A 28-year-old woman presents with a 3-day history of dysuria, urinary frequency, and suprapubic pain. She is otherwise well with no fever. Urine dipstick shows nitrites positive, leucocytes positive. What is the most appropriate first-line antibiotic treatment?

Trimethoprim 200mg BD for 3 days

Amoxicillin 500mg TDS for 7 days

Ciprofloxacin 500mg BD for 7 days

Nitrofurantoin 50mg QDS for 3 days

Co-amoxiclav 625mg TDS for 7 days

A 59-year-old man with type 1 diabetes for 25 years is admitted with acute pancreatitis. His usual insulin regimen is insulin glargine 32 units at bedtime and insulin lispro 8 units with meals. He is kept nil by mouth and started on intravenous fluids. His admission glucose is 16.2 mmol/L. According to best practice for managing insulin in acute illness with nil-by-mouth status, what is the most appropriate insulin management?

Continue insulin glargine at usual dose; omit insulin lispro while nil by mouth

Continue insulin glargine; give insulin lispro based on blood glucose readings every 4 hours

Stop all insulin until he is eating and drinking again

Convert to variable-rate intravenous insulin infusion at 0.05 units/kg/hour

Give half the usual total daily insulin dose as basal insulin only

A 68-year-old woman with non-valvular atrial fibrillation (CHA₂DS₂-VASc score 4) is on apixaban 5mg twice daily. She is diagnosed with intermediate-risk myelodysplastic syndrome requiring treatment with azacitidine chemotherapy, which carries significant thrombocytopenia risk (expected platelet nadir 20-50 × 10⁹/L). What is the most appropriate anticoagulation strategy during chemotherapy?

Temporarily stop all anticoagulation during chemotherapy cycles; restart when platelets >50 × 10⁹/L

Continue apixaban 5mg twice daily throughout chemotherapy; monitor platelets weekly

Reduce apixaban to 2.5mg twice daily during chemotherapy cycles

Switch to prophylactic-dose LMWH during chemotherapy cycles

Switch to warfarin with target INR 2-3 as it can be more easily reversed

A 55-year-old woman with type 2 diabetes is on insulin detemir 38 units at 22:00 and metformin 1g twice daily. Her blood glucose readings show: fasting 6-8 mmol/L, pre-lunch 12-15 mmol/L, pre-dinner 10-13 mmol/L, bedtime 8-10 mmol/L. HbA1c is 68 mmol/mol (8.4%). Understanding insulin pharmacodynamics, what is the most appropriate next step in optimizing her insulin regimen?

Add prandial rapid-acting insulin with main meals

Split insulin detemir to twice-daily dosing (20 units morning, 20 units evening)

Increase insulin detemir to 44 units at 22:00

Switch from insulin detemir to insulin glargine

A 64-year-old man with atrial fibrillation is on rivaroxaban 20mg once daily. He requires emergency laparotomy for perforated diverticulitis within 2 hours. He took his last dose of rivaroxaban 8 hours ago. His renal function shows eGFR 58 ml/min/1.73m². Pre-operative blood tests show Hb 118 g/L. What is the most appropriate management of his anticoagulation?

Give 4-factor prothrombin complex concentrate 50 units/kg before surgery

Proceed to surgery; accept increased bleeding risk as surgery is life-saving

Give fresh frozen plasma 15 ml/kg before surgery

Delay surgery 12 hours to allow rivaroxaban clearance

Give tranexamic acid 1g IV before surgery

A 46-year-old man with type 1 diabetes for 20 years presents with a 3-month history of unpredictable blood glucose control despite good insulin adherence. He reports that his hypoglycaemic episodes now occur without warning symptoms. Investigations show HbA1c 58 mmol/mol (7.5%) but frequent hypoglycaemia on continuous glucose monitoring. What is the most appropriate modification to his insulin regimen?

Relax blood glucose targets and accept higher HbA1c to restore hypoglycaemia awareness

Switch to insulin pump therapy with continuous glucose monitoring

Increase overall insulin doses to improve HbA1c

Add acarbose to slow carbohydrate absorption

Switch from rapid-acting to regular insulin analogues

A 58-year-old woman with atrial fibrillation is on edoxaban 60mg once daily. She develops acute bacterial endocarditis affecting the mitral valve and requires valve replacement surgery in 48 hours. Current renal function shows eGFR 65 ml/min/1.73m². What is the most appropriate approach to managing her anticoagulation perioperatively?

Stop edoxaban now, give PCC for reversal, start warfarin post-operatively with LMWH bridge

Continue edoxaban until 24 hours before surgery, then restart 6 hours post-operatively

Stop edoxaban 48 hours before surgery, bridge with LMWH, restart edoxaban post-operatively

Stop edoxaban now, start intravenous heparin infusion, restart edoxaban post-operatively

Stop edoxaban now, no bridging required, restart edoxaban 24-48 hours post-operatively

A 52-year-old woman with type 2 diabetes is established on insulin glargine 42 units at bedtime and metformin 1g twice daily. She is about to commence treatment for latent tuberculosis with rifampicin 600mg daily for 3 months. What is the most important consideration regarding her diabetes management?

Rifampicin may increase insulin requirements significantly due to enzyme induction

Rifampicin has no effect on insulin requirements

Rifampicin may decrease insulin requirements due to improved insulin sensitivity

Metformin dose should be reduced due to interaction with rifampicin

Insulin glargine should be switched to NPH insulin due to rifampicin interaction

A 71-year-old man with mechanical mitral valve replacement is on warfarin (target INR 2.5-3.5). He requires urgent colonoscopy for suspected lower GI bleeding. His current INR is 3.2. The procedure is needed within 12 hours. What is the most appropriate management of his anticoagulation?

Give intravenous vitamin K 5mg and proceed when INR <1.5

Omit warfarin doses and proceed when INR <1.5

Give oral vitamin K 1-2mg and proceed when INR <1.5

Give prothrombin complex concentrate (PCC) and proceed immediately

Proceed with colonoscopy at current INR of 3.2

A 63-year-old man with type 1 diabetes is admitted with severe diabetic ketoacidosis (pH 7.08, ketones 5.2 mmol/L, glucose 28 mmol/L). He is commenced on a fixed-rate intravenous insulin infusion at 0.1 units/kg/hour and receives fluid resuscitation. After 4 hours, his glucose has fallen to 14 mmol/L but ketones remain at 4.8 mmol/L and pH is 7.15. What is the most appropriate next step in his insulin management?

Continue current insulin infusion rate and add 10% glucose infusion

Reduce insulin infusion rate to 0.05 units/kg/hour as glucose is improving

Stop insulin infusion and switch to subcutaneous basal-bolus regimen

Increase insulin infusion rate to 0.15 units/kg/hour to accelerate ketone clearance

Continue current insulin infusion without adding glucose

High-risk medicines for UKMLA AKT: High-Yield Prescribing, Ethics & Patient Safety Lessons

Quick Overview

High-risk medicines require enhanced prescribing vigilance due to significant patient harm potential from incorrect use, dose, or monitoring. NICE NG5 emphasizes structured safety checks, mandatory documentation, and recognition of NPSA-identified drug categories. Mastery prevents Never Events and reduces medication-related morbidity/mortality.

Core Facts & Concepts

NPSA High-Risk Drug Categories:

Category	Examples	Key Risk
Anticoagulants	Warfarin, DOACs, heparin	Bleeding/thrombosis
Insulin	All formulations	Hypoglycaemia
Opioids	Morphine, fentanyl	Respiratory depression
Chemotherapy	Methotrexate, vincristine	Toxicity/wrong route
Sedatives	Midazolam, propofol	Over-sedation

Critical Prescribing Requirements:

Anticoagulants: Document indication, duration, target INR (warfarin 2-3 for AF/VTE, 2.5-3.5 for mechanical valves)
Insulin: State formulation type (rapid/short/intermediate/long-acting), device, timing relative to meals
Methotrexate: Weekly dosing only for rheumatology/dermatology (NOT daily), prescribe with folic acid 5mg once weekly (different day)
Potassium: Maximum 20mmol/hour via peripheral line, 40mmol/hour via central line

Figure 1: Chest X-ray showing bilateral pulmonary infiltrates from methotrexate pneumonitis

Never Events Related to Prescribing:

Mis-selection of strong potassium solutions
Overdose of insulin due to abbreviations or device errors
Overdose of methotrexate for non-cancer treatment
Intrathecal route administration of vincristine (always IV)

Problem-Solving Approach

Systematic High-Risk Prescription Check:

Verify indication - Is this drug appropriate for diagnosis?
Calculate dose - Use ideal/actual body weight appropriately; check renal/hepatic function
Check interactions - Review current medications (especially for warfarin, digoxin)
Confirm monitoring - Pre-prescription bloods required? (e.g., U&Es before ACEi, FBC before methotrexate)
Document clearly - Avoid abbreviations (write "units" not "U", "micrograms" not "μg")
Patient education - Explain monitoring requirements and warning symptoms

Figure 2: Blood film showing thrombocytopenia with reduced platelet count

Red Flags 🚩:

Abbreviations: "U" (units), "IU", "μg" → write in full
Decimal points without leading zeros: ".5mg" → write "0.5mg"
Trailing zeros: "5.0mg" → write "5mg"
Verbal orders for high-risk drugs → always obtain written prescription

Analysis Framework

Warfarin vs DOAC Decision:

Factor	Warfarin	DOACs
Monitoring	Regular INR	None required
Renal impairment	Safer in CKD 4-5	Avoid if eGFR <15-30
Mechanical valve	✓ Indicated	✗ Contraindicated
Reversibility	Vitamin K, PCC	Idarucizumab (dabigatran), andexanet alfa (Xa inhibitors)
Drug interactions	Extensive	Fewer

Insulin Error Prevention:

Use brand names (Lantus, Novorapid) not generic "insulin"
State dose in units (never "U")
Specify device: pen, vial, pump
Prescribe basal and bolus separately

Visual Aid

Monitoring Requirements Table:

Drug	Baseline	Ongoing Monitoring
Warfarin	INR, FBC, LFTs	INR (target-dependent frequency)
Methotrexate	FBC, U&Es, LFTs, CXR	FBC, LFTs every 2-4 weeks initially
Lithium	U&Es, TFTs, ECG	Lithium level 12h post-dose, U&Es, TFTs 6-monthly
Digoxin	U&Es, ECG	Digoxin level if toxicity suspected, annual U&Es
Amiodarone	TFTs, LFTs, CXR	TFTs, LFTs 6-monthly

Key Points Summary

✓ NPSA categories: Anticoagulants, insulin, opioids, chemotherapy, sedatives require enhanced vigilance

✓ Never abbreviate: Write "units" not "U", "micrograms" not "μg", avoid decimal errors (leading/trailing zeros)

✓ Methotrexate: Weekly dosing only for non-cancer indications; daily prescription = Never Event

✓ Warfarin targets: 2-3 for AF/VTE, 2.5-3.5 for mechanical valves; DOACs contraindicated in mechanical valves

✓ Potassium infusion limits: 20mmol/hour peripheral, 40mmol/hour central maximum rates

✓ Vincristine route: IV only - intrathecal administration is fatal Never Event

✓ Documentation mandatory: Indication, duration, monitoring plan, patient counselling for all high-risk medicines

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