Safe Prescribing — MCQs
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A 62-year-old woman with type 2 diabetes attends for review. She is on insulin detemir 28 units twice daily and insulin aspart with meals. Her home blood glucose monitoring shows fasting readings of 5-7 mmol/L, but her HbA1c has risen from 58 mmol/mol to 72 mmol/mol over 6 months. Her mealtime and evening glucose readings are 12-16 mmol/L. She reports taking her basal insulin reliably but admits often forgetting or deliberately missing mealtime insulin doses due to concerns about hypoglycaemia and weight gain. What is the most appropriate management strategy?
A 71-year-old man with atrial fibrillation is on warfarin with a target INR of 2-3. Over the past 8 weeks, his INR results have been: 2.1, 2.8, 1.6, 3.4, 1.9, 3.6, 2.2, and 3.8. His time in therapeutic range (TTR) is calculated at 52%. He is compliant with monitoring and takes no new medications. What is the most appropriate management approach?
A 48-year-old man with newly diagnosed type 2 diabetes is started on basal-bolus insulin therapy following failure of oral agents. He is prescribed insulin glargine 18 units at bedtime and insulin lispro before meals. He asks how to adjust his mealtime insulin when eating different amounts of carbohydrate. What is the most appropriate advice regarding insulin lispro dosing?
A 68-year-old woman on warfarin (target INR 2-3) for atrial fibrillation presents with an INR of 7.8. She has no active bleeding but reports noticing increased bruising over the past week. Her current warfarin dose is 5mg daily. According to current British Society for Haematology guidelines, what is the most appropriate immediate management?
A 56-year-old man with type 2 diabetes is on metformin 1g twice daily and insulin glargine 40 units at bedtime. He is admitted for elective inguinal hernia repair under general anaesthetic, scheduled as the first case at 8:00 AM. His fasting blood glucose at 6:00 AM is 8.2 mmol/L. What is the most appropriate perioperative insulin management?
A 72-year-old man with atrial fibrillation on apixaban 5mg twice daily is admitted with a suspected acute stroke. CT head shows a large ischaemic stroke with no haemorrhage. He last took apixaban 4 hours ago. Thrombolysis is being considered. What is the most appropriate management of his anticoagulation?
A 43-year-old woman with type 1 diabetes presents to the emergency department with a 2-day history of vomiting and diarrhoea. Her capillary blood glucose is 16.2 mmol/L and urinalysis shows 3+ ketones. Her regular insulin regimen is insulin aspart 8 units three times daily with meals and insulin glargine 22 units at bedtime. What is the most appropriate immediate insulin management?
A 67-year-old woman with atrial fibrillation is established on warfarin. She is prescribed a 7-day course of ciprofloxacin for a urinary tract infection. Which of the following best describes the mechanism of interaction between warfarin and ciprofloxacin and the appropriate management?
A 51-year-old man with psoriatic arthritis is being considered for methotrexate therapy. He drinks approximately 35 units of alcohol per week. What is the most appropriate action regarding methotrexate prescribing in this patient?
A 64-year-old woman with newly diagnosed deep vein thrombosis is commenced on rivaroxaban. She has normal renal function (eGFR 82 ml/min/1.73m²) and weighs 70kg. What is the appropriate initial treatment regimen for rivaroxaban in acute DVT according to current UK licensing?
Safe Prescribing UK Medical PG Practice Questions and MCQs
Question 141: A 62-year-old woman with type 2 diabetes attends for review. She is on insulin detemir 28 units twice daily and insulin aspart with meals. Her home blood glucose monitoring shows fasting readings of 5-7 mmol/L, but her HbA1c has risen from 58 mmol/mol to 72 mmol/mol over 6 months. Her mealtime and evening glucose readings are 12-16 mmol/L. She reports taking her basal insulin reliably but admits often forgetting or deliberately missing mealtime insulin doses due to concerns about hypoglycaemia and weight gain. What is the most appropriate management strategy?
- A. Increase insulin detemir to 36 units twice daily to improve overall control
- B. Switch to premixed insulin twice daily to simplify the regimen
- C. Address her concerns through education, consider adding GLP-1 receptor agonist, and optimize mealtime insulin dosing (Correct Answer)
- D. Switch basal insulin to once-daily insulin glargine U300 and continue current mealtime insulin
- E. Add SGLT2 inhibitor and reduce insulin detemir dose by 20%
Explanation: ***Address her concerns through education, consider adding GLP-1 receptor agonist, and optimize mealtime insulin dosing*** - The patient's elevated **HbA1c** and high **mealtime glucose readings** are primarily due to non-adherence to mealtime insulin, driven by her **fears of hypoglycemia and weight gain**; addressing these concerns through education is paramount. - A **GLP-1 receptor agonist** is an excellent addition as it promotes **weight loss**, improves **postprandial glucose control**, and carries a **low risk of hypoglycemia**, directly counteracting her primary concerns. *Increase insulin detemir to 36 units twice daily to improve overall control* - The patient's **fasting glucose readings** (5-7 mmol/L) are already within the target range, indicating that her current **basal insulin** dose is sufficient. - Increasing the basal insulin dose would primarily lower fasting glucose further, potentially causing **nocturnal or morning hypoglycemia**, and would not address the elevated postprandial glucose due to missed mealtime insulin. *Switch to premixed insulin twice daily to simplify the regimen* - While simplifying the regimen might improve adherence for some, **premixed insulin** still contains rapid-acting components that could cause **hypoglycemia** and contribute to **weight gain**, thus not addressing her core fears. - This approach offers less flexibility in managing fluctuating mealtime carbohydrate intake and may not resolve the underlying psychological barriers to insulin use. *Switch basal insulin to once-daily insulin glargine U300 and continue current mealtime insulin* - The patient's **basal insulin regimen** (insulin detemir) is effectively controlling her fasting glucose, so switching to another basal insulin provides no specific clinical advantage for her current problem. - This strategy fails to address the critical issue of her **non-adherence to mealtime insulin** due to her concerns about hypoglycemia and weight gain. *Add SGLT2 inhibitor and reduce insulin detemir dose by 20%* - While **SGLT2 inhibitors** can aid in weight loss and lower glucose, they are not primarily targeted at addressing **postprandial spikes** caused by missing mealtime insulin. - Reducing the **basal insulin dose** by 20% when fasting glucose is already well-controlled would likely lead to **fasting hyperglycemia** and would not resolve the issue of high postprandial readings.
Question 142: A 71-year-old man with atrial fibrillation is on warfarin with a target INR of 2-3. Over the past 8 weeks, his INR results have been: 2.1, 2.8, 1.6, 3.4, 1.9, 3.6, 2.2, and 3.8. His time in therapeutic range (TTR) is calculated at 52%. He is compliant with monitoring and takes no new medications. What is the most appropriate management approach?
- A. Continue warfarin with more frequent INR monitoring until control improves
- B. Switch to a direct oral anticoagulant (DOAC) such as apixaban (Correct Answer)
- C. Refer to anticoagulation clinic for specialist review of warfarin dosing regimen
- D. Add low-dose aspirin 75mg daily to improve thromboembolic protection
- E. Increase warfarin dose by 20% and review INR weekly for 4 weeks
Explanation: ***Switch to a direct oral anticoagulant (DOAC) such as apixaban***- The patient's **Time in Therapeutic Range (TTR)** of 52% is significantly below the recommended target of **>65-70%** for effective and safe anticoagulation with **warfarin** in atrial fibrillation.- Given the patient's compliance and absence of other influencing factors, switching to a **DOAC** is the most appropriate management to achieve stable anticoagulation and reduce the risk of **stroke** and **bleeding** events.*Continue warfarin with more frequent INR monitoring until control improves*- Frequent **INR monitoring** is typically used for initial stabilization or when fluctuations are due to identifiable, correctable factors; it is unlikely to resolve persistent, poor **TTR** despite compliance.- This approach would prolong the period of **sub-therapeutic** and **supra-therapeutic** anticoagulation, increasing the risks of both **thromboembolism** and **hemorrhage**.*Refer to anticoagulation clinic for specialist review of warfarin dosing regimen*- While specialist review can optimize warfarin therapy, current guidelines favor switching to a **DOAC** for persistently poor **TTR** in non-valvular atrial fibrillation, especially when compliance is good and no clear reversible causes exist.- Specialist review is often reserved for patients with contraindications to **DOACs**, mechanical heart valves, or very complex comorbid conditions.*Add low-dose aspirin 75mg daily to improve thromboembolic protection*- Adding **aspirin** to anticoagulation in atrial fibrillation significantly increases the **risk of major bleeding** without providing substantial additional benefit for stroke prevention compared to anticoagulation alone.- This strategy does not address the fundamental issue of inadequate and unstable **warfarin** control.*Increase warfarin dose by 20% and review INR weekly for 4 weeks*- An increase in **warfarin** dose is inappropriate as the patient's INR values are fluctuating both above and below the target range, indicating instability rather than consistent under-anticoagulation.- This action would likely lead to dangerous **over-anticoagulation**, significantly elevating the risk of serious **bleeding complications**, such as intracranial or gastrointestinal hemorrhages.
Question 143: A 48-year-old man with newly diagnosed type 2 diabetes is started on basal-bolus insulin therapy following failure of oral agents. He is prescribed insulin glargine 18 units at bedtime and insulin lispro before meals. He asks how to adjust his mealtime insulin when eating different amounts of carbohydrate. What is the most appropriate advice regarding insulin lispro dosing?
- A. Take a fixed dose of insulin lispro before each meal regardless of carbohydrate content
- B. Use a carbohydrate counting system with insulin-to-carbohydrate ratios to calculate mealtime insulin doses (Correct Answer)
- C. Double the insulin lispro dose for large meals and halve for small meals
- D. Take insulin lispro only when blood glucose is above 10 mmol/L before meals
- E. Adjust insulin lispro based on blood glucose level 2 hours after the previous meal
Explanation: ***Use a carbohydrate counting system with insulin-to-carbohydrate ratios to calculate mealtime insulin doses*** - **Carbohydrate counting** is the most physiological and flexible method for dosing **rapid-acting insulin** like **insulin lispro**, allowing for precise matching of insulin to glucose load. - This approach improves **glycemic control** and reduces the risk of **hypoglycemia** or postprandial hyperglycemia by utilizing a specific **insulin-to-carbohydrate ratio (ICR)**. *Take a fixed dose of insulin lispro before each meal regardless of carbohydrate content* - Using a **fixed dose** does not account for variations in carbohydrate intake, leading to poor control when meal sizes change. - This rigid approach increases the risk of **hypoglycemia** if a patient consumes fewer carbohydrates than the dose was intended for. *Double the insulin lispro dose for large meals and halve for small meals* - This method is far too imprecise and lacks the quantitative accuracy required for **safe insulin management**. - Arbitrary adjustments like doubling doses significantly increase the danger of **severe hypoglycemia** and unpredictable glucose fluctuations. *Take insulin lispro only when blood glucose is above 10 mmol/L before meals* - This is a reactive "sliding scale" approach that only treats existing **hyperglycemia** rather than preventing the rise caused by the meal. - Failing to cover mealtime carbohydrates with insulin results in significant **postprandial glucose spikes** and poor long-term HbA1c control. *Adjust insulin lispro based on blood glucose level 2 hours after the previous meal* - This approach is flawed because the glucose level 2 hours post-meal reflects the **previous dose's efficacy**, not the requirements for the upcoming meal. - Effective **basal-bolus therapy** requires dosing based on the **projected carbohydrate intake** of the meal about to be consumed.
Question 144: A 68-year-old woman on warfarin (target INR 2-3) for atrial fibrillation presents with an INR of 7.8. She has no active bleeding but reports noticing increased bruising over the past week. Her current warfarin dose is 5mg daily. According to current British Society for Haematology guidelines, what is the most appropriate immediate management?
- A. Withhold warfarin for 1-2 days, restart when INR <5, check INR daily
- B. Give oral vitamin K 1-5mg, withhold warfarin, check INR in 24 hours (Correct Answer)
- C. Give intravenous vitamin K 10mg, withhold warfarin, check INR in 6 hours
- D. Continue warfarin at reduced dose of 2.5mg, check INR in 3 days
- E. Withhold warfarin for 1 dose only, give oral vitamin K 500 micrograms, check INR next day
Explanation: ***Give oral vitamin K 1-5mg, withhold warfarin, check INR in 24 hours***- For an **INR of 7.8** with minor bleeding symptoms like **bruising**, British Society for Haematology guidelines recommend withholding warfarin and administering **oral vitamin K 1-5mg**.- This approach provides a controlled and timely reversal of anticoagulation, aiming to bring the INR back into the therapeutic range within **24 hours** without overshooting or causing future warfarin resistance.*Withhold warfarin for 1-2 days, restart when INR <5, check INR daily*- This management is typically appropriate for an **INR between 5.0 and 8.0** with **no bleeding** or only mild, non-progressive bruising.- Given the patient's INR is near 8.0 with noticed increased bruising, actively administering **oral vitamin K** is preferred to expedite INR correction and reduce bleeding risk.*Give intravenous vitamin K 10mg, withhold warfarin, check INR in 6 hours*- **Intravenous vitamin K 10mg** is reserved for scenarios with **major or life-threatening bleeding** (e.g., GI bleed, intracranial hemorrhage) or extremely high INR values (e.g., >8.0 with high bleeding risk).- Such an aggressive approach is unnecessary for minor bruising and can lead to **warfarin resistance**, complicating future anticoagulation management for atrial fibrillation.*Continue warfarin at reduced dose of 2.5mg, check INR in 3 days*- Continuing warfarin when the **INR is 7.8** is contraindicated and significantly increases the risk of **severe hemorrhagic complications**.- The priority at this elevated INR is to **reduce its value** quickly and safely, not to maintain any level of anticoagulation.*Withhold warfarin for 1 dose only, give oral vitamin K 500 micrograms, check INR next day*- A dose of **500 micrograms (0.5mg) oral vitamin K** is generally considered insufficient for an INR of 7.8 with clinical signs of over-anticoagulation like bruising.- Guidelines recommend a higher dose of **1-5mg oral vitamin K** in this situation to ensure effective and predictable INR reduction within 24 hours.
Question 145: A 56-year-old man with type 2 diabetes is on metformin 1g twice daily and insulin glargine 40 units at bedtime. He is admitted for elective inguinal hernia repair under general anaesthetic, scheduled as the first case at 8:00 AM. His fasting blood glucose at 6:00 AM is 8.2 mmol/L. What is the most appropriate perioperative insulin management?
- A. Omit morning insulin glargine, give usual dose in the evening after surgery
- B. Give 80% of usual insulin glargine dose (32 units) the evening before surgery, omit morning of surgery
- C. Start variable rate intravenous insulin infusion at 6:00 AM
- D. Give usual insulin glargine dose (40 units) the evening before surgery, no insulin on morning of surgery (Correct Answer)
- E. Give 50% of usual insulin glargine dose (20 units) on the morning of surgery
Explanation: ***Give usual insulin glargine dose (40 units) the evening before surgery, no insulin on morning of surgery*** - For a patient undergoing short, elective procedures as the first case on the morning list, the **usual dose of basal insulin** (like glargine) should be given the evening before to maintain stable glycaemic levels. - Since the patient is scheduled for 8:00 AM and is likely to return to a normal diet quickly, the previous evening's **basal coverage** is sufficient without additional morning doses. *Omit morning insulin glargine, give usual dose in the evening after surgery* - Basal insulin should not be omitted entirely as it is required to prevent **perioperative ketoacidosis** and basal hyperglycaemia in insulin-dependent patients. - Omitting the dose would cause a significant gap in **insulin coverage**, leading to poor metabolic control during the surgical stress response. *Give 80% of usual insulin glargine dose (32 units) the evening before surgery, omit morning of surgery* - While some guidelines suggest a minor reduction (20%) for certain patients, current UK perioperative guidance (JBDS) often recommends maintaining the **full dose of long-acting basal insulin** to ensure stable background levels. - Reducing the dose unnecessarily may lead to **perioperative hyperglycaemia** in a patient whose current control (fasting glucose 8.2 mmol/L) is already stable. *Start variable rate intravenous insulin infusion at 6:00 AM* - **Variable rate intravenous insulin infusion (VRIII)** is indicated for major surgery, prolonged fasting (skipping more than one meal), or poorly controlled diabetes (HbA1c > 69 mmol/mol). - For a short, elective **inguinal hernia repair** where the patient will eat shortly after, VRIII is overly invasive and unnecessary. *Give 50% of usual insulin glargine dose (20 units) on the morning of surgery* - If the basal insulin was normally taken in the morning, a **reduction (usually to 80%)** might be considered; however, this patient takes his glargine at **bedtime**. - Administering a half-dose on the morning of surgery when the patient is already fasting increases the risk of **hypoglycaemia** during the procedure and deviates from his established routine.
Question 146: A 72-year-old man with atrial fibrillation on apixaban 5mg twice daily is admitted with a suspected acute stroke. CT head shows a large ischaemic stroke with no haemorrhage. He last took apixaban 4 hours ago. Thrombolysis is being considered. What is the most appropriate management of his anticoagulation?
- A. Proceed with thrombolysis immediately; apixaban does not contraindicate thrombolysis
- B. Give idarucizumab to reverse anticoagulation, then proceed with thrombolysis
- C. Wait 24 hours from last apixaban dose, then consider thrombolysis if still within time window
- D. Thrombolysis is contraindicated; apixaban should be continued and patient managed with aspirin (Correct Answer)
- E. Measure anti-Xa level; if normal, proceed with thrombolysis
Explanation: ***Thrombolysis is contraindicated; apixaban should be continued and patient managed with aspirin*** - **Direct Oral Anticoagulants (DOACs)** like **apixaban** taken within the last 48 hours are a **contraindication** for intravenous thrombolysis due to a significantly increased risk of **intracranial haemorrhage**. - With the last dose taken only **4 hours ago**, thrombolysis is explicitly contraindicated. Long-term management for **atrial fibrillation** involves continuing **apixaban**, and acute management of the stroke often includes **aspirin** for antiplatelet effect, typically initiated after a safe interval (e.g., 24 hours post-stroke without haemorrhage). *Proceed with thrombolysis immediately; apixaban does not contraindicate thrombolysis* - Therapeutic anticoagulation with a **DOAC** taken within the last 48 hours is a major **exclusion criterion** for intravenous alteplase due to the significant risk of **haemorrhagic transformation**. - Proceeding with thrombolysis in this context would lead to a dangerously high risk of **intracerebral haemorrhage**, which is life-threatening. *Give idarucizumab to reverse anticoagulation, then proceed with thrombolysis* - **Idarucizumab** is a specific reversal agent for **dabigatran** (a direct thrombin inhibitor), not for **Factor Xa inhibitors** like apixaban. - The appropriate reversal agent for apixaban is **andexanet alfa**, but its routine use before thrombolysis in acute stroke is not standard practice and comes with its own risks and limited evidence. *Wait 24 hours from last apixaban dose, then consider thrombolysis if still within time window* - The contraindication for thrombolysis with DOACs extends to **48 hours** (or longer depending on renal function/dose), not just 24 hours. - Waiting 24 hours is insufficient to clear apixaban to safe levels for thrombolysis, and thrombolysis itself is time-dependent, making such a delay often render the patient outside the treatment window. *Measure anti-Xa level; if normal, proceed with thrombolysis* - While **anti-Xa levels** can measure apixaban's anticoagulant effect, determining a "normal" or safe threshold for thrombolysis is complex and not routinely used to guide thrombolysis decisions in acute stroke guidelines. - Most guidelines recommend against thrombolysis if DOACs were taken within the last 48 hours, regardless of measured levels, due to the high risk, and turnaround time for such a test would delay critical treatment.
Question 147: A 43-year-old woman with type 1 diabetes presents to the emergency department with a 2-day history of vomiting and diarrhoea. Her capillary blood glucose is 16.2 mmol/L and urinalysis shows 3+ ketones. Her regular insulin regimen is insulin aspart 8 units three times daily with meals and insulin glargine 22 units at bedtime. What is the most appropriate immediate insulin management?
- A. Omit all insulin until she is able to eat and drink normally
- B. Continue insulin glargine at usual dose, give 50% of usual insulin aspart doses
- C. Continue insulin glargine at usual dose, give additional correction doses of insulin aspart every 4-6 hours based on blood glucose (Correct Answer)
- D. Switch to variable rate intravenous insulin infusion immediately
- E. Increase insulin glargine to 30 units and omit insulin aspart doses
Explanation: ***Continue insulin glargine at usual dose, give additional correction doses of insulin aspart every 4-6 hours based on blood glucose***- During intercurrent illness, patients with **Type 1 Diabetes** must never stop their **basal insulin** (glargine) to prevent absolute insulin deficiency and rapid progression to **Diabetic Ketoacidosis (DKA)**.- Management involves following **sick day rules**, which include frequent monitoring and using **correction doses** of rapid-acting insulin (aspart) to manage hyperglycemia and ketonemia.*Omit all insulin until she is able to eat and drink normally*- Omitting insulin in Type 1 Diabetes is dangerous and significantly increases the risk of developing **life-threatening DKA**.- Even if oral intake is reduced, the body requires **basal insulin** to manage hepatic glucose production and prevent ketogenesis.*Continue insulin glargine at usual dose, give 50% of usual insulin aspart doses*- While the patient may not be eating full meals, simply reducing **bolus insulin** by half is insufficient when **ketonuria** and hyperglycemia (16.2 mmol/L) are present.- Fixed reductions do not account for the **increased insulin resistance** typically caused by the underlying illness and physiological stress.*Switch to variable rate intravenous insulin infusion immediately*- A **Variable Rate Intravenous Insulin Infusion (VRIII)** is primarily indicated if the patient is in **DKA**, is vomiting persistently, or is unable to manage subcutaneous doses.- In this stable presentation without confirmed acidosis, **subcutaneous management** and monitoring of sick day rules is the appropriate immediate step.*Increase insulin glargine to 30 units and omit insulin aspart doses*- Increasing **long-acting basal insulin** provides poor flexibility for managing the rapidly fluctuating glucose levels seen during acute illness.- Omitting **rapid-acting insulin** prevents necessary corrections of hyperglycemia and fails to address the metabolic demands caused by the current infection or illness.
Question 148: A 67-year-old woman with atrial fibrillation is established on warfarin. She is prescribed a 7-day course of ciprofloxacin for a urinary tract infection. Which of the following best describes the mechanism of interaction between warfarin and ciprofloxacin and the appropriate management?
- A. Ciprofloxacin induces CYP2C9, decreasing warfarin levels; increase warfarin dose and check INR in 3-5 days
- B. Ciprofloxacin inhibits CYP2C9, increasing warfarin effect; reduce warfarin dose and check INR in 3-5 days (Correct Answer)
- C. Ciprofloxacin displaces warfarin from plasma proteins; no dose adjustment needed but check INR after completing antibiotics
- D. Ciprofloxacin has no significant interaction with warfarin; continue both medications unchanged
- E. Ciprofloxacin inhibits CYP3A4, increasing warfarin levels; withhold warfarin during antibiotic course
Explanation: ***Ciprofloxacin inhibits CYP2C9, increasing warfarin effect; reduce warfarin dose and check INR in 3-5 days***- Ciprofloxacin is a known **enzyme inhibitor** that specifically targets the **CYP2C9** isoenzyme, which metabolizes the potent **S-enantiomer** of warfarin.- This inhibition leads to decreased clearance and **increased serum levels** of warfarin, necessitating a proactive **dose reduction** and close monitoring of the **INR** to prevent bleeding complications.*Ciprofloxacin induces CYP2C9, decreasing warfarin levels; increase warfarin dose and check INR in 3-5 days*- This incorrectly identifies ciprofloxacin as an inducer; enzyme induction (by drugs like **rifampicin** or **carbamazepine**) would lead to **decreased** warfarin efficacy and subtherapeutic INR.- Inducers typically take 1-2 weeks to exert their full effect, whereas ciprofloxacin's inhibitory effect on warfarin is **rapid**.*Ciprofloxacin displaces warfarin from plasma proteins; no dose adjustment needed but check INR after completing antibiotics*- While some drugs interact via **protein displacement**, the clinically significant interaction for fluoroquinolones is through **CYP450 inhibition**.- Monitoring only after the course is finished is dangerous, as the **anticoagulant effect** and bleeding risk increase shortly after starting the antibiotic.*Ciprofloxacin has no significant interaction with warfarin; continue both medications unchanged*- Fluoroquinolones are notorious for interacting with warfarin, often raising the INR significantly and increasing the risk of **major hemorrhage**.- Additionally, antibiotics can enhance warfarin's effect by altering **gut flora** that produce vitamin K, making an interaction even more likely.*Ciprofloxacin inhibits CYP3A4, increasing warfarin levels; withhold warfarin during antibiotic course*- While metabolism via CYP3A4 occurs, **CYP2C9** is the primary pathway for the most active form of warfarin; withholding the drug entirely risks **thromboembolic events** unnecessarily.- The correct management involves **titrating the dose** downwards based on INR results rather than complete cessation of therapy.
Question 149: A 51-year-old man with psoriatic arthritis is being considered for methotrexate therapy. He drinks approximately 35 units of alcohol per week. What is the most appropriate action regarding methotrexate prescribing in this patient?
- A. Prescribe methotrexate with increased frequency of liver function monitoring
- B. Advise reduction of alcohol intake to within recommended limits before starting methotrexate (Correct Answer)
- C. Start methotrexate at a reduced dose of 5mg weekly
- D. Prescribe methotrexate only if the patient agrees to complete abstinence from alcohol
- E. Methotrexate is contraindicated; select an alternative disease-modifying agent
Explanation: ***Advise reduction of alcohol intake to within recommended limits before starting methotrexate*** - **Methotrexate** is known to be **hepatotoxic**, and concurrent heavy alcohol consumption significantly increases the risk of liver fibrosis and cirrhosis. - Current guidelines recommend that alcohol intake should be within the safe limit of **14 units per week**; this patient consumes 35 units, necessitating a reduction before therapy begins. *Prescribe methotrexate with increased frequency of liver function monitoring* - While **Liver Function Test (LFT)** monitoring is essential for all patients on methotrexate, it does not mitigate the baseline risk caused by excessive alcohol intake. - Monitoring only identifies damage after it has occurred, whereas the goal is **prevention of hepatotoxicity** by addressing modifiable risk factors first. *Start methotrexate at a reduced dose of 5mg weekly* - Starting at a **sub-therapeutic dose** does not eliminate the synergistic risk of liver damage between alcohol and methotrexate. - Dosage should be based on **disease activity** and clinical response, while liver safety is primarily managed through lifestyle modification. *Prescribe methotrexate only if the patient agrees to complete abstinence from alcohol* - **Complete abstinence** is generally not required for patients on methotrexate unless there is pre-existing liver disease or high-risk factors. - Guidelines advise staying within **national recommended limits** (14 units/week) rather than enforcing total sobriety. *Methotrexate is contraindicated; select an alternative disease-modifying agent* - Excessive alcohol use is a **relative precaution** rather than an absolute contraindication for methotrexate use. - Methotrexate remains a **first-line DMARD** for psoriatic arthritis; therefore, resolving the alcohol issue is preferred over switching to potentially less effective or more expensive agents.
Question 150: A 64-year-old woman with newly diagnosed deep vein thrombosis is commenced on rivaroxaban. She has normal renal function (eGFR 82 ml/min/1.73m²) and weighs 70kg. What is the appropriate initial treatment regimen for rivaroxaban in acute DVT according to current UK licensing?
- A. 15mg once daily for 21 days, then 20mg once daily
- B. 20mg once daily from day 1
- C. 15mg twice daily for 21 days, then 20mg once daily (Correct Answer)
- D. 10mg twice daily for 21 days, then 10mg once daily
- E. 15mg twice daily for 7 days, then 15mg once daily
Explanation: ***15mg twice daily for 21 days, then 20mg once daily*** - For the initial management of **acute DVT**, rivaroxaban requires a high-intensity loading phase of **15mg twice daily** (BID) for the first **3 weeks (21 days)**. - Following the loading phase, the dose transitions to a maintenance phase of **20mg once daily** (OD) for the remainder of the treatment duration. *15mg once daily for 21 days, then 20mg once daily* - The **once-daily** administration during the first 21 days is incorrect and would provide inadequate anticoagulation for an **acute thrombus**. - High-risk initial windows in DVT treatment require higher frequency dosing to ensure **steady-state therapeutic levels**. *20mg once daily from day 1* - Starting immediately with the **maintenance dose** of 20mg OD is inappropriate for acute DVT/PE as it bypasses the necessary **loading phase**. - This regimen is more common for **Atrial Fibrillation (AF)** stroke prevention, not for the treatment of an active venous thromboembolism. *10mg twice daily for 21 days, then 10mg once daily* - This dosing regimen does not correspond to standard **UK NICE** or licensing guidelines for rivaroxaban in acute DVT management. - A **10mg OD** dose is typically only considered for long-term **extended prophylaxis** after at least 6 months of initial treatment. *15mg twice daily for 7 days, then 15mg once daily* - This duration is incorrect; the **21-day loading period** is specific to rivaroxaban, whereas a 7-day loading period is seen with **Apixaban** (10mg BID). - Switching to **15mg OD** as maintenance is only indicated in specific populations with significant **renal impairment** (CrCl <50 ml/min).
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