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Clinical Revision NICE CKS BNF Cardiovascular Respiratory 12 September 2026 · 11 min read

NICE CKS vs BNF 87/88: Mastering the High-Weighting Therapeutic Clinical Scenarios

Step-by-step decision algorithms for Hypertension (NG136), Asthma (BTS/SIGN vs NICE NG80), and Type 2 Diabetes (NG28) for GPhC Paper 2.

1. The Clinical Hierarchy in GPhC Paper 2

In Paper 2 single best answer (SBA) questions, all 5 options are frequently plausible clinical interventions. However, the correct answer is the first-line evidence-based recommendation according to UK national guidance (NICE CKS and BNF).

The GPhC Registration Assessment Paper 2 heavily prioritises high-weighting clinical areas defined in the GPhC syllabus: Cardiovascular, Central Nervous System (CNS), Endocrine, Infections, and Respiratory.

2. Cardiovascular: Hypertension (NICE Guideline NG136)

Diagnostic Thresholds:

  • Clinic Blood Pressure >= 140/90 mmHg + ABPM/HBPM daytime average >= 135/85 mmHg defines Stage 1 Hypertension.
  • Clinic Blood Pressure >= 160/100 mmHg + ABPM/HBPM >= 150/95 mmHg defines Stage 2 Hypertension.

Pharmacological Treatment Algorithm:

  1. Type 2 Diabetes (any age/ethnicity) OR Non-black patient aged < 55:
  • Step 1: ACE Inhibitor (e.g. Ramipril) OR ARB (e.g. Losartan).
  • Step 2 (if uncontrolled): Dual Therapy: (ACEi / ARB) + CCB (e.g. Amlodipine) OR Thiazide-like Diuretic (e.g. Indapamide).
  • Step 3: Triple Therapy: (ACEi / ARB) + CCB + Thiazide-like Diuretic.
  • Step 4 (Resistant): If K+ <= 4.5 mmol/L add low-dose Spironolactone; if K+ > 4.5 mmol/L add Alpha-blocker or Beta-blocker.
  1. Black African/African-Caribbean origin OR Age >= 55 without Type 2 Diabetes:
  • Step 1: Calcium Channel Blocker (CCB - e.g. Amlodipine). (If not tolerated: Thiazide-like Diuretic).
  • Step 2: CCB + (ACEi / ARB / Thiazide-like Diuretic).

3. Respiratory: Asthma Inhaler Stepping (NICE NG80 vs BTS/SIGN 158)

ParameterBTS / SIGN GuidelineNICE NG80 Guideline
Step 1 (Mild/Infrequent)SABA as required (e.g. Salbutamol 100 mcg)SABA as required
Step 2 (Regular Preventer)Low-dose Inhaled Corticosteroid (ICS)Low-dose ICS
Step 3 (First Add-on)Add LABA to Low-dose ICSAdd LTRA (e.g. Montelukast 10 mg)
Step 4 (Escalation)Switch to MART OR increase ICSAdd LABA (with or without LTRA)
MART CounsellingPatient stops separate SABA; combination inhaler acts as preventer and reliever.

4. Endocrine: Type 2 Diabetes Glycaemic Management (NICE NG28)

Target HbA1c Levels:

  • 48 mmol/mol (6.5%): Managed by lifestyle alone, or single drug not associated with hypoglycaemia (Metformin).
  • 53 mmol/mol (7.0%): Managed by a drug associated with hypoglycaemia (Sulfonylurea, Meglitinide, Insulin).

Cardiovascular Disease (CVD) Stratification:

  • If the patient has established atherosclerotic cardiovascular disease (CVD) or chronic heart failure:

First-line Therapy = Metformin + SGLT2 Inhibitor (e.g. Empagliflozin / Dapagliflozin)

  • *Safety check:* Assess eGFR before initiating SGLT2i and counsel on signs of euglycaemic Diabetic Ketoacidosis (DKA) and genital mycotic infections.

5. Summary Checklists for Examination Day

  1. Check Renal Function First: In any clinical vignette, check Serum Creatinine, eGFR, or CrCl using the Cockcroft-Gault equation.
  2. Review Interactions with OTC/Herbal Preparations: Look for St John's Wort (CYP3A4 inducer), NSAIDs (triple whammy with ACEi + Diuretics), and Oral Decongestants.
  3. Verify Prescription Legality: Always ensure dose, form, strength, and directions comply with the latest MEP standards.