LANGE Pharmacology

A 34-year-old female presents to the clinic with complaints of intermittent flushing and blushing that started 3 to 4 weeks ago. Since then, she has noticed several inflammatory papules on the cheeks, nose, and chin. Upon examination, you notice an overall rosy hue to the face and the absence of any comedones. Which of the following would be the best course of topical therapy at this time? (A) Hydrocortisone 1% cream (B) Metronidazole gel (C) Permethrin cream (D) Mupirocin ointment (E) Tretinoin gel

(B) Metronidazole is the topical treatment of choice for papulopustular rosacea, which is consistent with the clinical findings in this 34-year-old female patient. (Maier, 2014)

Which of the following is the drug of choice for treating a primary herpes simplex virus (HSV) infection? (A) Acyclovir (B) Amantadine (C) Nystatin (D) Zanamivir (E) Zidovudine

(A) Acyclovir is the treatment of choice for primary HSV infection, typically in oral doses of 200 mg five times daily or 400 mg three times daily. Famciclovir and valacyclovir are also first-line treatments. (Albrecht, 2014)

A 1-year-old male with no known drug allergies is diagnosed in your clinic with bilateral acute otitis media. Which of the following is the initial antibiotic of choice? (A) Amoxicillin (B) Doxycycline (C) Gentamicin (D) Levofloxacin (E) Nitrofurantoin

(A) First-choice antibiotic treatment for acute otitis media is amoxicillin (80-90 mg/kg/day in two divided doses). (Klein & Pelton, 2014)

Nasal formulations of which vitamin can be used to successfully treat pernicious anemia? (A) B12 (cobalamin) (B) D (C) K (D) Folate (E) Niacin

(A) The primary problem in pernicious anemia is a lack of intrinsic factor that is required for vitamin B12 absorption in the ileum. Parental forms of vitamin B12 can be used to circumvent the problem created by a lack of intrinsic factor. (Schrier, 2014)

Which of the following antineoplastic medications is most likely to cause cardiac toxicity and precipitate heart failure? (A) Cisplatin (B) Cyclophosphamide (C) Doxorubicin (D) Tamoxifen (E) 6-Mercaptopurine

(C) Doxorubicin is a common antineoplastic drug used for a variety of cancers, including breast, bladder, ovarian, and endometrial, among many others. It has well-established, dose-dependent cardiotoxic effects. (Floyd & Morgan, 2014)

A 25-year-old female complains of chest pain, shortness of breath, sweating, and trembling. After an extensive negative work-up, the patient is diagnosed with panic disorder. Which of the following would be most appropriate for sustained treatment? (A) Buspirone (B) Clomipramine (C) Clorazepate (D) Paroxetine (E) Ramelteon

(D) For sustained treatment of panic disorder, SSRIs are the initial drugs of choice, based on their efficacy and propensity for minimal side effects. (Roy-Byrne, 2013)

Which of the following agents is most appropriate to help manage a known acute opioid overdose? (A) Activated charcoal (B) Butorphanol (C) Methadone (D) Nalbuphine (E) Naloxone

(E) Naloxone is a specific opioid antagonist administered intravenously in cases of opioid overdose. (Stolbach & Hof man, 2014)

A 68-year-old male is recently diagnosed with depression associated with the loss of his close sister to an automobile accident. He is currently taking oxybutynin for overactive bladder disease and lisinopril for hypertension. He has no known drug allergies. Which of the following medications would be most appropriate to prescribe for this patient? (A) Alprazolam (B) Amitriptyline (C) Buspirone (D) Desipramine (E) Sertraline

(E) Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are usually considered first-line antidepressants due to their relative safeness in overdose and their minimal affinity for muscarinic, α-adrenergic, and histamine receptors, thereby causing fewer side effects. Tricyclic antidepressants such as amitriptyline and desipramine produce several adverse effects associated with their antimuscarinic properties (e.g., dry mouth, constipation, blurred vision, urinary retention, etc.). The patient is already taking the antimuscarinic agent oxybutynin, so a tricyclic antidepressant could attenuate these adverse effects. Orthostatic hypotension is also common with tricyclic antidepressants, and because the patient is taking lisinopril for hypertension, the risk for a significant drop in blood pressure is high. Buspirone and alprazolam are not indicated for depression. (Katon & Ciechanowski, 2014)

Which of the following exerts its action by inhibiting cell wall synthesis? (A) Amoxicillin (B) Ciprofloxacin (C) Doxycycline (D) Erythromycin (E) Gentamicin

(A) All β-lactam antibiotics, including the penicillins (e.g., amoxicillin) and cephalosporins, prevent bacterial growth by inhibiting cell wall synthesis. Fluoroquinolones (e.g., ciprofloxacin) block bacterial DNA synthesis. Erythromycin, doxycycline, and gentamicin all inhibit protein synthesis but via different mechanisms. (Calderwood, 2014)

A 9-year-old male reaches under his friend's porch to retrieve a baseball and suffers a small puncture wound to his left hand as a result of a bite by the friend's cat. Which of the following would be most appropriate to give prophylactically to this patient to reduce the risk of infection? (A) Amoxicillin-clavulanate (B) Cephalexin (C) Ciprofloxacin (D) Dicloxacillin (E) Erythromycin

(A) Pasteurella multocida is the typical cause (approximately 75%) of an early infection (within 24 hours) due to a cat bite. Amoxicillin- clavulanate offers the best coverage for P. multocida, compared to other antibiotics. (Baddour, 2014)

Which of the following acts as a direct thrombin inhibitor to inactivate circulating and clot-bound thrombin? (A) Clopidogrel (B) Dabigatran (C) Heparin (D) Rivaroxaban (E) Warfarin

(B) Dabigatran is an oral direct thrombin inhibitor (DTI). Rivaroxaban is a direct factor Xa inhibitor that inactivates circulating and clot-bound factor Xa. Clopidogrel is an antiplatelet agent. Warfarin interferes with the actions of vitamin K in the liver in producing vitamin K-dependent clotting factors (II, VII, IX, and X). Heparin is an indirect thrombin inhibitor that binds to antithrombin, converting it from a slow to a more rapid inactivator of thrombin. (Leung, 2014)

Which of the following is a potential adverse effect associated with unfractionated or low-molecular weight heparin? (A) Excessive cough (B) Hyperglycemia (C) Hypothyroidism (D) Muscle cramps (E) Thrombocytopenia

(E) Heparin-induced thrombocytopenia (HIT) is a potentially serious complication of unfractionated heparin therapy and has been reported in up to 5% of patients exposed to heparin for more than 4 days. (Coutre, 2014)

In general, the bioavailability of a drug will be the greatest when it is administered by which of the following routes? (A) Intramuscular (B) Intravenous (C) Oral (D) Respiratory (E) Subcutaneous

(B) Bioavailability represents the fraction of an administered drug that reaches the systemic circulation. Because the intravenous route represents direct administration of a drug into the circulation, the bioavailability would be 100%. All of the other routes listed as choices possess biologic barriers to a drug before it can be absorbed into the vasculature. These barriers can often impede a percentage of the drug dose from reaching the blood. In addition, some drugs (particularly when given orally) can also be metabolized by enzymes or influenced by the first-pass effect through the liver before reaching the circulation. (Kester et al., 2012)

Assuming no contraindications to their use, which of following antihypertensives are most appropriate for treating hypertension in the type 2 diabetic patient with early signs of diabetic nephropathy? (A) Angiotensin converting enzyme inhibitors (AECIs) (B) α-Receptor blockers (C) β-Blockers (D) Calcium channel blockers (E) Thiazide diuretics

(A) In patients with diabetic nephropathy, ACE inhibitors and angiotensin receptor blockers (ARBs) may slow kidney disease progression more effectively than other antihypertensive drugs. (Bakris, 2014)

Assuming no contraindications, which of the following class of medications is considered the preferred long-term control therapy in adult patients with mild persistent asthma? (A) Inhaled corticosteroids (B) Leukotriene antagonists (C) Long-acting β2-agonists (D) Methylxanthines (E) Muscarinic antagonists

(A) Inhaled corticosteroids (e.g., beclomethasone, fluticasone, triamcinolone, etc.) are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness. Low- to medium-dose inhaled corticosteroids offer several advantages over other medications, including the ability to reduce bronchial hyperresponsiveness, improve overall lung function, and reduce severe exacerbations that often lead to emergency department visits and hospitalizations. (Fanta, 2014b)

Which of the following inhibits bone resorption and can be used for the treatment of Paget disease in patients who are symptomatic? (A) Adalimumab (B) Alendronate (C) Anakinra (D) Probenecid (E) Sulfasalazine

(B) Bisphosphonates, such as alendronate, inhibit bone resorption with relatively few side effects. They have been widely used for the prevention and treatment of postmenopausal osteoporosis, but are also primary agents used in the initial treatment of Paget disease. (Seton, 2013)

Which of the following is most appropriate for prophylactic treatment of variant (Prinzmetal) angina? (A) Atenolol (B) Diltiazem (C) Isosorbide dinitrate (D) Lisinopril (E) Propranolol

(B) Both long-acting nitrates and calcium channel blockers are effective prophylactically for spasm of coronary arteries. Calcium channels blockers are generally preferred over nitrates because of the need for a nitrate-free interval to avoid tolerance. The use of β-blockers is not advised because the use of these drugs can cause unopposed α1 -mediated vasoconstriction of coronary arteries, thereby worsening the ischemia. ACE inhibitors do not have a role in the treatment of variant angina. (Pinto et al., 2014)

A history of which of the following warrants special consideration when initially prescribing levothyroxine? (A) Coronary heart disease (B) Obesity (C) Parkinson disease (D) Peptic ulcer disease (E) Rheumatoid arthritis

(A) Multiple factors influence the initial dose of levothyroxine when used for thyroid replacement therapy, including age, the duration and severity of hypothyroidism, and the presence of certain underlying conditions. Thyroid hormone increases myocardial oxygen demand, which is associated\ with a small risk of inducing cardiac arrhythmias, angina pectoris, or myocardial infarction in older patients. In hypothyroid patients with a history of coronary heart disease, initial levothyroxine doses are typically smaller and then titrated upward. This regimen prevents a more immediate increase on the heart's workload that could occur with usual doses and minimizes the chances of an exacerbation of angina. (Ross, 2014a)

A 4-year-old male swallows several tablets of a medication that he found in his parent's bathroom cabinet underneath the sink. Approximately 4 to 5 hours after ingesting the tablets, there were no symptoms other than nausea and vomiting. Forty-eight hours after ingesting the tablets, elevated aminotransferase levels were detected followed by jaundice, hepatic encephalopathy, renal failure, and death. What did the child most likely swallow? (A) Acetaminophen (B) Aspirin (C) Diazepam (D) Oxycodone (E) Phenobarbital

(A) Acetaminophen toxicity may result from a single toxic dose (at least 150 mg/kg for a child), from repeated ingestion of large doses of acetaminophen (greater than 12 g in a 24-hour period), or from chronic ingestion of the drug. Dose-dependent hepatic necrosis is the most serious acute toxic effect associated with overdose and is potentially fatal. The patient's progression of sign and symptoms is consistent with acetaminophen toxicity. (Heard & Dart, 2014)

Drugs such as donepezil and rivastigmine that are used for Alzheimer disease exert their effects by which of the following mechanisms? (A) Acetylcholinesterase inhibitors (B) Muscarinic agonists (C) Muscarinic antagonists (D) Serotonin agonists (E) Serotonin antagonists

(A) Acetylcholinesterase inhibitors for Alzheimer disease were designed around the "cholinergic hypothesis," which stated that the replenishment of acetylcholine could help restore memory and cognitive ability, both of which are lost as the disease progresses. While numerous cholinergic pathways are destroyed during Alzheimer disease, many others are also lost. Even though these acetylcholinesterase inhibitors are indicated for Alzheimer disease, they are not curative and do not restore function. (Press & Alexander, 2014)

Hyperkalemia is a contraindication to the use of which of the following medications? (A) Amiloride (B) Cimetidine (C) Glipizide (D) Metformin (E) Verapamil

(A) Amiloride is a K+ -sparing diuretic based on its mechanism of action. In the kidneys, it will lead to less K+ excretion in the urine and hence retention of plasma K+ . In patients with elevated plasma K+ , amiloride can cause further hyperkalemia, which can impact neuromuscular and cardiac function. (Brater, 2013)

A patient with myasthenia gravis would most likely experience symptomatic benefit with which of the following? (A) Acetylcholinesterase inhibitors (B) α1 -Blockers (C) β-Blockers (D) Dopamine agonists (E) Muscarinic antagonists

(A) Myasthenia gravis is characterized by autoantibodies directed against nicotinic cholinergic receptors at neuromuscular junctions. By inhibiting the enzyme responsible for metabolizing acetylcholine (acetylcholinesterase), the synaptic concentration of acetylcholine increases and can bind more frequently to functional nicotinic receptors yet to be affected by the disease. This can alleviate the symptoms such as limb weakness, difficulty swallowing, and difficulty chewing associated with the disease. Examples of acetylcholinesterase inhibitors include neostigmine and pyridostigmine. (Bird, 2014)

Vinca alkaloids such as vincristine and vinblastine are classified as chemotherapeutic agents because they __________. (A) block hormone receptors. (B) crosslink or alkylate DNA. (C) inhibit the function of microtubules. (D) inhibit the synthesis of RNA. (E) inhibit topoisomerase.

(C) Vinca alkaloids (e.g., vincristine, vinblastine) bind to tubulin, the structural protein that forms the microtubules, which comprise the mitotic spindle. Through this binding, the microtubules are unable to assemble to form the mitotic spindle, which results in a cell's (both normal and cancerous) in-ability to divide. (Lee & Wen, 2014)

Which of the following is the primary site of action for warfarin? (A) Blood (B) Kidneys (C) Liver (D) Red bone marrow (E) Small intestine

(C) Warfarin interferes with the actions of vitamin K in the liver. Within hepatocytes, vitamin K is a cofactor required for the activation of clotting factors II (prothrombin), VII, IX, and X. By disrupting the actions of vitamin K, warfarin indirectly results in a slower rate of synthesis of these four clotting factors, thereby creating the anticoagulant effect. (Valentine & Hull, 2014)

The risk of extrapyramidal side effects (pseudoparkinsonism) and tardive dyskinesia is associated with which class of medications? (A) Amphetamines (B) Benzodiazepines (C) Monoamine oxidase inhibitors (MAOIs) (D) Tricyclic antidepressants (TCAs) (E) Typical (first-generation) antipsychotics

(E) Typical antipsychotics (e.g., haloperidol, chlorpromazine, fluphenazine) can produce extrapyramidal symptoms (EPS) via blockade of dopamine (D2 ) receptors in the nigrostriatum. Symptoms can include akinesia, bradykinesia, mask-like facial expression, tremor, cogwheel rigidity, and postural abnormalities. Tardive dyskinesia may also occur. (Jibson, 2014)

Angiotensin receptor blockers (ARBs) are not as likely to produce cough compared to angiotensin converting enzyme inhibitors (ACEIs) because they do not ___________. (A) cause hyperkalemia. (B) cause hyponatremia. (C) cross the blood-brain barrier. (D) increase bradykinin levels. (E) undergo a first-pass effect.

(D) ACEIs not only inhibit the conversion of angiotensin I to angiotensin II, but they also block the metabolism of bradykinin, thus elevating bradykinin levels. Cough and other side effects of ACEIs are believed to be due to increased bradykinin. ARBs do not appear to inhibit bradykinin metabolism and hence, they have limited, if any, potential in causing cough. (Kaplan, 2014a)

Disulfiram increases the level of which of the following to produce flushing, throbbing headache, vomiting, and palpitations during alcohol intake? (A) Acetic acid (B) Acetaldehyde (C) Alcohol dehydrogenase (D) Creatinine (E) Glucuronic acid

(B) Disulfiram inhibits the hepatic enzyme aldehyde dehydrogenase in the biochemical pathway for alcohol degradation. This effect causes acetaldehyde to accumulate which produces severe facial flushing, throbbing headache, nausea and vomiting, palpitations, weakness, dizziness, blurred vision, and confusion. This reaction only occurs if the patient drinks alcohol while taking disulfiram. In the absence of alcohol, disulfiram has little or no effect. (Johnson, 2014)

Which of the following therapeutic regimens is most appropriate for a 17-year-old female diagnosed with chlamydial urethritis? (A) Amoxicillin-clavulanate (B) Azithromycin (C) Ceftaroline (D) Metronidazole (E) Trimethoprim-sulfamethoxazole

(B) In general, C. trachomatis is highly susceptible to tetracyclines and macrolides. Within these two classes, first-line agents include doxycycline and azithromycin, respectively. The CDC recommends either agent as first-line therapy for the treatment of chlamydial infection. Sulfonamides and cephalosporins have limited activity and should not be used. (Marrazzo, 2014)

A 35-year-old male is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? (A) Donepezil (B) Lorazepam (C) Phenobarbital (D) Phenytoin (E) Valproate

(B) In most patients suffering from generalized convulsive status epilepticus (GCSE), benzodiazepines such as lorazepam and diazepam are effective initial therapies due to their relatively high lipid solubility. As a result, they are able to cross the blood-brain barrier easily, which gives them the potential to stop seizures quickly. Lorazepam's lipid solubility is less compared to diazepam, and it also redistributes to fat more slowly. Hence, lorazepam tends to have a longer duration of action (12-24 hours) than diazepam (20-30 minutes). (Drislane, 2014)

Which of the following are common adverse effects associated with aminoglycosides? (A) Blurred vision and hyperglycemia (B) Diarrhea and bone marrow depression (C) Headache and hypoglycemia (D) Ototoxicity and nephrotoxicity (E) Rash and dyspepsia

(D) All aminoglycosides are ototoxic and nephrotoxic. The likelihood of experiencing these toxicities occurs when treatment lasts beyond 5 days, at higher doses, in elderly patients, and those suffering from renal insufficiency. Other agents that produce either of these toxicities should not be used concurrently. (Drew, 2014)

In the treatment of asthma, long-acting β2 -agonists are _______________________. (A) an effective substitute for inhaled corticosteroids as monotherapy for long-term control of mild persistent asthma. (B) effectively used as an adjunct to inhaled corticosteroid therapy for providing long-term control of moderate persistent asthma. (C) of limited use due to their low therapeutic index, risk of life-threatening toxic, and various drug interactions. (D) the drugs of choice for providing prompt relief of bronchoconstriction and its accompanying acute symptoms such as cough, chest tightness, and wheezing. (E) the most effective at reducing inflammation of bronchial airways.

(B) Long-acting β2 -agonists are the preferred adjunctive therapy to inhaled corticosteroids in the long-term treatment of moderate persistent asthma. A combination of an inhaled corticosteroid and long-acting β2 -agonist provides greater asthma control than increasing the dose of the inhaled corticosteroid alone. Because they lack anti-inflammatory properties, long-acting β2 -agonists should not be used as monotherapy for long- term control of asthma. (Fanta, 2014a)

A 57-year-old female with a 10-year history of hypertension presents for her quarterly check-up. She has been treated with amlodipine and her blood pressure has been in control with this medication. However, her current blood pressure is 156/94 mm Hg with a pulse of 54 beats/min. She otherwise appears in good health and has made several lifestyle changes to reduce her blood pressure. Which of the following is the most appropriate approach to managing the patient at this time? (A) Add benazepril to the current medication regimen (B) Add diltiazem to the current medication regimen (C) Discontinue the amlodipine and start hydrochlorothiazide (D) Discontinue the amlodipine and start metoprolol (E) Remain with the current regimen of amlodipine

(A) Based upon the results of the ACCOMPLISH trial and the choices given, the most appropriate step is to initiate combination therapy consisting of her current long-acting dihydropyridine calcium channel blocker (amlodipine) plus a long-acting ACE inhibitor (benazepril). The elevated blood pressure warrants the addition of a second medication, plus there is no reason given in the vignette to discontinue the amlodipine for monotherapy from a different class of antihypertensive. For patients requiring combination therapy, the ACCOMPLISH trial demonstrated that benazepril plus amlodipine was more effective than benazepril plus hydrochlorothiazide at reducing cardiovascular events in hypertensive patients at risk for such events. (Mann, 2014)

Constipation, abdominal distention, bloating, and flatulence are common adverse effects associated with which class of drugs? (A) Bile acid sequestrants (B) Fibrates (C) Proton pump inhibitors (D) Statins (E) Triptans

(A) Bile acid sequestrants (e.g., cholestyramine, colestipol, colesevelam) are used for lowering LDL-C. They bind bile acids in the intestinal lumen, thereby preventing them from carrying out their normal functions of emulsification and micelle formation. Emulsification is an important process for lipid digestion, while the formation of micelles is required for lipid absorption. These actions not only inhibit lipid digestion and absorption from the intestinal lumen, but they also deplete the hepatic pool of cholesterol as a result of increased bile acid synthesis. Normally, bile acids are recirculated (enterohepatic circulation) from the intestine and back to the liver for reincorporation into the bile. Resins cause the bile acids to be excreted with the feces, so the liver needs to continually synthesize new bile acids from endogenous cholesterol. Constipation, abdominal distention, bloating, and flatulence result from the increased lipid content of the stool, because lipids are not being absorbed across the intestinal wall. These adverse effects can often be managed by increasing fluid and fiber intake and also using stool softeners. (Rosenson, 2014a)

A 61-year-old male arrives at the emergency department (ED) and is determined to be suffering from an ischemic stroke. Which of the following agents should be administered as quickly as possible to induce thrombolysis? (A) Alteplase (B) Clopidogrel (C) Eptifibatide (D) Heparin (E) Warfarin

(A) Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both eptifibatide and clopidogrel are considered antiplatelet agents. Eptifibatide is a glycoprotein (GP) IIb/IIIa inhibitor, which inhibits the final common pathway of platelet aggregation, the crossbridging of platelets secondary to fibrinogen binding to the activated GP IIb/IIIa receptor. Clopidogrel blocks the adenosine diphosphate receptor P2Y12 on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus. Alteplase therapy should be initiated within three hours of clearly defined symptom onset in order to achieve most favorable outcomes. (Samuels et al., 2014; Simons, 2014)

A 48-year-old male is brought to the emergency department (ED) by his sister after suffering from loss of consciousness, followed by muscle rigidity and rhythmic contractions, and then a return to a normal state. When asked about medication use, the patient states he is currently being treated with a drug for depression but cannot remember the name. He claims that he has never had a seizure or seizure-like activity prior to this event. Approximately three hours after the first episode, the patient suffers a second one while still in the ED. Which of the following medications is the patient most likely taking? (A) Bupropion (B) Duloxetine (C) Fluoxetine (D) Mirtazapine (E) Nortriptyline

(A) Bupropion has been shown in some patients to cause seizures in a dose-dependent fashion, particularly in those with a history of head trauma or electrolyte abnormalities. Tricyclic antidepressants (e.g., nortriptyline), selective serotonin reuptake inhibitors (e.g., fluoxetine), serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) and mirtazapine are typically associated with seizures. (Hirsch & Birnbaum, 2014a)

Both rifampin and certain antiepileptics such as phenytoin and carbamazepine have been shown to reduce the effectiveness of which of the following? (A) Combined oral hormonal contraceptives (B) Nicotine replacement therapy (C) Nonsteroidal anti-inflammatory drugs (D) Proton pump inhibitors (E) Statins

(A) Certain medications have been implicated in decreasing the efficacy of oral contraceptives, including rifampin and some of the antiepileptics (AEDs). A back-up method of contraception is suggested for females taking rifampin and combined hormonal contraceptives concomitantly on a short-term basis. For those patients taking either phenytoin or carbamazepine for seizure disorder, an alternative method of contraception is highly recommended. (Martin & Barbieri, 2014)

Which of the following type 2 diabetes mellitus medications is correctly paired with its mechanism of action? (A) Glipizide; enhancement of insulin secretion (B) Metformin; reduction of postprandial glucagon secretion (C) Miglitol; enhancement of insulin sensitivity at skeletal muscle (D) Rosiglitazone; inhibition of intestinal sucrase and glucoamylase (E) Sitagliptin; enhancement of hepatic insulin sensitivity

(A) Glipizide is an example of a sulfonylurea, which, as a class of medications, enhances the secretion of insulin from pancreatic β-cells. Hence, sulfonylureas are sometimes known as insulin secretagogues. Metformin, a biguanide, enhances insulin sensitivity of both hepatocytes and skeletal muscle cells, by decreasing gluconeogenesis. Miglitol, an α-glucosidase inhibitor, inhibits intestinal enzymes that degrade carbohydrates. Thiazolidinediones (TZDs) or glitazones, such as rosiglitazone, also enhance insulin sensitivity in hepatic and skeletal muscle tissues. Sitagliptin belongs to a relatively new class of type 2 diabetes medications known as DPP-IV (dipeptidyl peptidase 4) inhibitors, which stabilize blood levels of an incretin called glucagon-like peptide-1 (GLP-1). During hyperglycemia, incretins stimulate insulin secretion and inhibit glucagon secretion. DPP-IV metabolizes incretins. Hence, DPP-IV inhibitors block this enzyme, thereby increasing the level of incretins. (Kester et al., 2012)

A 27-year-old male visits the clinic for a preemployment physical. He has a 15-year history of intermittent asthma that is currently being managed prn with a metered-dose inhaler of albuterol. The patient tells you he has been using it daily for the past 6 to 8 weeks due to increased shortness of breath and that it does not seem to be working too well. Which of the following is the most rationale approach to managing the patient at this time? (A) Add fluticasone for use on a daily basis and continue albuterol prn (B) Add ipratropium bromide for use on a daily basis and continue albuterol prn (C) Add methylprednisolone for use on a daily basis and continue albuterol prn (D) Discontinue the albuterol and prescribe fluticasone for use on a daily basis (E) Increase the dose of albuterol and keep using prn

(A) The patient is likely in need of long-term control therapy due to his worsening symptoms. Whenever increased use of a quick-relief medication such as a β2-agonist (albuterol) occurs, it is usually indicative of needing to add a long-term control agent to the therapeutic regimen or to increase the dose of an already prescribed long-term control medication. Inhaled corticosteroids like fluticasone are considered first-line long-term control medications for patients with mild persistent asthma. (Fanta, 2014a)

A 39-year-old female suffering from palpitations, tachycardia, tremulousness, anxiety and heat intolerance is diagnosed with Graves' disease. She decides to begin a course of thionamide therapy to treat her condition. Which of the following medications would be appropriate to also prescribe at the initiation of thionamide therapy? (A) Atenolol (B) Diazepam (C) Ethinyl estradiol (D) Sertraline (E) Verapamil

(A) Thionamides inhibit the synthesis of newly synthesized thyroid hormones. Because of the thyroid gland's ability to store significant amounts of thyroid hormone, hyperthyroid symptoms can persist for a time until this stored hormone is released and metabolized. During the period, β- blockers like atenolol are beneficial for symptom control until the patient reaches a euthyroid state with thionamide therapy. (Ross, 2014b)

A 50-year-old male presents to the emergency department with an episode of paroxysmal supraventricular tachycardia (PSVT). He is hypotensive (88/58 mm Hg), does not feel faint, nor is complaining of any chest pain. His electrocardiogram (ECG) shows a regular arrhythmia with no P-waves, narrow QRS complexes, and a heart rate of 172 beats/min. Successive Valsalva maneuvers fail to terminate the PSVT. Which of the following intravenous treatments would be most appropriate for the patient at this time? (A) Adenosine (B) Amiodarone (C) Atenolol (D) Digoxin (E) Morphine

(A) This patient only has mild symptoms resulting from his PSVT. In these situations, nonpharmacologic measures that increase vagal activity (e.g.,Valsalva maneuver) to the heart can be attempted to help restore a sinus rhythm. Because this failed in this patient, drug therapy is the best option. Adenosine is often the drug of first choice in patients with PSVT, as it slows conduction and interrupts the reentry pathways through the AV node. (Ganz, 2014)

From the choices given below, which medication is considered the safest for use during pregnancy? (A) Esomeprazole (B) Isotretinoin (C) Lisinopril (D) Misoprostol (E) Warfarin

(A) Warfarin is contraindicated in all trimesters and is listed as category X by the FDA, because it has been shown to induce fetal bleeding and cause several teratogenic effects including CNS malformations, structural deformities of the nose, and bone dysplasias. ACEIs (e.g., captopril) should not be used due to their increased risk of causing fetal hypotension, fetal renal damage, and major congenital malformations. Isotretinoin is also listed as category X and is a known teratogen that causes malformations of the CNS, face, and ears. Misoprostol is a synthetic prostaglandin analog indicated for reducing the risk of NSAID-induced gastric ulcers in patients at high risk of complications from gastric ulcer. It also has oxytocic properties, meaning that it can induce uterine contractions that may endanger pregnancy. The drug comes with a black box warning stating that administration to women who are pregnant can cause abortion, premature birth, or birth defects. Esomeprazole is category B and has not been shown to cause birth defects or threaten pregnancy. (Lockwood & Magriples, 2014)

A 67-year old male has signs and symptoms of moderate congestive heart failure that includes a modest degree of left ventricular systolic dysfunction, shortness of breath, fatigue, reduced exercise tolerance, and ankle edema. Which of the following drug combinations would be the most appropriate choice for initial treatment? (A) Digoxin and hydrochlorothiazide (B) Enalapril and furosemide (C) Isosorbide dinitrate and furosemide (D) Metoprolol and enalapril (E) Metoprolol and triamterene

(B) A combination of a loop diuretic and an ACE inhibitor is typically the initial treatment in patients with volume overload and left ventricular systolic heart failure. ACE inhibitors improve survival in patients with left ventricular systolic dysfunction. Loop diuretics offer the best option to reduce the congestive symptoms in the lungs and fluid retention in the ankles. (Colucii, 2014)

Which of the following, when combined with chemotherapy, can be effective in treating Philadelphia chromosome positive acute lymphoblastic leukemia in adults? (A) Adalimumab (B) Imatinib (C) Methotrexate (D) Raloxifene (E) Tamoxifen

(B) A key component of Philadelphia chromosome positive acute lymphoblastic leukemia therapy is the use of a BCR-ABLtyrosine kinase inhibitor (TKI), which is directed against the protein product of the Philadelphia chromosome. The TKI must be combined with other therapy since remissions induced by TKI therapy alone are short-lived. The largest experience has been with imatinib combined with conventional acute lymphoblastic leukemia chemotherapy regimens. (Larson, 2014b)

Drug X is an antiseizure medication that is labeled as a "CYP2D6 inducer." CYP2D6 enzymes do not metabolize drug X. Drug Y is an antihypertensive medication that is typically metabolized to inactive products by CYP2D6 enzymes. Assuming the patient has been taking drug Y for the last 3 months and now begins taking drug X simultaneously, the patient will: (A) be at greater risk for having a seizure. (B) likely experience an increase in blood pressure. (C) likely experience a decrease in blood pressure. (D) likely experience a decrease in blood pressure and be at greater risk for having a seizure. (E) likely experience an increase in blood pressure and be at greater risk for having a seizure.

(B) As a CYP2D6 inducer, the antiepileptic medication will stimulate or increase the activity of the enzymes responsible for metabolizing the antihypertensive medication into harmless by-products. As a result, the patient is more susceptible to having his/her blood pressure elevate, because the dose of the antihypertensive drug is being cleared from the body more quickly. (Larson, 2014a)

A 24-year-old male is on a two-injection regimen for his type 1 diabetes mellitus that includes NPH and regular insulin taken before breakfast and then again before dinner. One evening, he has an abnormally light dinner and in the middle of the night, he awakens in a cold sweat with his heart pounding. He obtains a glucometer reading and discovers that his blood glucose is 44 mg/dL. He eats some candy and then goes back to sleep. Immediately after awakening the next morning, his blood glucose is 297 mg/dL. Which of the following would most appropriate to do at this time? (A) Decrease the morning NPH dose and leave the morning regular insulin dose unchanged (B) Leave the morning NPH dose unchanged and increase the morning regular insulin dose (C) Increase both the morning NPH and regular doses (D) Increase the morning NPH dose and leave the morning regular insulin dose unchanged (E) Take the usual morning insulin regimen after breakfast instead of before breakfast

(B) Regular insulin is a short-acting insulin that starts working 30 to 60 minutes after administration. Increasing the dose by a few units can help quickly restore a normoglycemic state. NPH is an intermediate-acting insulin, which has an onset of action of 2 to 4 hours. Therefore, adjusting the NPH dose at breakfast time will not correct the morning hyperglycemia. If the NPH dose was increased, it could cause him to experience hypoglycemia in the middle of the day once it starts to work. (McCulloch, 2014)

Along with diuretic therapy, which of the following agents is considered appropriate therapy in a 52-year-old male with hypertension who develops systolic heart failure with an ejection fraction of 30%? (A) Diazoxide (B) Lisinopril (C) Prazosin (D) Salmeterol (E) Verapamil

(B) The goals of antihypertensive therapy in the setting of reduced ejection fraction are to reduce both preload (by using diuretics) and afterload (by using antagonists of the renin-angiotensin-aldosterone system). When administered to patients with mild to advanced systolic heart failure, ACE inhibitors increase cardiac output, diminish congestive symptoms, reduce the rate of progressive cardiac dysfunction, and decrease cardiovascular mortality. (Kaplan, 2014b)

Which of the following medications increases the risk of developing Reye syndrome in the pediatric patient when used to treat influenza and other viral illnesses? (A) Acetaminophen (B) Aspirin (C) Ibuprofen (D) Naproxen (E) Oseltamivir

(B) The pathogenesis of Reye syndrome is unknown, but there is an association between aspirin use and the development of the disease. Reye syndrome is marked by hepatic failure and encephalopathy and has a poor prognosis. (Chiriboga, 2014)

A 25-year-old male is hospitalized with symptoms of delusion, paranoia, rambling statements coupled with disorganized thought, and flattened affect. The companion who brings him to the hospital claims this is the first time she has ever witnessed any of these symptoms and is not aware of any medication he is currently taking. Which of the following medications is most appropriate for this patient? (A) Clomipramine (B) Risperidone (C) Sertraline (D) Thioridazine (E) Topiramate

(B) The patient is showing signs and symptoms of schizophrenia for which antipsychotic agents are the treatment of choice. Risperidone is an atypical antipsychotic (e.g., second-generation) that has less risk of causing extrapyramidal side effects (EPS) compared to typical antipsychotics (e.g., first-generation) such as thioridazine. Because of the risk of EPS, typical or first-generation antipsychotics are not considered first-line treatments. Even though both typical and atypical antipsychotics appear to have similar efficacy, the atypical agents also tend to be better tolerated, which enhances compliance. (Stroup & Marder, 2014)

A 52-year-old male is brought to the emergency department by his daughter because she recently notices that he gets extremely tired, has periodic tremors in his hands, and suffers from increasing memory lapses. Initial laboratory work shows a serum creatinine of 2.2 mg/dL. His medical history is significant for bipolar disorder, for which he has been taking the same drug for the past 32 months. Which of the following is most likely responsible for the patient's symptoms? (A) Carbamazepine (B) Lithium carbonate (C) Olanzapine (D) Risperidone (E) Valproate

(B) The patient's symptoms are consistent with long-term lithium therapy, which can cause a variety of neuropsychiatric side effects (e.g., tremor, ataxia, mental confusion, fatigue, poor concentration). Lithium is also known to produce adverse effects on the kidneys that can lead to nephrogenic diabetes insipidus and increased serum creatinine concentrations. (Janicak, 2014)

Serotonin 1b/1d agonists, or triptans, are most effective for the acute treatment of which of the following? (A) Absence seizures (B) Acute migraine (C) Chemotherapy-induced nausea and vomiting (CINV) (D) Myoclonic seizures (E) Nocturia

(B) The serotonin 1b/1d agonists (triptans) are effective for the acute treatment of migraine. The triptans are considered to be specific therapies for acute migraine since, in contrast to analgesics, they act at the pathophysiologic mechanism of the headache. (Bajwa & Sabahat, 2014)

A 56-year-old female is currently being treated with daily warfarin for thrombophlebitis. She has contracted a serious lower respiratory tract infection and is admitted to the hospital. The patient is started on ciprofloxacin upon admission, and after 3 days of treatment, her INR increases from 2.7 to 7.4. She also reports a nosebleed on the third night in the hospital. Her lower respiratory function has improved slightly, but the infection has still not resolved. Which of the following is the most likely explanation for the increase in the patient's INR? (A) Decreased warfarin absorption in the small intestine (B) Decreased warfarin metabolism by the liver (C) Increased plasma protein binding of warfarin (D) Increased warfarin absorption in the small intestine (E) Increased warfarin metabolism by the liver

(B) There are several clinically important warfarin drug interactions, with most of them causing an increase in the drug's anticoagulant effect (i.e., increasing the INR). Warfarin metabolism occurs via hepatic cytochrome P450 enzymes that can be inhibited by a large number of drugs, including the fluoroquinolones. When this inhibition occurs, plasma levels of warfarin rise, thereby enhancing the anticoagulant effect. (Valentine & Hull, 2014)

A 35-year-old female diagnosed with depression 3 weeks ago has been taking a medication prescribed by her clinician. Recently, she reports complaints of dry mouth, constipation, and visual sensitivity to bright light. Which of the following medications was the patient most likely prescribed? (A) Bupropion (B) Nortriptyline (C) Phenelzine (D) Sertraline (E) Venlafaxine

(B) Tricyclic antidepressants (e.g., nortriptyline) produce anticholinergic side effects not seen with other types of antidepressants such as SSRIs, SNRIs, and MAOIs. Anticholinergic side effects include dry mouth, constipation, photophobia, blurred vision, urinary retention, and tachycardia. (Hirsch & Birnbaum, 2014a)

Of the following choices, which regimen is considered first-line therapy for Helicobacter pylori-positive individuals with peptic ulcer disease (PUD) and no known drug allergies? (A) Misoprostol, clarithromycin, and metronidazole (B) Omeprazole, clarithromycin, and amoxicillin (C) Omeprazole, ranitidine, and clarithromycin (D) Ranitidine, amoxicillin, and bismuth subsalicylate (E) Ranitidine, ciprofloxacin, and metronidazole

(B) Triple-therapy regimens consisting of a proton pump inhibitor (PPI) and two antibiotics are considered first-line therapy for the eradication of H. pylori. PPI-based regimens that combine clarithromycin and amoxicillin or clarithromycin and metronidazole have been shown to have the most effective eradication rates. There are also 4-drug (quadruple) regimens that include a PPI, two antibiotics, and bismuth subsalicylate that have been shown to be effective as well. Histamine receptor antagonists like ranitidine have been shown to be less effective than PPIs in controlling acid secretion. Misoprostol is used for reducing the risk of nonsteroidal anti-inflammatory agent (NSAIA)-induced gastric ulcer in patients at high risk of developing complications from these ulcers and in patients at high risk of developing gastric ulceration. It has no effect on H. pylori eradication. (Crowe, 2014)

Which agent is most appropriate for the treatment of allergic rhinitis in a 32-year-old male taxi driver? (A) Diphenhydramine (B) Ergotamine (C) Flunisolide (D) Hydroxyzine (E) Promethazine

(C) Because the patient is employed as a taxi driver, remaining alert is of prime importance. Intranasal corticosteroids are nonsedating and are presently the most effective single maintenance therapy for allergic rhinitis. First-generation antihistamines (e.g., diphenhydramine, hydroxyzine) have a much higher potential for causing sedation and should be avoided in this particular patient. (deShazo & Kemp, 2014)

Which of the following medications is indicated for the treatment of anemia associated with chronic kidney disease? (A) Dabigatran (B) Deferoxamine (C) Erythropoietin (D) Protamine sulfate (E) Warfarin

(C) Erythropoietin (EPO) is a naturally occurring hormone synthesized and secreted by the kidneys. Recombinant human erythropoietin and other erythropoiesis-stimulating agents (ESAs) have become the standard of care for the treatment of the anemia that occurs in most patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). In patients with CKD and ESRD, EPO production is usually impaired, and this EPO deficiency leads to anemia. Deferoxamine is an iron-chelating compound that can be given systemically in situations of iron overdose. Warfarin and argatroban are both anticoagulants and do not typically affect red cell count. Protamine sulfate is a heparin-chelating compound that can be given in cases of heparin overdose. (Berns, 2013)

A 47-year-old female with moderately active and refractory Crohn disease has repeatedly suffered relapses after achieving remission with firstline agents. Assuming no contraindications or barriers to treatment, which of the following is the most appropriate pharmacologic therapy to attempt in this patient? (A) Abatacept (B) Anakinra (C) Infliximab (D) Oxycodone (E) Tocilizumab

(C) First-line agents for Crohn disease include glucocorticoids, 5-aminosalicylic acids and antibiotics. Patients are considered refractory if they repeatedly relapse after achieving remission with first-line agents, or if they remain symptomatic despite adequate doses of first-line agents. Antitumor necrosis factor (anti-TNF) therapies are approved for treatment of Crohn disease, including infliximab. (Farrell & Peppercorn, 2014)

Which of the following pairs of medications are antiepileptics approved by the Food and Drug Administration (FDA) for the treatment of neuropathic pain? (A) Aripiprazole and topiramate (B) Duloxetine and venlafaxine (C) Gabapentin and pregabalin (D) Modafinil and tolterodine (E) Quetiapine and risperidone

(C) Gabapentin and pregabalin are both antiepileptics that have proven efficacy versus placebo in several neuropathic pain conditions. Gabapentin is particularly effective for the treatment of postherpetic neuralgia and painful diabetic neuropathy. Pregabalin has been show to effective in patients with postherpetic neuralgia, painful diabetic neuropathy, central neuropathic pain, and fibromyalgia. (Rosenquist, 2014)

Abrupt cessation of which of the following antihypertensives can produce significant rebound hypertension, tachycardia, and exacerbation of ischemic symptoms? (A) Angiotensin converting enzyme inhibitors (ACEIs) (B) Angiotensin receptor blockers (ARBs) (C) β-Blockers (D) Potassium-sparing diuretics (E) Thiazide diuretics

(C) Gradual tapering of β-blockers over a period of 1 to 2 weeks is advised before discontinuation to avoid rebound hypertension, tachycardia, and exacerbation of ischemic symptoms. Abrupt cessation of β-blockers has also been shown to cause unstable angina, myocardial infarction, and even death in the hypertensive patient with coronary artery disease. (Podrid, 2014)

A 50-year-old female is diagnosed with primary adrenal insufficiency (Addison's disease), and treatment with hydrocortisone and fludrocortisone is started. One month later, she still complains of weakness and fatigue. Which of the following would suggest that the dose of fludrocortisone be increased? (A) Bilateral ankle edema (B) Elevation in blood pressure (C) Hyperkalemia (D) Hypernatremia (E) Increased darkening of the skin

(C) Most patients with primary adrenal insufficiency eventually require mineralocorticoid replacement to prevent sodium loss, intravascular volume depletion, and hyperkalemia. Oral fludrocortisone is a potent synthetic mineralocorticoid. Physiologically, mineralocorticoids cause renal sodium retention and potassium excretion. Hypertension, edema, and hypokalemia are signs of excessive mineralocorticoid replacement. Hyperkalemia is a sign of inadequate mineralocorticoid replacement. (Lieman, 2014)

A 17-year-old female attempts suicide by swallowing several tablets of acetaminophen. Which of the following is considered the most effective antidote to administer to this patient? (A) Diazepam (B) Flumazenil (C) N-acetylcysteine (D) Sodium bicarbonate (E) Sodium nitroprusside

(C) N-acetylcysteine is the accepted antidote for acetaminophen poisoning and should be administered to all patients at significant risk for hepatotoxicity. (Heard & Dart, 2014)

A 46-year-old male with a history of nephrolithiasis presents to the clinic with a red, swollen joint at the base of the great toe and is diagnosed with gouty arthritis. Assuming no contraindications, which of the following would be most appropriate for resolution of his acute attack of gout? (A) Allopurinol (B) Cyclosporine (C) Naproxen (D) Probenecid (E) Sulfasalazine

(C) NSAIDs, colchicine, and glucocorticoids have all been used successfully to treat acute attacks of gout. Probenecid is classified as a uricosuric drug, meaning it increases the renal clearance of uric acid. Allopurinol is an inhibitor of xanthine oxidase, a key enzyme necessary for the production of uric acid. Both probenecid and allopurinol are used for prevention of recurrent attacks of gout, not for ongoing attacks. Cyclosporine and sulfasalazine are not indicated for acute management of gout or for prophylactic therapy. (Becker, 2014)

A 33-year-old female treated with a first-generation antipsychotic for the past 2 weeks is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? (Aelayed allergic reaction (B) Malignant hyperthermia (C) Neuroleptic malignant syndrome (D) Rhabdomyolysis (E) Serotonin syndrome

(C) Neuroleptic malignant syndrome is an uncommon but serious complication with therapeutic doses of antipsychotic drug therapy, particularly the first-generation (typical) class. Cardinal signs and symptoms include a body temperature above 100.4°F, altered state of consciousness, autonomic dysfunction, and rigidity. (Wijdicks, 2014)

A 43-year-old male employed as an airline pilot is interested in quitting his 20-year habit of smoking. His medical history includes type 2 diabetes mellitus diagnosed 6 years ago for which he is currently taking metformin. Which of the following would be most appropriate to recommend to this patient? (A) Alprazolam (B) Clonidine (C) Nicotine replacement therapy (D) Nortriptyline (E) Varenicline

(C) Nicotine replacement therapy is relatively safe in the majority of patients and comes in many forms (transdermal patches, gums, sprays, and inhalers). Both clonidine and nortriptyline are considered second-line smoking cessation agents because of their many side effects. Neither has been approved by the FDA for smoking cessation. Alprazolam is also not indicated, and there is currently no evidence that it aids in smoking cessation. Varenicline is a partial agonist to α4-β2 nicotinic acetylcholine receptors. It has been approved by the FDA; however, varenicline is banned from use by pilots and air traffic controllers as per the Federal Aviation Administration (FAA). (Rennard et al., 2014)

Which of the following lists the common adverse effects caused by nitroglycerin when administered sublingually at high doses? (A) Constipation, blurred vision, tinnitus (B) Dyspepsia, abdominal distention, vomiting (C) Facial flushing, headache, lightheadedness (D) Photophobia, excessive salivation, excessive tearing (E) Wheezing, cough, heartburn

(C) Nitroglycerin produces venodilation and vasodilation, which causes secondary responses of flushing and headache. Lightheadedness can also occur with the drop in blood pressure produced by the vasodilation. (Kannam & Gersh, 2014)

A 64-year-old female who underwent total knee arthroplasty is to begin a 10- to 14-day regimen of oxycodone for pain control. Which of the following would be most appropriate to administer to the patient during this time? (A) Antidiarrheal agent (B) Benzodiazepine (C) Laxative (D) Proton pump inhibitor (E) Sulfonylurea

(C) Patients treated with opioids, either for short-term use or chronic administration, can experience a variety of unpleasant side effects including nausea and vomiting, abdominal cramping, pruritus, sedation, and constipation. The use of a laxative regimen, along with increased fluid and fiber consumption, can help prevent and alleviate opioid-induced constipation. (Rosenquist, 2014)

Which of the following medications used for the treatment of insomnia in not a scheduled substance? (A) Eszopiclone (B) Quazepam (C) Ramelteon (D) Zaleplon (E) Zolpidem

(C) Ramelteon is a melatonin receptor agonist and is not a scheduled substance. Quazepam is a benzodiazepine and is a schedule IV drug (C-IV). Eszopiclone, zaleplon, and zolpidem are nonbenzodiazepine receptor agonists and are all C-IV. (Bonnet & Arand, 2014)

Which of the following most accurately describes the mechanism of action of sildenafil? (A) Antagonizes nitric oxide receptors (B) Increases cyclic AMP levels by competitively inhibiting acetylcholinesterase (C) Increases cyclic GMP levels by competitively inhibiting phosphodiesterase-5 (D) Stimulates the release of acetylcholine (E) Stimulates the release of norepinephrine

(C) Sildenafil is classified as a phosphodiesterase-5 (PDE-5) inhibitor and is used for the treatment of erectile dysfunction. The rationale for the use of PDE-5 inhibitors is based upon the role of nitric oxide-induced vasodilation, which is mediated by cyclic guanosine monophosphate (GMP) in initiating and maintaining an erection; detumescence is associated with catabolism of cyclic GMP by the PDE-5 enzyme. PDE-5 inhibitors act by increasing intracavernosal cyclic GMP levels by competitively inhibiting the PDE-5 enzyme, and as a result, increase both the number and duration of erections in men with ED. (Cunningham & Seftel, 2014)

A 19-year-old female presents to the clinic with complaints of nausea, diarrhea, flatulence, stomach cramps, and bloating. A stool sample provided while at the clinic has frothy and greasy characteristics but is free of any visible blood. She explains that she just returned from a 2-week camping trip where she did a great deal of lake swimming. Which of the following medications would be most appropriate for this patient? (A) Doxycycline (B) Erythromycin (C) Metronidazole (D) Nystatin (E) Trimethoprim-sulfamethoxazole

(C) The patient is most likely suffering from giardiasis that could have been contracted on her camping trip. While swimming, she may have inadvertently swallowed water contaminated with Giardia lamblia, whose incubation period is generally 1 to 3 weeks, after which symptoms develop. An effective treatment is metronidazole. (Munoz, 2013)

A 50-year-old male with asymptomatic hyperuricemia is to begin therapy for newly diagnosed hypertension. Which of the following is most likely to increase his serum uric acid levels further and possibly precipitate a gout attack? (A) Amlodipine (B) Candesartan (C) Hydrochlorothiazide (D) Ramipril (E) Verapamil

(C) Thiazide diuretics can raise plasma levels of uric acid, which can be problematic in patients who already have hyperuricemia or a previous history of gout. (Kaplan, 2014c)

A 62-year-old male is recently diagnosed with colorectal cancer and is to begin a course of chemotherapy that is highly emetic (i.e., >90% risk of emesis). Which of the following regimens would be most appropriate to use prophylactically for treating his potential acute nausea and vomiting? (A) Lorazepam + diphenhydramine (B) Metoclopramide + dexamethasone (C) Metoclopramide + prochlorperazine (D) Ondansetron + dexamethasone (E) Prochlorperazine + diphenhydramine

(D) Chemotherapy-induced nausea and vomiting (CINV) is a common problem for cancer patients that can often be avoided if treated prophylactically. Patients who receive chemotherapeutic regimens that are classified as being of high emetic risk should receive a serotonin (5- HT3) receptor antagonist (e.g., ondansetron, granisetron, dolasetron) and dexamethasone. Single-agent 5-HT3 receptor antagonists are more effective than less-specific agents such as high-dose metoclopramide and as effective as the combination of high-dose metoclopramide and dexamethasone. When 5-HT3 antagonists are used in combination with dexamethasone, they are more effective than high-dose metoclopramide plus dexamethasone. Other agents that have been used in the treatment or prevention of CINV include phenothiazines (e.g., prochlorperazine), butyrophenones, and cannabinoids. These agents have a lower therapeutic index than the 5-HT3 receptor antagonists and glucocorticoids for highly or moderately emetogenic chemotherapy regimens. (Hesketh, 2014)

A progestin-only contraceptive, or "minipill," would be most appropriate for which of the following female patients? (A) 25-year-old in excellent overall health (B) 28-year-old with a 20-year history of epilepsy (C) 32-year-old with a past episode of pelvic inflammatory disease (D) 36-year-old who smokes 2 packs cigarettes per day and has a 2-year history of adequately controlled hypertension (E) 38-year-old with a 25-year history of asthma and bronchitis

(D) In the majority of cases, a combined hormonal contraceptive (i.e., one that contains both an estrogen and progestin) is the preferred method of oral contraception because of its efficacy when used perfectly (>99%). However, for women older than 35 years of age who are smokers or are obese, or who have a history of hypertension or vascular disease, progesterone only contraceptives are recommended. Progestin-only contraceptives, however, tend to be less effective than the combined hormonal contraceptives. (Kaunitz, 2014)

In addition to insulin and fluid replacement with 0.9% saline, which electrolyte is commonly infused in the type 2 diabetic patient who arrives in the emergency department in a hyperglycemic, hyperosmolar, nonketotic state? (A) Bicarbonate (B) Calcium (C) Magnesium (D) Potassium (E) Sulfate

(D) Insulin not only causes cellular uptake of glucose but also of potassium. Hypokalemia may develop when insulin is infused to correct either a hyperglycemic hyperosmolar state or a diabetic ketoacidosis. Hence, in order to avoid hypokalemia or correct an ongoing hypokalemia, potassium chloride can be administered. (Kitabchi et al., 2014)

When used for advanced carcinoma of the prostate, chronic administration of leuprolide inhibits the synthesis of androgens by _____________________. (A) blocking gonadotropin-releasing hormone (GnRH) receptors at the anterior pituitary. (B) blocking luteinizing hormone (LH) receptors on interstitial (Leydig) cells of the testes. (C) increasing the secretion of GnRH from the hypothalamus. (D) inhibiting pulsatile secretion of gonadotropins from the anterior pituitary. (E) upregulation of the number of GnRH receptors at the anterior pituitary.

(D) Leuprolide is a GnRH (LHRH) agonist that suppresses the pulsatile secretion of follicle-stimulating hormone (FSH) and LH (gonadotropins) from the anterior pituitary when given chronically. Continuous administration of a GnRH agonist causes downregulation of GnRH receptors on gonadotropes, which, in turn suppresses gonadotropin release and gonadal function. Decreased amounts of LH, in particular, lead to diminished production of androgens by the testes which support prostate growth. It is believed that by using this form of androgen deprivation therapy (ADT), tumor development and metastasis is slowed. (Lee & Smith, 2014)

A 66-year-old male is diagnosed with idiopathic Parkinson disease (IPD) and is suffering from tremor and bradykinesia that has become troublesome in his job-related activities as a teacher. The patient has expressed that he would like to continue working for another 3 to 4 years and is seeking the most effective medication to control his symptoms. Which of the following would be most appropriate to prescribe to this patient? (A) Amantadine (B) Benztropine (C) Entacapone (D) Levodopa/carbidopa (E) Selegiline

(D) Levodopa/carbidopa is the most effective symptomatic therapy for Parkinson disease (PD) and should be prescribed when the patient feels that life quality is substantially compromised. It is particularly effective for the management of bradykinetic symptoms, which appears to be an issue in this particular patient. While the other choices are indeed used for the treatment of PD in various situations, they are not as effective as monotherapy in controlling symptoms compared to levodopa/carbidopa. (Tarsey, 2014)

Which of the following requires drug-free periods to avoid tolerance when used as prophylaxis for chronic stable angina? (A) Digoxin (B) Diltiazem (C) Metoprolol (D) Isosorbide dinitrate (E) Propranolol

(D) Long-acting nitrates are often added to β-blockers for prophylactic control of chronic (exertional) stable angina. β-Blockers are typically recommended as first-line therapy to reduce anginal episodes and improve exercise tolerance. However, when used in combination with β- blockers, nitrates can often produce greater antianginal and anti-ischemic effects. The development of tolerance is a major limiting step in the efficacy of nitrates when used long term. The degree of tolerance can be limited by utilizing a regimen that includes a minimum 8- to 14-hour period per day without nitrates no matter the route of delivery (oral or transdermal). (Kannam & Gersh, 2014)

Which of the following medications is capable of causing agranulocytosis? (A) Desmopressin (B) Insulin (C) Metformin (D) Methimazole (E) Prednisone

(D) Methimazole is an antithyroid agent known as a thionamide. It decreases the synthesis of thyroid hormone by inhibiting the oxidation of iodide and the coupling of iodotyrosines. Minor adverse reactions include skin rash, nausea, vomiting, and drowsiness. Agranulocytosis is a rare but serious complication of thionamide therapy, with a prevalence of 0.1% to 0.5%, and usually occurs within the first 2 months of treatment. Patients who receive methimazole should be closely supervised and cautioned to report immediately any evidence of illness, including sore throat, skin eruptions, fever, headache, or general malaise. In such cases, methimazole should be discontinued and white blood cell and differential counts should be made to determine whether agranulocytosis has developed. (Ross, 2013)

Chronic therapy with which of the following meds can potentially lead to abrupt, unpredictable, and transient motor fluctuations (from mobility to immobility) often referred as the "wearing-offphenomenon"? (A) Carbamazepine (B) Cyclobenzaprine (C) Diazepam (D) Levodopa/carbidopa (E) Methotrexate

(D) One of the drug therapies used to manage the symptoms of Parkinson disease is the combination of levodopa (L-DOPA) and carbidopa. Levodopa is the precursor to dopamine, which is the neurotransmitter whose decreased concentrations in the substantia nigra lead to symptoms of tremor, rigidity, bradykinesia, and postural instability. Levodopa is converted into dopamine by dopa decarboxylase, an enzyme found within the nervous tissue and also the peripheral circulation. Levodopa is used instead of dopamine because it can cross the blood-brain barrier. While levodopa can improve symptoms, it does not halt progression of the disease. Carbidopa inhibits peripheral dopa decarboxylase, which allows more levodopa to cross the blood-brain barrier instead of being converted into dopamine within the circulation. Carbidopa itself does not cross the blood-brain barrier. A complication that can potentially develop over time with this therapy is the "wearing-off phenomenon," which is characterized by abrupt, unpredictable, and transient fluctuations in motor symptoms. (Tarsey, 2014)

Which of the following is active against influenza A and B and can shorten the duration of influenza symptoms when initiated promptly? (A) Amantadine (B) Atazanavir (C) Efavirenz (D) Oseltamivir (E) Rimantadine

(D) Oseltamivir is a neuraminidase inhibitor active against both influenza A and B. Amantadine and rimantadine are only active against influenza A. (Zachary, 2014)

A 27-year-old female with Sjögren's syndrome suffers from dry mouth, but continues to have residual salivary gland activity. Which of the following agents would be most appropriate to administer to potentially alleviate the patient's dry mouth? (A) Atropine (B) Diphenhydramine (C) Oxybutynin (D) Pilocarpine (E) Salmeterol

(D) Pilocarpine is a muscarinic agonist that stimulates all muscarinic receptors (M1, M2, and M3) and can significantly increase aqueous secretions in patients with residual salivary gland function. Atropine and oxybutynin are muscarinic antagonists and would worsen dry mouth, as would the antihistamine diphenhydramine due to its anticholinergic properties. Salmeterol is a β2 -agonist and can also potentially cause dry mouth. (Fox, 2013)

Which of the following is considered an osmotic laxative? (A) Docusate sodium (B) Loperamide (C) Methylcellulose (D) Polyethylene glycol (E) Senna

(D) Polyethylene glycol (PEG) is an example of an osmotic laxative that leads to water retention in the bowel. It is often used when complete colonic cleansing is required prior to gastrointestinal endoscopic procedures or colorectal surgeries. Senna is a plant derivative found in preparations such as Senokot and Ex-Lax. While the exact mechanism is unknown, it is believed that Senna induces peristalsis by directly stimulating the enteric nervous system of the bowel. Docusate is a typical ingredient found in stool softeners, whereas methylcellulose is a plant product used in bulk-forming laxatives. Loperamide is not a laxative, but rather an antidiarrheal agent. (A-Rahim & Falchuk, 2014)

A 54-year-old male with chronic stable angina is being treated with daily doses of metoprolol and sublingual nitroglycerin prn to control occasional angina attacks. Approximately 45 minutes after taking sildenafil, the patient suffers a severe attack and takes several nitroglycerin tablets within a short time frame that ultimately leads to his death. Which of the following best explains what occurred? (A) Metoprolol/sildenafil combination led to severe bronchospasm (B) Metoprolol/sildenafil combination triggered a fatal coronary vasospasm (C) Nitroglycerin/sildenafil combination led to a fatal arrhythmia (D) Nitroglycerin/sildenafil interaction led to severe hypotension (E) Nitroglycerin/sildenafil interaction triggered acute arterial thromboembolism

(D) Sildenafil and other selective phosphodiesterase (PDE) inhibitors (e.g., tadalafil, vardenafil) profoundly potentiate the vasodilatory effects (e.g., a greater than 25 mm Hg decrease in systolic blood pressure) of organic nitrates and potentially life-threatening hypotension or hemodynamic collapse can result. Nitrates promote the formation of cyclic guanosine monophosphate (cGMP) by stimulating guanylate cyclase. Sildenafil acts to decrease the degradation of cGMP by inhibiting the enzyme that degrades it (PDE type 5). Together, these combined effects of the nitrate and PED- 5 inhibitor result in increased accumulation of cGMP, which causes more pronounced smooth muscle relaxation and vasodilation than with either drug alone. In this scenario, the profound hypotension led to a significant decrease in coronary blood flow, thereby worsening the patient's ischemia that he was experiencing during his angina attack. Because of the serious risk of concomitant use of organic nitrates and selective PDE inhibitors, such combined use is contraindicated. (Cunningham & Seftel, 2014)

A 28-year-old female in the emergency department is administered an intravenous paralytic agent prior to endotracheal intubation. The agent produces transient muscle fasciculations, particularly over the thorax and abdomen, prior to paralysis. Which of the following was the patient most likely administered? (A) Carbamazepine (B) Pyridostigmine (C) Rocuronium (D) Succinylcholine (E) Tubocurarine

(D) Tubocurarine and rocuronium are classified as nondepolarizing neuromuscular blocking drugs, whereas succinylcholine is depolarizing. Nondepolarizing agents competitively block nicotinic receptors on skeletal muscle, which leads to flaccid muscle paralysis. Depolarizing agents, on the other hand, activate nicotinic receptors on skeletal muscle cells leading to membrane depolarization, initial fasciculations, and intense contractions. Succinylcholine is not metabolized efficiently at neuromuscular junctions; hence, the cells remain depolarized and are unable to repolarize or recover back to a resting state. This failure to repolarize then leads to a flaccid muscle paralysis. Pyridostigmine in an acetylcholinesterase inhibitor indicated for myasthenia gravis and causes an increase in skeletal muscle activity. (Caro, 2014)

A 45-year-old male with recently diagnosed elevation of low-density lipoprotein (LDL-C) is to begin treatment with atorvastatin. Which of the following would be most appropriate to perform or order prior to the initiation of atorvastatin? (A) Arterial blood gas (ABG) and urinalysis (B) Chest radiography and serum lipase/amylase (C) Electrocardiogram (ECG) and serum creatinine (D) Glycated hemoglobin (A1C) and serum ketones (E) Serum creatine kinase (CK) and serum aminotransferases

(E) Hepatic dysfunction and myopathy are two side effects that can occur with use of statins. It is useful to obtain baseline serum creatine kinase (CK) and aminotransferase levels prior to starting statin therapy should these side effects develop. Patients treated with statins should always be alerted to immediately report any new onset of myalgias or weakness. (Rosenson, 2014a)

Which of the following medications would be most appropriate for an otherwise healthy 57-year-old man seeking relatively quick relief from urinary obstructive symptoms with slight prostatic enlargement due to benign prostatic hyperplasia (BPH)? (A) Atropine (B) Desmopressin (C) Finasteride (D) Tamsulosin (E) Testosterone

(D) α1 -Adrenergic antagonists (blockers) such as tamsulosin cause relaxation of the internal urethral sphincter and also decrease prostatic smooth muscle tone. As a result, urinary outflow from the bladder is enhanced and the patient is less likely to experience obstructive symptoms such as weak urine flow, straining to initiate urine flow, dribbling after urination, and the constant feeling of a full bladder. 5α-Reductase inhibitors such as finasteride and dutasteride decrease the production of intraprostatic dihydrotestosterone (DHT) by inhibiting the enzyme type II 5α-reductase. Within the prostate, this enzyme converts testosterone into DHT, which causes prostatic enlargement and growth. As a result, 5α-reductase inhibitors shrink the prostate, which subsequently can provide relief of obstructive symptoms. α1 -Adrenergic antagonists are faster acting in providing symptom relief compared to the 5α-reductase inhibitors, which often take up to 6 months to maximally shrink an enlarged prostate gland. Hence, patients with troublesome symptoms seeking quick relief generally do not prefer 5α-reductase inhibitors. The use of testosterone would not be indicated as this could raise DHT levels and cause further prostatic enlargement. Desmopressin is a synthetic analog of antidiuretic hormone (ADH) and would cause urinary retention, thus exacerbating symptoms. Atropine is a muscarinic antagonist and would also worsen symptoms. (Cunningham & Kadmon, 2014)

A 24-year-old male presenting to the clinic 4 days ago was diagnosed with depression and subsequently prescribed 10 mg/day of fluoxetine. He unexpectedly shows up today and states that he is not experiencing any improvement since starting the medication. What is the best treatment option at this time? (A) Discontinue the fluoxetine and start amitriptyline (B) Discontinue the fluoxetine and start sertraline (C) Double the dose of fluoxetine to 20 mg/day and assure the patient that he will experience improvement in the next 48 hours (D) Maintain the current dose of fluoxetine and add phenelzine to the medication regimen (E) Maintain the current dose of fluoxetine and comfort the patient that the medication may still take several weeks to have its full effect

(E) Alleviation of symptoms associated with depression is typically slow in onset following initiation with SSRIs. Fluoxetine, for instance, can take anywhere between 2 and 6 weeks to achieve substantial benefit when used for depression. After just 4 days of therapy, there is little justification to increase the current dose or switch to another SSRI such as sertraline. Switching the patient to a TCA such as amitriptyline at this point would further delay symptom relief, as TCAs can take several weeks to produce improvement. Compared to SSRIs, TCAs are also more likely to create unwanted side effects such as weight gain, orthostatic hypotension, and constipation. Combining an SSRI with a monoamine oxidase inhibitor (MAOI) such as phenelzine can cause serotonin syndrome that can be lethal. In order to avoid interaction between SSRIs and MAOIs, it is recommended that at least 4 to 5 weeks pass after discontinuing one and starting the other. (Hirsch & Birnbaum, 2014b)

Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects? (A) Acting as dopamine receptor agonists (B) Acting as NMDA receptor antagonists (C) Acting as serotonin receptor antagonists (D) Decreasing reuptake of serotonin and norepinephrine (E) Increasing GABAA receptor-mediated chloride conductance

(E) Benzodiazepines bind to GABAA receptors, which consist of many peripheral subunits that form chloride channels at their core. GABA is one of the major inhibitory neurotransmitters in the brain; hence, benzodiazepines enhance this inhibitory influence to produce sedation and calm. (Bystritsky, 2014)

Following a gunshot wound to the lower abdomen, a 29-year-old male is hospitalized and treated with clindamycin for a potential anaerobic infection. After 3 days of clindamycin therapy, while recuperating in the hospital, he develops severe diarrhea, dehydration, and lower abdominal cramping. A stool culture is ordered and later discovered to contain Clostridium difficile. After discontinuing the clindamycin and assuming no known drug allergies, which of the following would be the most appropriate treatment? (A) Amoxicillin (B) Cephalexin (C) Ciprofloxacin (D) Doxycycline (E) Metronidazole

(E) C. dif icile is a gram-positive, anaerobic, spore-forming bacillus that is responsible for the development of antibiotic-associated diarrhea and colitis. C. dif icile colitis results from a disturbance of the normal bacterial flora of the colon, colonization with C. dif icile, and release of toxins that cause mucosal inflammation and damage. Antibiotic therapy is the key factor that alters the colonic flora. Specific therapy aimed at eradicating C. dif icile is indicated if symptoms are persistent or severe. The drugs of choice are oral metronidazole or oral vancomycin. (Kelly & Lamont, 2014)

One of the most common adverse effects with centrally acting skeletal muscle relaxants such as carisoprodol and cyclobenzaprine is their tendency to cause which of the following? (A) Hyperglycemia (B) Hypertension (C) Myalgia (D) Rash (E) Sedation

(E) Centrally acting skeletal muscle relaxants are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute and painful musculoskeletal conditions (e.g., low back pain). The primary adverse effects of centrally acting skeletal muscle relaxants are sedation and dizziness and are common to all drugs within this class. Patients should be advised not to use these drugs with alcohol or other central nervous system (CNS) depressants, as these combinations can cause significant sedation. Operating machinery or driving a motor vehicle should be avoided while taking carisoprodol or cyclobenzaprine. (Knight et al., 2014)

Which of the following induces atrophy of the adrenal glands and, if discontinued, must be tapered following chronic administration? (A) Atorvastatin (B) Dabigatran (C) Metformin (D) Omeprazole (E) Prednisone

(E) Chronic therapy with systemic corticosteroids can induce atrophy of the adrenal glands, which significantly depresses the adrenal response to adrenocorticotropic hormone (ACTH). Stopping prednisone suddenly would leave the body without a source of glucocorticoids, because the hypothalamic-pituitary-adrenal axis needs time to reestablish its normal functioning. As a result, an acute adrenal crisis (Addisonian crisis) that is marked by dehydration with severe vomiting and diarrhea, hypotension, shock, and loss of consciousness can develop and potentially lead to a fatality. (Furst & Sagg, 2014)

Which drug can potentially lead to oropharyngeal candidiasis, and which agent can be used to treat this type of infection? (A) Albuterol; ketoconazole (B) Cromolyn sodium; levofloxacin (C) Flunisolide; metronidazole (D) Fluticasone; amantadine (E) Triamcinolone; fluconazole

(E) If they coat the mouth and throat, inhaled corticosteroids (e.g., triamcinolone, fluticasone, flunisolide) can alter the local bacteria and fungal population, thereby enhancing fungal growth. In cases of oropharyngeal candidiasis (thrush), white spots on the tongue and hard palate can be visualized, and the patient usually has pain on swallowing. In the asthma patient, the utilization of a spacer with a metered dose inhaler (MDI) can help minimize the chances of oropharyngeal candidiasis, as can routine gargling and rinsing following each inhaled treatment. Fluconazole is an antifungal agent that is effective in treating oropharyngeal candidiasis. (Kauf man, 2014)

50-year-old male undergoes a physical examination during which time his blood pressure is determined to be 150/98. An electrocardiogram reveals the presence of atrial fibrillation. No other abnormalities are noted, and otherwise, the patient appears to be in good health. He is not currently taking any medications. Which of the following would be most appropriate to prescribe to the patient at this time? (A) Candesartan (B) Doxazosin (C) Hydrochlorothiazide (D) Lisinopril (E) Verapamil

(E) In this particular patient, the atrial fibrillation is a compelling indication for a calcium channel blocker. A nondihydropyridine calcium channel blocker is effective for rate control in patients with atrial fibrillation, and is considered one of the major options for treating hypertension, along with thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). These other options, however, are not effective for rate control in patients with atrial fibrillation. (Mann, 2014)

Which of the following is the primary emergency treatment for anaphylaxis? (A) Aminophylline (B) Antihistamines (C) Atropine (D) Dopamine (E) Epinephrine

(E) Intramuscular administration of epinephrine is the drug of choice to quickly reverse the considerable vasodilation (and subsequent drop in blood pressure) and bronchoconstriction that often occurs with anaphylaxis. Several adjunctive therapies (e.g., intravenous fluids, antihistamines, corticosteroids) may also be necessary to help maintain blood pressure, reduce inflammation, and prevent bronchospasm. However, epinephrine should be the first drug administered. (Simons & Carmargo, 2014)

Which of the following has the potential for causing cyanide toxicity? (A) Clonidine (B) Diazoxide (C) Hydralazine (D) Reserpine (E) Sodium nitroprusside

(E) Intravenous nitroprusside is a medication used for hypertensive emergencies. It is metabolized to cyanide and then to thiocyanate, which is excreted in the urine. Risk factors for nitroprusside-induced cyanide poisoning include a prolonged treatment period (>24-48 hours), underlying renal impairment, and the use of doses that exceed the capacity of the body to detoxify cyanide (i.e., more than 2 μg/kg per minute). (Elliot & Varon, 2014)

Which of the following drugs block the actions of leukotrienes and can be used for long-term control of mild persistent asthma? (A) Cromolyn sodium (B) Ipratropium bromide (C) Omalizumab (D) Nedocromil sodium (E) Zafirlukast

(E) Leukotrienes are inflammatory mediators that are generated within the lungs. When they bind to specific receptors, they induce a variety of responses, including bronchospasm and mucus production. Zafirlukast (and also montelukast) are leukotriene receptor antagonists that block these effects in the lungs and improve asthma symptoms. Zafirlukast is considered an alternative therapy for long-term control of asthma, as it has been shown to be less effective than inhaled corticosteroids. Both cromolyn and nedocromil are mast cell stabilizers and can also be used as an alternative treatment to inhaled corticosteroids. Omalizumab is an anti-IgE antibody, whereas ipratropium bromide is a muscarinic receptor antagonist. (Fanta, 2014b)

A single dose of 1.5-mg levonorgestrel or two 0.75-mg tablets of levonorgestrel taken 12 hours apart are effective as _________. (A) a method to increase the chances of becoming pregnant by inducing ovulation. (B) a method for preventing hot flashes in postmenopausal women. (C) a method of protection against HIV transmission. (D) analgesia for pain associated with endometriosis. (E) emergency contraception following unprotected intercourse.

(E) Levonorgestrel is available as a single dose emergency contraceptive containing 1.5 mg in a single tablet and as a pack that contains two 0.75 mg tablets to be taken 12 hours apart. (Zieman, 2014)

A 26-year-old female in her 31st week of pregnancy is diagnosed with acute cystitis. Which of the following would be the most appropriate empiric treatment for this patient? (A) Doxycycline (B) Erythromycin (C) Levofloxacin (D) Metronidazole (E) Nitrofurantoin

(E) Nitrofurantoin has been shown to be a safe and effective drug during pregnancy for treating acute cystitis. Tetracyclines and fluoroquinolones are not recommended for use in pregnancy because of the various risks they pose on the fetus. (Hooton & Gupta, 2014)

A type 1 diabetic patient who does not experience many of the normal warning signs of hypoglycemia when her blood glucose is 57 mg/dL is most likely receiving which of the following antihypertensive medications? (A) Diltiazem (B) Enalapril (C) Hydrochlorothiazide (D) Losartan (E) Propranolol

(E) Nonselective β-blockers can mask many of the signs and symptoms of hypoglycemia in patients who tightly regulate their blood glucose levels. This is due to the fact that many of the symptoms are mediated through the sympathetic nervous system and β-receptors, including tachycardia, palpitations, and tremor. Sweating is another warning sign of hypoglycemia, but should still occur with β-blocker therapy, because it is mediated via cholinergic receptors. (Podrid, 2014)

Which compound can be applied topically and acts as a keratolytic to remove corns, calluses, and common warts? (A) Acetaminophen (B) Colchicine (C) Hydrocortisone (D) Hydroxychloroquine (E) Salicylic acid

(E) Salicylic acid is a commonly used over-the-counter keratolytic that is typically applied as a lotion, gel, or plasters to corn pads. (Goldstein & Goldstein, 2014)

Which of the following is a common adverse effect associated with the use of stimulants such as methylphenidate for attention-deficit hyperactivity disorder (ADHD) in adults? (A) Diarrhea (B) Hypoglycemia (C) Hypotension (D) Paresthesias (E) Reduced appetite

(E) Stimulants (e.g., amphetamines, methylphenidate) are considered first-line therapy in the majority of cases of ADHD in adults. Both amphetamines and methylphenidate block dopamine and norepinephrine reuptake, while amphetamines also stimulate norepinephrine release. Elevated levels of CNS norepinephrine have been associated with an anorexigenic effect, leading to reduce caloric intake and potential weight loss. (Bukstein, 2014)

A 55-year-old female with a 3-month history of rheumatoid arthritis presents to the clinic with complaints of painful bilateral swelling of her ankles and hands, morning stiffness, loss of appetite, and fatigue. She has taking naproxen sodium 500 mg twice per day since diagnosed. Which medication(s) would be most appropriate to add to this patient's medication regimen? (A) Acetaminophen (B) Allopurinol (C) Cyclosporine (D) Oxycodone (E) Methotrexate

(E) Whereas NSAIDs such as naproxen provide some symptomatic relief in rheumatoid arthritis, they do not alter disease progression like DMARDs (disease-modifying antirheumatic drugs). Support for an early aggressive approach with a DMARD is based upon evidence that joint damage, which may ultimately result in disability, begins early in the course of disease and that, the longer active disease persists, the less likely the patient is to respond to therapy. Hence, her NSAID would best be used in conjunction with a DMARD as she was just diagnosed 3 months ago.