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Hard Neurology

Q 14 / 30

Scenario: A 34-year-old woman attends with 18 hours of right-sided facial weakness, noticed when brushing her teeth. She cannot raise her right eyebrow or close her right eye fully. There are no vesicles in or around the ear and limbs are normal. Examination confirms an isolated lower motor neurone facial nerve palsy with forehead involvement.

Question: According to NICE CKS, what is the most appropriate initial management?

A. Urgent same-day neurology referral

B. Prednisolone 50 mg daily for 10 days plus eye care✓

C. Prednisolone plus aciclovir 800 mg five times daily

D. Aciclovir alone for 7 days

E. Reassure — treatment only if no recovery at 3 weeks

Core Lens: high-yield takeaways

Pred within 72 h — 50 mg/day for 10 days, no routine antivirals.

Forehead spared = think stroke, not Bell’s — refer urgently.

↗ NICE CKS · Bell’s palsy

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✓ The correct answer is B: Add an SGLT2 inhibitor (e.g. Dapagliflozin) for cardiorenal protection.

Core Lens · High-Yield Takeaways

SGLT2 inhibitors are now indicated in T2DM + CKD. Per NICE NG28 and NG203, offer when ACR ≥ 25 mg/mmol and consider when ACR 3–25 — independent of HbA1c control.
Don’t stop the ACE inhibitor. Ramipril is renoprotective and CV-protective; continue unless K⁺ ≥ 5.5 or there is established AKI.
Watch the eGFR trajectory. A 27% drop over six months meets NICE criteria for nephrology referral — but adding the SGLT2i is the immediate, prognosis-changing step.
Metformin needs review, not switching. At eGFR < 45 reduce to 500 mg BD; stop only when eGFR < 30.

Click here for Deep Dive

🩺 The cardiorenal triad

Why this is the right move

This patient ticks every threshold for an SGLT2 inhibitor: T2DM with CKD G3b (eGFR 38), A3 albuminuria (ACR 45 mg/mmol), and already on a maximally tolerated ACE inhibitor. Dapagliflozin and empagliflozin both have NICE technology appraisals (TA775, TA992) supporting use in CKD irrespective of diabetes status. The DAPA-CKD and EMPA-KIDNEY trials showed significant reductions in CKD progression, all-cause mortality and CV events — additive on top of maximal ACEi.

Per NICE NG203 (CKD, updated 2023): offer an SGLT2 inhibitor in T2DM with CKD when ACR ≥ 25 mg/mmol. With ACR 45, this patient is firmly in the offer category.

Why the other options don’t fit

Stop Ramipril: ACE inhibitors slow CKD progression in proteinuric disease — they are the foundation, not the problem. Discontinue only if K⁺ ≥ 5.5 mmol/L or in AKI. A modest eGFR fall on initiation is expected and acceptable.
Refer routinely to nephrology and continue current treatment: Referral is appropriate (eGFR has fallen > 25%), but it isn’t the most appropriate next step. The intervention that actually changes the prognosis — adding an SGLT2i — should happen now, in primary care.
Increase Ramipril to 20 mg: The maximum licensed daily dose is 10 mg (BNF); titrating above this is unlicensed and adds hyperkalaemia/AKI risk without proven benefit.
Stop Metformin and switch to Gliclazide: Metformin should be dose-reviewed at eGFR < 45 (typically halved), not stopped or switched. Gliclazide carries hypoglycaemia risk and offers no cardiorenal benefit — SGLT2 inhibitors are preferred.

Red flags & key decision points

eGFR drop ≥ 25% in 12 months → consider nephrology referral and screen for reversible causes.
ACR ≥ 70 mg/mmol → nephrology referral irrespective of eGFR.
Check K⁺ before, and 1–2 weeks after, starting or uptitrating an ACEi or SGLT2i.
Counsel on sick-day rules (withhold SGLT2i and Metformin during D&V to reduce AKI risk).

Relevance to general practice

Starting an SGLT2 inhibitor is now a core primary-care skill, not a specialist task. AKT examiners reward candidates who recognise the cardiorenal indication independently of glycaemic control. The same drugs are also licensed for heart failure (with or without diabetes), so the same logic surfaces under cardiology, nephrology and diabetes stems.

Clinical Pearl

If the stem gives you T2DM plus CKD plus ACR ≥ 3 mg/mmol, the answer is almost always “add an SGLT2 inhibitor.” Memorise this triad — it appears in AKT questions disguised as renal, cardiology or diabetes scenarios.

Core Summary: In T2DM with CKD and albuminuria, adding an SGLT2 inhibitor is the highest-yield, NICE-recommended next step — additive on top of maximal ACE inhibition and independent of current glycaemic control.

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