another serotonergic agent is dangerous and examinable.
Macrolide + warfarin or statin — erythromycin/clarithromycin inhibit CYP3A4, raising warfarin/statin levels. INR rises; rhabdomyolysis risk.

💡 Formulation and Unit Errors

Modified release vs immediate release — different dosing intervals; not interchangeable. Diltiazem: always prescribe by brand (bioavailability varies).
mg vs micrograms — writing "mg" when "micrograms" was intended gives 1000× the dose. Never abbreviate micrograms as "mcg" or "μg" — always write in full.
Wrong insulin preparation — multiple insulin types, different concentrations and devices. Never copy a hospital insulin prescription without careful verification.
NSAID gels vs oral — for musculoskeletal pain in patients with GI or renal risk, topical NSAID has significantly better safety profile. Often overlooked as first option.
Underdosed antibiotics — subtherapeutic dosing drives resistance and treatment failure. Check NICE CKS / BNF for weight-adjusted doses in children.

🔥 If You Memorise Only This, You Will Gain AKT Marks

CYP450 inducers (SCRAP GPS) reduce co-prescribed drug effectiveness
CYP450 inhibitors (SICKFACES.COM G) enhance co-prescribed drug effects → toxicity
QTc >440 ms (men) / >470 ms (women) = prolonged. Every 10 ms increase = 5–7% ↑ arrhythmia risk
Metformin: stop if eGFR <30, caution if <45. Max dose 2 g/day
Methotrexate: weekly only. FBC + LFTs every 3 months. Folic acid co-prescribed
Opioid breakthrough dose = one-sixth of total daily dose
Yellow Card: anyone can report; mandatory for ALL suspected reactions to ▼ (black triangle) drugs

DOAC monitoring: eGFR at least annually (more often in CKD/elderly)
Lithium therapeutic range: 0.4–1.0 mmol/L. Toxicity: coarse tremor, confusion, ataxia
Amiodarone: TFTs + LFTs + CXR every 6 months. Causes hyper AND hypothyroidism
Triple whammy: NSAID + ACEi + diuretic = AKI risk, especially in elderly/dehydration
Serotonin syndrome: tramadol + SSRIs (or other serotonergic drugs) — avoid combination
Valproate in women of childbearing potential: requires MHRA Pregnancy Prevention Programme
Hypertension first-line: ACEi/ARB if <55 and not Black ethnicity; CCB if ≥55 or Black

🎯 SCA High-Yield Tips

Prescribing is where the SCA is silently failed. Good history and rapport count for nothing if the prescribing is unsafe, unexplained, or unindividualised. Here is what examiners actually mark.

❌ The Failing Pattern

Names a drug and moves on
No explanation of why this drug
No safety check — allergies, renal, pregnancy
No side effect discussion
No monitoring plan mentioned
No safety-net — "take this and goodbye"
Refuses antibiotics correctly, but handles the patient badly
Prescribes a drug without tailoring it to the patient

✅ The Passing Pattern

Explains clinical reasoning — why this drug for this patient
Safety check done and verbalised — says it out loud
Mentions key side effects (common, serious, relevant)
Involves the patient — shared decision-making
States monitoring plan with timeframe
Clear, specific safety-net
Handles antibiotic refusal with empathy AND explanation
Considers deprescribing where appropriate

🎯 The Single Most Important SCA Prescribing Insight

Prescribing in the SCA is not about the drug. It is about demonstrating safe clinical thinking.

The hidden examiner checklist covers: clinical reasoning · safety awareness · patient-centred care · monitoring plan · clear communication. You score on all five — not just the drug name.

🧠 The APRIL Safety Checklist — Run It Before Every Prescription

🔑 APRIL — Pre-Prescribing Mental Safety Check

Allergies — to this drug or drug class?

Pregnancy — could she be pregnant? Does this affect the choice?

Renal function — safe at this dose with this eGFR?

Interactions — anything on the drug list it clashes with?

Liver function — hepatically metabolised? Dose adjustment needed?

💡 Use APRIL in Exam AND in Clinic

In the SCA, run through APRIL silently before naming a drug — then verbalise the ones relevant to the case. "Before I recommend anything, can I just check — do you have any allergies to penicillin?" is a single sentence that covers A and signals safe prescribing thinking to the examiner.

⚡ The Default Prescribing Scaffold — Use Every Time

Trainees who pass the SCA consistently follow a mental scaffold for every prescribing discussion. It takes 60–90 seconds and covers all examiner domains:

Diagnosis / working diagnosis — "Based on what you've told me, I think this is likely..."
First-line recommendation — "The usual first treatment for this is..." State the drug. Give an approximate dose range. Say it is first-line.
Check safety (APRIL) — Verbalise the relevant checks. Say them out loud: "Any allergies? Any chance of pregnancy?"
Explain the drug — Use the layered technique (see below): what it does, how it works, why it matters for this patient specifically.
Side effects — Common ones + the one serious one that matters. "Most people tolerate this well. The main things to watch for are..."
Monitoring — "We'd need to check [blood test] in [timeframe] to make sure it's working and safe for you."
Safety-net — Specific symptom + specific timeframe + specific action.

🔬 SCA Prescribing Micro-Skills

⏱ The 30-Second Prescribing Block

When time is short, compress to this structure:

Name the drug
Say why this drug
Check one safety point out loud
Explain briefly — one sentence
Safety-net — one specific symptom

🔖 The Bookend Technique

Frame your entire prescribing discussion:

Open: "The usual first treatment is..."

Close: "Does that sound reasonable to you?"

Opening signals evidence-based practice. Closing signals shared decision-making.

🥪 The Risk Sandwich

Structure side effects so they feel balanced, not alarming:

Benefit first: "This should help within a few days."

Risk middle: "Some people get mild stomach upset."

Reassurance last: "But most people tolerate it well."

🧅 The Layered Explanation

Explain medication in three progressive layers:

Layer 1 — Simple: "This helps lower your blood pressure."

Layer 2 — Mechanism: "It works by relaxing your blood vessels."

Layer 3 — Personal relevance: "That reduces your risk of stroke."

Patients remember Layer 3. Examiners mark Layer 3. Always end with personal relevance.

🗣 The "Say It Out Loud" Principle — Examiners Cannot Assume Your Thinking

Examiners cannot award marks for thoughts you did not verbalise. Say everything important — explicitly.

Instead of thinking: "eGFR is probably fine"
Say: "Given your kidney function, this dose is safe."

Instead of thinking: "she's not pregnant"
Say: "Is there any chance you could be pregnant? No? Good — this is safe."

Instead of thinking: "this is first-line"
Say: "This is first-line according to guidelines."

Instead of thinking: "needs monitoring"
Say: "We'd need a blood test in four weeks to make sure your kidneys are handling it well."

💡 The Antibiotic Negotiation — A Repeated SCA Failure Pattern

Trainees repeatedly report: "I made the right clinical decision — no antibiotics — and still failed." Correct clinical decision. Poor communication. Fail in Relating to Others.

"I can see why you were hoping for antibiotics — many people feel they help. In your case, this looks viral, so antibiotics wouldn't help and could cause harm. What I can do is..."

Then: offer alternatives + safety-net clearly + leave the door open

⏰ SCA Time Management — The Prescribing Timing Trap

Rule of thumb: your prescribing discussion should begin by minute 6–7 of a 12-minute consultation. If you have not started management by then, move on. Prescribing is marked as much as history-taking.

💡 Deprescribing = Hidden Marks (Especially in Elderly Cases)

Reviewing or stopping medications consistently scores well — particularly in elderly or polypharmacy cases. Most candidates add drugs; high scorers also consider removing them.

Long-term PPI with no clear indication
Benzodiazepines or Z-drugs in elderly patients
Duplicate antihypertensives causing dizziness or falls
Anticholinergics causing confusion in older patients

"I notice you're on several medications — it would be worth reviewing whether all of these are still needed."

🚩 Contraindications You MUST Explicitly Rule Out

Drug	Must Explicitly Ask / Check
NSAIDs	CKD (eGFR), age ≥65, GI ulcer history, heart failure, anticoagulants, SSRIs
COCP	Migraines with aura, smoking over age 35, personal/family VTE history
ACEi / ARBs	Pregnancy, bilateral renal artery stenosis, hyperkalaemia
Metformin	eGFR (stop if <30, caution <45), sick day rules explained and documented
Any antibiotic	Allergy to that class — always ask, always document
Beta-blockers	Asthma — always ask about respiratory history first
Opioids	Driving implications, dependence risk, regular review plan

🎯 Three SCA Prescribing Pearls to Carry Into the Exam

APRIL before you prescribe. Run the checklist in your head. Verbalise the relevant ones. One sentence covers safety and scores marks.
Monitoring is easy marks most people miss. Every chronic medication — say the blood test, the timeframe, and the purpose. Out loud. Every time.
The examiner cannot see your thinking. Explain your reasoning, not just your conclusion. "I'm recommending X because Y" scores more than "I'll start X."

📋 Must-Drill SCA Prescribing Cases

Practice these 10 scenarios until you can handle each one fluently. They combine pharmacological knowledge with consultation skills and cover the SCA prescribing domains most consistently tested.

#	Scenario	Key Prescribing Challenge	Domain Focus
1	URTI / sore throat / otitis media / sinusitis	Antibiotic or not? Why not? How to explain without alienating the patient	Stewardship + communication
2	LRTI / suspected pneumonia	When to prescribe, which antibiotic, when to admit (CURB-65)	Safety + antibiotic choice
3	Cystitis — non-pregnant vs pregnant; recurrent UTI	Drug choice varies by pregnancy status, eGFR, trimester	Safety + individualisation
4	Asthma uncontrolled — step-up	Which inhaler step, SABA overuse, steroid card, action plan	Management + safety-net
5	New AF — anticoagulation pros/cons	CHA₂DS₂-VASc, DOAC vs warfarin, "blood thinner" anxiety	Shared decision-making
6	New T2DM — starting metformin	GI side effects, sick day rules, dose titration, monitoring	Counselling + safety
7	Contraception or HRT	Choosing an option; VTE/breast cancer risk explanation	Risk communication
8	Depression — starting SSRI	Side effects, timing of benefit, addiction concerns, suicide safety-net	Counselling + risk
9	Polypharmacy in older adult with falls or cognitive decline	Deprescribing plan; prioritise symptoms vs prevention	Deprescribing + frailty
10	Medication error — wrong dose or duplicated drug discovered	Acknowledge, clarify, correct, apologise appropriately, safety-net	Communication + safety

🗣 Useful Consultation Phrases for Medication

Prescribing-specific consultation phrases that sound human, not scripted. Built for medication discussions in both real clinic and the SCA exam.

Exploring Ideas About Medication (ICE)

What are your thoughts about starting a medication for this?
Is there anything about the medication that concerns you?
Have you taken anything like this before?
What have you heard about this type of treatment?
What were you hoping I might be able to do today?

Checking Safety (APRIL) — Say It Out Loud

Before I recommend anything, can I just check — do you have any allergies to medications?
Is there any chance you could be pregnant? No? Good — this medication is fine to use.
Are you taking any other medications, including anything over the counter?
No allergies, kidney function is fine, and there are no interactions with your current medications — so we're safe to go ahead.

Opening the Prescribing Discussion

Based on your symptoms and what I've found, I think this is likely... The usual first treatment for this is...
Given your symptoms and examination, this looks like a bacterial infection. First-line treatment would be amoxicillin — unless you've had any allergies to penicillin?
The usual first treatment we recommend for this is...
This is first-line according to guidelines and usually works well for this type of problem.

Explaining a New Medication (Layered)

Let me explain what this does — it helps lower your blood pressure. It works by relaxing your blood vessels, which reduces your risk of stroke.
The way I'd explain this is... The main thing to know is... And why it matters for you specifically is...
We'd usually start at a low dose and increase gradually depending on how you respond.

Side Effects — The Risk Sandwich

This should help your symptoms within a few days. Some people get mild stomach upset, but most people tolerate it well.
The most common side effects are X and Y — they usually settle after the first couple of weeks. If you get [serious symptom], I'd want to hear about that straight away.
Like all medications it can have some side effects. The common ones are... but the one important thing to watch for is...

When a Patient Has Concerns About Side Effects

That's a really important thing to raise — tell me more about what you've heard.
Most people tolerate this medication well, but I want to be honest about what you might notice.
If you notice anything that worries you, please come back straight away.

Monitoring — Verbalise Every Time

We'd need to check your [blood test] in [timeframe] to make sure it's working and safe for you.
Given your kidney function, we'd want to recheck your U&Es in about two weeks.
Baseline bloods before we start, then a repeat in [timeframe] to make sure everything is fine.
We'd need to monitor this with a blood test — that's routine for this type of medication.

Shared Decision-Making

We've got a couple of options — let's talk through what might suit you best.
How do you feel about starting medication versus trying non-medication options first?
What matters most to you in how we manage this?
We can safely start treatment here in GP, and I'll monitor you closely.
We have a few options — medication is one, but we can also look at lifestyle changes. What feels right for you?

When a Patient Declines Medication

I completely understand — it's your decision and I respect that.
Can I ask what's making you feel that way? It would help me understand your concerns.
I want to make sure you have all the information you need to make the best decision for you.
If you change your mind or want to discuss it again, please come back.

Antibiotic Refusal — Done Well

I can see why you were hoping for antibiotics — many people feel they help. In your case, this looks viral, so antibiotics wouldn't help and could cause harm. What I can do is...
At the moment, I don't think antibiotics are needed because this looks viral. However, if X or Y happens, we would reconsider.
I'd like to suggest a backup prescription — take it with you, and if things aren't better in [timeframe], use it then.

Deprescribing Phrases

I notice you're on several medications — it would be worth reviewing whether all of these are still needed.
Some of these medications may no longer be necessary. We can review them together.
This medication was started a while ago — given how things have changed, we might not need it anymore.

Safety-Netting (Prescribing-Specific)

If you notice X, Y, or Z — please come back sooner or call 111.
I'd like to see you again in [timeframe] to see how you're getting on with it.
If you develop [serious side effect], stop the medication and contact us immediately.
Come back if you're worried at any point — that's what we're here for.

Closing the Prescribing Discussion

Does that sound reasonable to you?
Does that all make sense?
Is there anything else you wanted to cover today?
Do you feel happy with the plan we've agreed?
Any questions before you go?

🎯 Adaptable Prescribing Template — Use For Any New Medication

"Based on your [symptoms / examination findings / history], I think this is likely [working diagnosis]. The usual first treatment is [drug name — state it is first-line]. Before we go ahead — any allergies? [Pause.] Good. This works by [brief mechanism]. The common side effects are [X and Y] — most people tolerate it well. We'd need to check [blood test] in [timeframe]. And if you notice [red flag symptom], please come back straight away or call 111. Does that all make sense?"

This template covers all seven elements of the default prescribing scaffold in under 90 seconds. Adapt the bracketed elements to the case.

🎭 SCA Prescribing Case Vignettes

Six high-yield prescribing cases with key moves and example phrases. Practice these until the reasoning flows naturally — not just the phrases, but the clinical thinking behind them.

Case 1 — "I want antibiotics for this cough" (Antibiotic stewardship)+

📋 Scenario

45-year-old, 5-day cough, no SOB, normal observations, viral picture. Already told by a friend "GP will give antibiotics."

Domains: Data gathering · Clinical management · Relating to others (handling disappointment)

Key Moves

Clarify features of serious illness (SOB, chest pain, confusion, high fever, comorbidity — use CURB-65 thinking)
Explore ICE — "What were you hoping I could do today?"
Explain viral vs bacterial clearly, limited benefit of antibiotics, side effects and resistance
Offer genuine alternatives (analgesia, fluids, honey/lemon, self-care) — don't just refuse and move on
Clear, specific safety-net

Example Phrases

From your story and examination, there are no signs of pneumonia or anything more serious today.
Antibiotics don't help viral infections like this and can cause side effects such as diarrhoea or thrush — so they'd likely do more harm than good in your case.
What I can offer today is paracetamol or ibuprofen for the discomfort, plenty of fluids, and rest. Honey and lemon drinks can also help with the cough.
If you become breathless at rest, develop chest pain, cough up blood, or your fever lasts more than 7–10 days, I want you to contact us urgently or call 111.

Case 2 — Methotrexate and sore throat (High-risk drug + urgent action)+

📋 Scenario

62-year-old with rheumatoid arthritis on methotrexate calls with sore throat and mouth ulcers for 3 days.

Domains: Data gathering (recognise red flag) · Clinical management (urgent FBC, stop drug) · Communication (explaining without alarming)

Key Moves

Recognise red flag: possible neutropenia / bone marrow suppression
Stop methotrexate today and arrange urgent FBC
Check for systemic features: fever, bruising, breathlessness, bleeding
Explain risk in understandable terms without causing panic
Clear escalation safety-net (A&E / 999 if systemically unwell)
Communicate with rheumatology as appropriate

Example Phrases

Because of the medication you're on to control your arthritis, a sore throat and mouth ulcers can sometimes signal a serious drop in your white blood cells.
I'd like you to stop the methotrexate today and we need a blood test urgently to check your blood count — we need this done today.
If you feel shivery, very unwell, struggle to breathe, or your temperature is high, go straight to A&E or call 999 — this could be an emergency that can't wait.
Once we have your blood results back, I'll contact you and we'll discuss next steps with the rheumatology team.

Case 3 — New AF: Anticoagulation discussion (Risk communication + shared decision)+

📋 Scenario

70-year-old with newly diagnosed AF. CHA₂DS₂-VASc score of 3. No absolute contraindication to anticoagulation. Anxious about "blood thinners."

Domains: Clinical management · Risk communication · Shared decision-making

Key Moves

Explore what the patient already knows and what concerns them about anticoagulation
Explain stroke risk in simple numbers — anchor to a meaningful comparator
Explain benefit of treatment honestly (roughly halves risk)
Discuss DOAC vs warfarin simply — check patient preferences around blood tests and stable dosing
Explain bleeding risks rationally — distinguish minor (bruising) from serious (black stools, vomiting blood)
Reach shared decision, arrange follow-up for review

Example Phrases

With your heart rhythm and your risk factors, without treatment about 3 in 100 people like you would have a stroke each year. The tablet I'm recommending roughly halves that risk.
It does thin the blood, so there's a slightly higher chance of bleeding. Most bleeding is minor — like bruising more easily — but serious bleeding is possible and I want you to know the signs.
If you ever notice black stools, vomiting blood, or a sudden severe headache, you must seek emergency help immediately.
There are two main options — this newer tablet means no regular blood tests, which many people prefer. Would you like me to explain the differences so we can decide together?

Case 4 — Polypharmacy, falls and frailty (Deprescribing)+

📋 Scenario

82-year-old on 10 medications including a night-time benzodiazepine, a strong opioid, and three antihypertensives. Recent falls and increasing confusion.

Domains: Clinical management (deprescribing) · Relating to others (patient priorities) · Safety

Key Moves

Acknowledge the burden of medication and check patient's own priorities (pain relief? sleep? staying mobile?)
Identify candidates for deprescribing or dose reduction: benzodiazepine at night, strong opioid, over-aggressive BP control
Explain rationale clearly — falls and fracture risk, confusion, constipation
Agree gradual changes — one at a time — and arrange follow-up
Safety-net for withdrawal effects (e.g. benzodiazepine taper)

Example Phrases

You're on quite a lot of tablets, and some of them can make you dizzy or drowsy — which might be contributing to your falls.
Rather than adding more medication, I'd like us to see whether we can gently reduce one or two that may be doing more harm than good at this stage.
We'll make one change at a time, starting with the sleeping tablet, and I'll arrange a follow-up in two weeks to review how you're feeling.
The aim is to keep you as well as possible while reducing the risk of another fall. Staying steady and safe is more important right now than treating every number on paper.

Case 5 — Medication error: double dose of DOAC (Error management)+

📋 Scenario

68-year-old on apixaban. A dispensing misunderstanding means they have taken double the prescribed dose for 3 days. No active bleeding at this point.

Domains: Clinical management · Communication (open disclosure) · Safety-netting

Key Moves

Clarify exact dose taken, timing, comorbidities, and other medications
Assess for bleeding symptoms — if none and stable, follow local guidance on dose management
Communicate clearly — acknowledge the error, express appropriate concern without catastrophising
Apologise appropriately where the practice contributed
Explain next steps and specific, actionable safety-net
Document and flag for significant event analysis (not part of the consultation, but important in real practice)

Example Phrases

Thank you for telling me — it was absolutely the right thing to do. Let me just clarify how much you've taken over the last few days so I can work out the best plan.
The good news is you have no signs of serious bleeding at the moment, which is reassuring.
I'd like you to pause the tablets for [X] doses and then restart at the correct dose. I'll also make sure your records are updated clearly.
If you notice black or tarry stools, vomiting blood, very unusual bruising, red or brown urine, or a sudden severe headache, please seek emergency help immediately — 999 if it feels urgent.

Case 6 — Depression: starting an SSRI (Counselling + risk)+

📋 Scenario

30-year-old with moderate depression, no active self-harm plans. First time on antidepressants. Worried about "getting addicted."

Domains: Counselling · Risk communication · Safety-netting (self-harm)

Key Moves

Explore the concern about addiction — what do they mean by that? What have they heard?
Explain clearly: SSRIs are not addictive in the way opioids or benzodiazepines are; stopping is gradual and managed
Discuss time to effect: 2–4 weeks; some feel worse initially (more anxious or nauseous) — normalise this
Discuss key side effects and what to do
Suicide/self-harm safety-net — explicit and specific
Offer follow-up in 2 weeks; consider psychological therapy referral alongside

Example Phrases

This medication isn't addictive in the way some sleeping tablets or painkillers can be. The aim is to help your brain chemistry rebalance over the next few months while you work on coping strategies.
Most people don't feel better immediately — it can take 2–4 weeks. Some people feel a bit more anxious or nauseous in the first week or two; if that happens, please let me know and we can discuss it.
When the time comes to stop, we'd reduce the dose slowly over a few weeks to avoid any discontinuation effects — you won't just be cut off.
If you ever feel you might act on thoughts of harming yourself, call us urgently, ring 111, or 999 if the risk feels immediate. Please don't wait until your next appointment.

📋 The MRCGP Prescribing Assessment

Mandatory for all ST3 GP trainees. It is designed as a learning exercise, not a pass/fail exam — but if you find no errors, your trainer will find that in itself quite unusual.

🎬 Video Introduction to the MRCGP Prescribing Assessment

Watch before starting your prescribing assessment for a clear overview of what is expected and how to approach it.

📌 Why Does This Assessment Exist?

Prescribing errors are among the leading causes of preventable patient harm in the NHS. High-profile serious cases have occurred with qualified doctors. The only way to improve is to regularly review and reflect on prescribing habits — not bury our heads in the sand. All qualified GPs already have prescribing reviewed periodically; trainees should do the same.

The Six Prescribing Capabilities Being Assessed

#	Capability	What This Means
1	Assessing risks and benefits	Including risks posed by other medications and conditions; reducing polypharmacy where possible
2	Unlicensed medicines	Identifying when prescribing unlicensed medicines and informing patients appropriately
3	Adhering to guidelines	National or local guidelines, OTC recommendations, and evidence-based medicine
4	Antimicrobial stewardship	Using antimicrobials appropriately; reducing unnecessary prescribing
5	Counselling patients	Giving instructions for taking medicines safely in line with up-to-date literature
6	Reviewing and monitoring	Blood testing and monitoring at appropriate intervals

How the Assessment Works — Step by Step

The trainee runs a computer search (EMIS, SystmOne, or Vision) to retrieve their last 50 retrospective prescriptions from a set date.
Using the RCGP Prescribing Manual, the trainee reviews these prescriptions, maps them against potential prescribing errors in the provided spreadsheet, and identifies any issues. Causes and methods of avoidance are noted.
The GP trainer independently reviews 20 of these same prescriptions (including some where the trainee did not identify errors) and adds to the spreadsheet.
The trainee completes the trainee reflection form on FourteenFish ePortfolio, reflecting using the GP prescribing proficiencies. PDP entries are created where appropriate.
The trainee and GP trainer/supervisor have a tutorial discussing the findings. Both complete the assessment form on FourteenFish.
Both parties submit questionnaires. The trainee uploads the anonymised spreadsheet to their learning log.

💡 Important: There Is No Pass/Fail Standard

The prescribing assessment is a learning exercise. There is no defined pass mark. However — if a trainee identifies no errors at all, and the trainer also identifies none, this would be highly unusual and would raise concerns about the quality of the review. Every single prescribing review conducted to date has identified some area for learning.

Key Documents and Links

📊

RCGP Prescribing Assessment Presentation

Official overview slides explaining the purpose and process of the prescribing assessment.

📘

Manual for GP Trainee Prescribing Review

The prescribing manual used to identify errors and suboptimal prescribing during the review process.

📋

Prescribing Data Collection Spreadsheet

The spreadsheet for recording your 50 prescriptions and any errors identified.

✅

Trainee Prescribing Checklist / Types of Errors

What to look for when reviewing your prescriptions — a checklist of error categories.

🖊️

Trainee Self-Reflection Form

The reflection form to complete on FourteenFish as part of the assessment.

❓

Prescribing Assessment FAQ

Answers to the most common questions trainees and trainers have about the assessment process.

🖥️ Getting Your 50 Prescriptions — System-Specific Instructions

EMIS and SystmOne have built-in searches to retrieve your prescriptions. For EMIS: use the built-in prescribing search (instructions and video available via RCGP link above). For SystmOne: follow Ardens instructions. For Vision: separate PDF guide available. If the built-in search fails or you're in Scotland on EMIS: a downloadable EMIS search file (ZIP) is available from the RCGP website.

🏁

Final Take-Home Points

The things to remember tomorrow — in clinic, in the exam, and beyond.

🛡️

Check Before You Prescribe

Allergy, interactions, renal function, indication — every time. It only takes 30 seconds and it can prevent a catastrophic error.

🧬

CYP450 Is Everywhere

SCRAP GPS induces. SICKFACES.COM G inhibits. Warfarin, COCP, statins, and theophylline are the drugs at risk. This shows up in AKT every year.

💓

QT Prolongation Is a Real Risk

Multiple common GP drugs prolong QT. The danger is combining them. Check CredibleMeds before co-prescribing. An ECG is cheap. Torsades de Pointes is not.

🔄

Deprescribing Is Prescribing

Stopping a medication can be as therapeutic as starting one. Polypharmacy harms. Review regularly. Not everything needs to stay on the list forever.

🎯

Prescribing Is a Consultation Skill

A technically perfect prescription issued without shared decision-making is not good practice. Ask what the patient thinks about taking the medication. You'll be surprised how often this changes everything.

📋

MRCGP Assessment Is a Learning Tool

Every single trainee who has completed the prescribing assessment has found something to learn from it. That's not a failure — that's the point. Embrace it and your prescribing will genuinely improve.

🩺

Sick Day Rules — Document Every Time

Metformin, ACEi/ARBs, and NSAIDs need to be stopped when patients are acutely unwell or dehydrated. This advice needs to be given and documented every single time you prescribe them.

✍️

Never Write "As Directed"

Spell it out. Every time. The patient deserves to know exactly how to take their medication. And so does the pharmacist. And so will you, when you look at that prescription in six months.

"Good prescribing isn't just about knowing the right drug. It's about knowing the right drug for this patient, at this dose, at this moment — and explaining it so clearly they actually take it."

Bradford VTS · Prescribing & Prescribing Assessment

Information provided on this medical website is intended for educational purposes only. Always verify clinical content against current NICE/BNF guidance. Users are strongly advised to consult reliable medical sources and healthcare professionals for accurate and personalised guidance — especially with protocols, guidelines, and doses.

Bradford VTS · bradfordvts.co.uk · Created by Dr Ramesh Mehay

Prescribing Theory - incl. cytochome P40 & prolonged QT interval

Below is Torsades de Pointes

So… look at the ECG!
Correct the QT interval using the fomula at MDCALC
Determine the increase from baseline

MILD EFFECT: if the prolongation INCREASE is 10 msec or less, the effect is low and you don’t need to worry too much. However, be careful of co-prescribing several medications which are known to have a low effect because the combination might push the prolongation into the moderate or severe ranges!
MODERATE EFFECT: if the prolongation INCREASE is 10-20 msec. This is clinically significant. Assess risk vs benefit. Consider dose reduction or switch to alternative. Monitor with repeat ECGs.
HIGH EFFECT: if the prolongation INCREASE is greater than 20 msec, this is dangerous. You need to do something about it now! Assess risk vs benefit. Stop the offending drugs if possible or switch to alternative. Monitor with repeat ECGs.

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