Safe Prescribing — MCQs

What is the recommended initial frequency for monitoring international normalised ratio (INR) when a patient is first started on warfarin therapy following a deep vein thrombosis?

A 56-year-old man with type 2 diabetes is established on insulin detemir 32 units subcutaneously at 22:00 hours and insulin aspart 8 units three times daily with meals. Over the past week, his pre-breakfast glucose readings have been consistently between 3.8-4.2 mmol/L, while his pre-lunch, pre-dinner, and bedtime readings are all 7-9 mmol/L. He denies any hypoglycaemic symptoms. What is the most appropriate adjustment to his insulin regimen?

A 71-year-old man with atrial fibrillation is on warfarin with a target INR of 2.0-3.0. He is admitted with community-acquired pneumonia and started on clarithromycin 500mg twice daily. His INR on admission is 2.4. After 3 days of antibiotics, he develops haematuria and his INR is found to be 7.8. He is haemodynamically stable with no other bleeding. What is the most appropriate immediate management?

A 39-year-old woman with type 1 diabetes on basal-bolus insulin therapy (insulin glargine 24 units at bedtime and insulin aspart with meals) is admitted with acute appendicitis requiring emergency surgery. She last ate 6 hours ago. Her current blood glucose is 8.2 mmol/L. The operation is scheduled in 2 hours. What is the most appropriate management of her insulin during the perioperative period?

According to the National Patient Safety Agency guidance on high-risk medicines, which of the following monitoring parameters is specifically recommended for patients on long-term amiodarone therapy?

A 50-year-old man with bipolar disorder has been stable on lithium carbonate 800mg twice daily for 18 months. His most recent lithium level 3 months ago was 0.75 mmol/L (therapeutic range 0.6-1.0 mmol/L). He now presents to his GP with a 5-day history of diarrhoea and vomiting following a gastrointestinal infection. He appears clinically dehydrated with a coarse tremor. What is the most appropriate immediate management?

A 63-year-old woman with metastatic breast cancer is started on enoxaparin for prophylaxis of venous thromboembolism. She has a past medical history of hypertension and stage 3 chronic kidney disease with eGFR of 35 ml/min/1.73m². Her weight is 55 kg. According to current prescribing guidance, what adjustment should be made to the standard dose of enoxaparin?

A 63-year-old man with type 2 diabetes is established on a complex insulin regimen comprising insulin glargine 38 units at 22:00, insulin aspart 12 units with breakfast, 10 units with lunch, and 14 units with evening meal. He is admitted with acute pancreatitis and made nil by mouth, and a variable rate intravenous insulin infusion (VRIII) is commenced at 09:00 on Monday. His last dose of insulin glargine was at 22:00 on Sunday night. He improves and is ready to resume eating at 18:00 on Wednesday. When is the most appropriate time to discontinue the VRIII?

A 77-year-old man with atrial fibrillation and a mechanical mitral valve replacement is on warfarin with target INR 3.0-4.0. He requires urgent colonoscopy for suspected lower gastrointestinal bleeding (haemoglobin dropped from 125 to 95 g/L over 48 hours with melaena). His current INR is 3.6. He is haemodynamically stable. What is the most appropriate anticoagulation management strategy prior to the procedure?

A 42-year-old woman with newly diagnosed type 1 diabetes is being established on a basal-bolus insulin regimen. Over the past week, her pre-meal and bedtime capillary glucose readings have been: breakfast 6.2-7.8 mmol/L, lunch 11.5-14.2 mmol/L, evening meal 7.1-8.9 mmol/L, bedtime 9.8-12.4 mmol/L. She is currently on insulin detemir 18 units at bedtime and insulin lispro 6 units before each meal. Which insulin adjustment would most appropriately address her glucose pattern?