MCQ 2

Patient JR was on the following meds PTA: -Amiodarone 200mg q day -Furosemide 40mg q day -Levothyroxine 100mcg q day -Metoprolol tartrate 25mg BID -KCl 20 mEq q day -Atorvastatin 40mg q day -Warfarin 2mg q day -Ibuprofen 400 mg PRN mild to moderate pain As discussed in class- How should we optimize JR's Medications? Comment on each of the listed medications, (No change, decrease to xx mg, increase to xx mg, discontinue) and include any other medications and doses that should be added to his regimen

-Amiodarone 200mg q day--> No change -Furosemide 40mg q day-->Increase 40 mg BID -Levothyroxine 100mcg q day--> No change -Metoprolol tartrate 25mg BID -->Change to Metoprolol succinate (extended release) -KCl 20 mEq q day -->No change -Atorvastatin 40mg q day--> No change -Warfarin 2mg q day-->No change -Ibuprofen 400 mg PRN mild to moderate pain -->Discontinue and add acetaminophen 1. Add an ARB (Losartan 25 mg tablet PO daily) 2. increase Furosemide to 40 mg bid 3. Change to Extended Release metoprolol 4. Consider aldosterone antagonist (Spironolactone, initially 12.5 to 25 mg PO once daily) 5. Change ibuprofen to acetaminophen

Heparin MOA

Activates anti-thrombin

___________ reduce the activity of the sympathetic nervous system

Beta adrenergic antagonists

An allergic reaction to a nonantibacterial sulfonamide such as celecoxib in a patient with an allergy to sulfamethoxazole may be due to: A) Both drugs have an arylamine group at the N4 position of the sulfonamide moiety B) Both drugs have a 5 or 6 member nitrogen containing ring at the N1 nitrogen C) A predispostion to drug-induced allergic reactions D) Circulating IgE antibodies to sulfamethoxazole

C) A predispostion to drug-induced allergic reactions

__________ relaxes vascular smooth muscle and reduces total peripheral resistance (TPR)

Calcium Channel antagonists

Identify the correct maintenance dose for amiodarone: A) To control supraventricular arrythmia the maintenance dose is 800 to 1600 mg orally each day B) To control supraventricular arrythmia the maintenance dose is 50 mg/kg orally each day C) To control supraventricular arrythmia start at 200 mg orally a day, and double the dose every other day until the dose is up to 2 Grams per day D) To control supraventricular arrythmia the maintenance dose is usually 200 mg orally each day

D) To control supraventricular arrythmia the maintenance dose is usually 200 mg orally each day

ACE-inhibitors

Decrease afterload by decreasing TPR through prevention of angiotensin induced vasoconstriction, and decrease preload by limiting aldosterone secretion

Clinical benefit of: Thiazide diuretics

Demonstrate improvements in mortality in most patients. Also useful to offset fluid retention caused by vasodilators

Dabigatran MOA

Direct thrombin inhibitor

Phenothiazines as well as Butyrophenones for example compazine, droperidol

Dopamine antagonists

"Because I want it" is what kind of medicine?

Eminence based medicine

This clotting factor has the shortest half life

Factor VII

Rivaroxaban MOA

Factor Xa inhibitor

Advantages and disadvantages to H2Receptor Antagonists

Good efficacy, well tolerated and safe, but doses need to be adjusted if renal function is impaired

Digoxin

Inhibits Na-K-ATPase which increases intracellular calcium resulting in vagomimetic action, positive inotropic action, and reduced sympathetic response

Beta-adrenergic antagonists

Reduce sympathetic activity

5-HT3 receptor antagonists for example ondansetron

Serotonin antagonists

Heparin

The aPTT is used to measure the intensity of pharmacologic effect

Warfarin

The normalized prothrombin time is used to measure the intensity of pharmacologic effect

________ act on the distal tubule to reduce sodium reabsorption.

Thiazide type diuretics

Which statement about management of CDI is correct? A) Encourage frequent use of hand sanitizers B) Treatment includes oral metronidazole or IV Vancomycin C) Treatment includes oral metronidazole or oral Vancomycin D) Use fidaxomicin for initial treatment

Treatment includes oral metronidazole or oral Vancomycin

Today's patients is a 41-year-old otherwise healthy woman presenting with fever, myalgia, and cough that began the day before. Rapid antigen testing is positive for influenza A. Which statement about antiviral treatment for this patient is correct? Treatment with oseltamivir could be considered since onset of symptoms was <48 hours ago. Treatment is not recommended because her symptoms began >24 hours ago. Treatment with amantadine could be considered since onset of symptoms was <48 hours ago. Otherwise healthy persons should not receive antiviral treatment for influenza.

Treatment with oseltamivir could be considered since onset of symptoms was <48 hours ago. Greatest benefit when administered early.

Harms are the opposite of benefits. True or False?

True

Match the allergy classification with the most correct time of onset; mediator; and clinical signs. Type I-IV Reaction Late Reaction; IgG; Drug fever Late Reaction; IgG; Interstitial nephritis Delayed Reaction; T-cells; Maculopapular rash Immediate Onset; IgE; Anaphylaxis

Type I - Immediate Onset; IgE; Anaphylaxis Type II - Late Reaction; IgG; Interstitial nephritis Type III - Late Reaction; IgG; Drug fever Type IV - Delayed Reaction; T-cells; Maculopapular rash

heparin and LMWH

activates antithrombin

buprenorphine

agonist/antagonist

aspirin

inhibits prostaglandin and thromboxane synthesis

NSAIDs

inhibits the synthesis of prostaglandins

Most important adverse effect from acetaminophen is

liver toxicity

methadone

longest duration of action of this group

Phenylpiperidines

meperidine, fentanyl

eptifibatide

prevents binding of fibrinogen and vWF to the GP llb/llla receptor

Acetaminophen

the exact mechanism is unknown but this medication appears to work via inhibition of prostaglandin synthesis, although this compound does not have anti-inflammatory or anti-thrombotic properties

An 87-year-old woman was recently seen in a hospital emergency department (ED) for pain in her back and buttocks after a fall 2 weeks earlier. She was diagnosed with sciatica and given prescriptions for a short course of prednisone and baclofen and sent home. Three days later, she developed delirium, necessitating another trip to the ED and a subsequent admission to the hospital. Her mental status returned to baseline 2 days later and she was discharged home. The final diagnosis was drug-induced delirium. A few weeks later, she returned to the ED complaining of stomach pain. She was given prescriptions for an antibiotic and a proton-pump inhibitor and asked to follow up with a gastroenterologist.Within a month, she developed severe diarrhea of several days' duration, and again returned to the ED, where this time she was given a prescription for dicyclomine. Two days after beginning this new drug regimen, she again became delirious and was readmitted to the hospital for several days. She was subjected to multiple laboratory tests and imaging studies, the results of which were all normal. Thankfully, she was again discharged home. 1. Which medications were unintentionally prescribed to manage a side effect of another medication? 2. Which prescribed medications for this case were unnecessary?

1. The antibiotics and proton-pump inhibitor were unintentionally prescribed for the stomach pain that was most likely secondary to prednisone and baclofen. Dicyclomine was also unintentionally prescribed to manage the diarrhea, which was likely due to the antibiotic therapy. 2. The pain in her back was most likely due her fall, not sciatica. Thus , local trauma is not considered an indication for prednisone. The antibiotics and the proton-pump inhibitor should have not been prescribed because the stomach pain was due prednisone and baclofen side effect, and NOT a bacterial infection. She should have not been prescribed dicyclomine after having already experienced a drug-induced delirium (prednisone and baclofen). In addition, GI referral was unnecessary.

The most important adverse effect of loop diuretics is: A) Hypokalemia B) hyponatremia C) renal insufficiency D) angioedema

A) Hypokalemia MOA: Inhibits water transport across Loop of Henle, and you get increased excretion of H20, Cl-, Na+, K+

Warfarin MOA

A vitamin K antagonist

Which of the following is an analgesic and antipyretic drug that lacks an anti-inflammatory action? A) Acetaminophen B) Celecoxib C) Colchicine D) Indomethacin

A) Acetaminophen Acetaminophen is the only drug that fits this description. Indomethacin is a nonselective COX inhibitor and celecoxib is a COX-2 inhibitor; both have analgesic, antipyretic, and anti-inflammatory effects. Colchicine is a drug used for gout that also has an anti-inflammatory action.

A 73 year old white man having a prior medical history of COPD, CKD, and gout is admitted for a MI. Prior to discharge, you plan to start a beta blocker. Which of the following beta blockers would be the best choice based on his history? A) Atenolol B) Esmolol C) Nadolol D) Propranolol

A) Atenolol Because of the patient's COPD, a beta-1 selective agent would be preferred over a non-selective agent. Of the agents listed, atenolol and esmolol are beta-1 selective, however, esmolol is only available in an IV formulation, therefore atenolol is the correct answer.

Cefotaxime, or ceftriaxone, or ampicillin/ sulbactam are considered first line antibiotic treatments for SBP because: A) Because of their activity against E coli, and proteus B) Because they are useful agents for patients having a documented severe allergic reaction to penicillin C) Because of their activity against staph, strep, and atypical bacteria. D) Are only used when symptoms of infection are supported by a positive culture of ascitic fluid

A) Because of their activity against E coli, and proteus

A 64-year-old woman presents with pain in her left thigh muscle. Duplex ultrasonography indicates the presence of deep vein thrombosis (DVT) in the affected limb.The decision was made to treat this woman with enoxaparin. Relative to unfractionated heparin, enoxaparin_______ A) Can be used without monitoring the patient's aPTT B) Is more likely to cause thrombosis and thrombocytopenia C) Has a shorter duration of action D) Is less likely to have a teratogenic effect

A) Can be used without monitoring the patient's aPTT Enoxaparin is an Low Molecular Weight heparin. LMW heparins have a longer half-life than standard(High molecular weight) heparin and a more consistent relationship between dose and therapeutic effect. Enoxaparin is given subcutaneously, not intravenously. It is less, not more, likely to cause thrombosis and thrombocytopenia. Neither LMW heparins nor standard heparin are teratogenic. The aPTT is not useful for monitoring the effects of LMW heparins.

PMH: your patient has stage 2 hypertension and is at risk for type 2 diabetes. At the follow up appointment you note that He/she has lost a small amount of weight, has an improved diet, and has begun to exercise on a regular basis. You noted a small decrease in blood pressure. After confirming your diagnosis you initiated treatment with an ACE Inhibitor. On the next follow up appointment you note that blood pressure was reduced by about 10 mmHg after 2 months of treatment. Based on your interview and the patients response you are confident that patient adherence is to diet, exercise and medication is high. Your patient is unaware of any side effects from the ACE inhibitor. However blood pressure remains elevated. You decide it is time to change therapy for hypertension. Your next step should be to: A) Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic. B) Keep raising the dose of ACE inhibitor until the patients reaches blood pressure goal. C) Stop the ACE inhibitor and initiate treatment with a calcium channel antagonist. D) Stop the ACE inhibitor and initiate treatment with the newest medication available.

A) Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic.

Identify the statement that is NOT a risk factor for NSAID associated gastroduodenal ulcers A) Exposure to ancient sumerians B) age C) concomitant use of corticosteroids D) history of ulcer

A) Exposure to ancient sumerians

Which of the following pathways is NOT a site for neurotransmitters involved in nausea and vomiting? A) Facebook B) Serotonin type 3 C) Neurokinin-1 D) Dopamine-2

A) Facebook

A 59 year old African American man with Chronic Kidney Disease (CKD) (baseline CrCl 30-35 mL/min) was diagnosed with HTN and started on lisinopril 5mg PO QD (taken at 0800). He does not like taking medications, but has a very high health literacy and takes this new medication very regularly. He reliably and accurately monitors his blood pressure at home since his diagnosis. After a month of therapy, he returns for a follow up visit and reports his 0700 SBP ranges 140-160 mmHg, his 1400 BP ranges 100-120s mmHg, and his 2100 SBP ranges 130-150 mmHg. Given his preferences about avoiding multiple medications and also his medical history, what medication change should be made at this time? A) Increase lisinopril to 10mg PO QD B) Continue lisinopril 5mg, add HCTZ 25mg PO QD C) Continue lisinopril 5mg, add amlodipine 5mg QD D) Was not on appropriate medication initially, switch to amlodipine 5mg PO QD

A) Increase lisinopril to 10mg PO QD An ACEI inhibitor (or ARB) is indicated in this patient with CKD per JNC 8 guidelines. ACE inhibitors have a "flat dose response," and the patient is achieving mid-day blood pressures at goal with elevations in the PM. Therefore, the dose should be increased to sustain response for 24 hours. Polypharmacy should be minimized when possible (especially in a patient with a stated preference), and thiazides might be less effective in a patient with a reduced CrCl.

Use only a few drugs and learn to use them well. A) Is an important principle of conservative prescribing B) Is not recommended as clinicians are encouraged to experiment with newly approved drugs C) Instead clinicians should rush to prescribe newly approved drugs having unique mechanisms of action. D) Clinicians should only prescribe medications that are heavily advertised to the public.

A) Is an important principle of conservative prescribing

Which statement best describes the common factors thought to precipitate cardiac arrythmias? A) Ischemia, acidosis-alkalosis, electrolyte abnormalities, adverse drug reactions. B) contrast studies, statins, echocardiograms C) MCQ exams, Capstone Projects, Moving D)None of the above

A) Ischemia, acidosis-alkalosis, electrolyte abnormalities, adverse drug reactions. Others include--> excessive catecholamine exposure, autonomic influences, drug toxicity, over stretching of cardiac fibers, and the presence of scarred or disease tissue

Identify the preferred triple therapy for treatment of h pylori infection. A) Lansoprazole 30 mg PO twice daily with amoxicillin (1 gm twice daily) and clarithromycin (500 mg twice daily) for 10—14 days B) Famotidine 40 mg PO twice daily with amoxicillin 1 gm twice daily and clarithromycin 500 mg twice daily for 10-14 days. C) Pepto bizmol every hour plus ranitidine 150 mg twice a day plus ciproloxacin 750 mg twice a day plus imipenem 1 gm IV every 6 hours for 10-14 days. D) Maalox 30 ml po every hour until symptoms improve

A) Lansoprazole 30 mg PO twice daily with amoxicillin (1 gm twice daily) and clarithromycin (500 mg twice daily) for 10—14 days

As you might expect from understanding the mechanism of action for digoxin this medication is cleared from the body via metabolism. However about 30% of digoxin is cleared by the kidney. Also it is known that renal failure by itself can impair the activity of Na-K ATP'ase. Based upon the above statements which response is correct? A) Patients having renal insufficiency and also taking digoxin should be monitored carefully for safety and efficacy. It may be necessary to reduce the dose of digoxin in proportion to the reduced renal function to prevent serious digoxin toxicity B) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most patients it will not be necessary to reduce the dose of digoxin to prevent serious digoxin toxicity. C) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most renal patients it will be necessary to dramatically increase the dose of digoxin to preserve digoxin efficacy. D) Patients having renal insufficiency and also taking digoxin need not be monitored carefully for safety and efficacy. For most renal patients it will be necessary to add another medication that interferes with the metabolism of digoxin so that the effect of digoxin on Na-K ATP'ase is enhanced.

A) Patients having renal insufficiency and also taking digoxin should be monitored carefully for safety and efficacy. It may be necessary to reduce the dose of digoxin in proportion to the reduced renal function to prevent serious digoxin toxicity

Secondary Risk factors for PONV include all EXCEPT A) Type of health insurance (Does not include risk of nausea when you receive your bill) B) Type of surgery- laprascopic, Gyne, ENT, Neuro C) Duration of surgery D) Use of general anesthesia

A) Type of health insurance (Does not include risk of nausea when you receive your bill)

Which of the following factors is least associated with a higher risk of developing myopathy or rhabdomyolysis in patients taking statins? A) Use of a low statin dose B) Kidney disease C) Female sex D) Age 65 years or older

A) Use of a low statin dose Some of the known risk factors associated with increased or frequent side effects when using statins include the following: Age 65 years or older Female sex Using multiple cholesterol-lowering medications (eg, fibrates, high-dose niacin, lomitapide) High statin dose Smaller body frame Kidney disease Liver disease Alcohol use

The most effective antiarrhythmic drug for maintenance of sinus rhythm is: A) amiodarone B) propafenone C) dronedarone D) sotalol

A) amiodarone

Which statement about amiodarone is NOT correct? A) amiodarone has a short half life, and is eliminated entirely by the kidney B) amiodarone accumulates in the heart, lung, liver, skin and tears C) Dose-related pulmonary toxicity is the most important adverse effect D) amiodarone can interfere with the metabolism of many drugs including statins, warfarin, and digoxin E) Use of amiodarone may result in hypothyroidism or hyperthyroidism

A) amiodarone has a short half life, and is eliminated entirely by the kidney The elimination half-life is complex, with a rapid component of 3-10 days (50% of the drug) and a slower component of several weeks. After discontinuation of the drug, effects are maintained for 1-3 months. Measurable tissue levels may be observed up to 1 year after discontinuation.

Which statement about warfarin is correct: A)Foods containing large amounts of vitamin K can antagonize warfarin B)Warfarin exerts its effect on coagulation through activation of antithrombin III C)Patients should stop eating fruits and vegetables when treated with warfarin D)Warfarin has an immediate effect on coagulation

A)Foods containing large amounts of vitamin K can antagonize warfarin

What type of ADR occurs from increasing dose of warfarin and having bleeding after? A. Pharmacologic B. Idiosyncratic C. Allergic D. None of the above

A. Pharmacologic

clopidogrel

An active metabolite binds to and inhibits the platelet ADP receptors

____________ reduces the activity of the Renin system.

Angiotensin converting enzyme inhibitors

Scopolamine

Anticholinergic

Which two classes of drugs interfere with the elimination of Bradykinin? A) ARBs and NSAIDs B) ACE inhibitors and Neprilysin inhibitors C) Nesiritide and Neprilysin inhibitors D) Loop diuretics and ARBs

B) ACE inhibitors and Neprilysin inhibitors

In addition to an ACE-I, ARB, or ARNI all patients with HFrEF should take a beta blocker. Which statement is correct? A) Metoprolol is more likely than carvedilol to cause hypotention. B) Beta blockers should be used cautiously if at all in patients with severe bradycardia. C) Discontinue the beta blocker if there is no significant improvement during the first week of treatment. D) All beta blockers are shown to reduce hospitalizations, and mortality.

B) Beta blockers should be used cautiously if at all in patients with severe bradycardia.

A patient develops severe thrombocytopenia in response to treatment with unfractionated heparin and still requires parenteral anticoagulation. Your best option is: A) Eptifibitide B) Bivalirudin C) Abciximab D) clopidogrel

B) Bivalirudin Direct thrombin inhibitors such as bivalirudin and argatroban provide parenteral anticoagulation similar to that achieved with heparin, but the direct thrombin inhibitors do not induce formation of antiplatelet antibodies.

Which statement about carvedilol is correct? A) Carvedilol is a cardioselective beta antagonist B) Carvedilol is a combined alpha- and nonselective beta-blocker C) Carvedilol and labetalol have balanced alpha and beta blocking action D) Carvedilol is contraindicated in heart failure

B) Carvedilol is a combined alpha- and nonselective beta-blocker

NSAIDS and Opioids promote histamine release via: A) IgE Mediated Type I Reaction B) Direct Pharmacologic Effect C) Promotion of prostaglandin synthesis. D) Activation of central pathways that promote appreciation of pain.

B) Direct Pharmacologic Effect

There is compelling evidence to support non-drug treatment for the following conditions: A) Hypertension, Type 1 Diabetes, insomnia and back pain B) Hypertension, Type 2 diabetes, insomnia and back pain C) arthritis, headache, and congestive heart failure D) Non-Hodgkins Lymphoma, von Willebrands disease, and HIV

B) Hypertension, Type 2 diabetes, insomnia and back pain

Today's patient is a 58 yr old man, taking 8 different medications on a daily basis. Pantoprazole was started 12 weeks ago while hospitalized. He is concerned about the cost,side effects, his long term health and wants to know if all of these medications are really necessary. Which indication listed below would be eligible for deprescribing of pantoprazole? A) Severe esophagitis B) ICU Stress Ulcer Prophylaxis C) Documented history of bleeding GI ulcer D) Barrett's esophagus

B) ICU Stress Ulcer Prophylaxis

A patient taking verapamil for hypertension and angina has become constipated. Which of the following drugs is an osmotic laxative that could be used to treat the patient's constipation? A) Ranitidine B) Magnesium hydroxide C) Aluminum hydroxide D) Metoclopramide

B) Magnesium hydroxide A laxative that mildly stimulates the gut is suitable for a patient taking a smooth muscle relaxant drug like verapamil. By holding water in the intestine, magnesium hydroxide provides additional bulk and stimulates increased contractions.

Concerns about the overuse and adverse effects associated with proton pump inhibitors (PPIs) have prompted deprescribing in some situations. Deprescribing PPIs is recommended in patients with which of the following conditions? A) Barret esophagus B) Mild to moderate esophagitis C) Documented history of bleeding gastrointestinal (GI) ulcer D) Chronic nonsteroidal anti-inflammatory drug (NSAID) use with bleeding risk

B) Mild to moderate esophagitis Deprescribing of PPIs is recommended in patients with the following conditions: Mild to moderate esophagitis Gastroesophageal reflux disease treated for 4-8 weeks (esophagitis healed, symptoms controlled) Peptic ulcer disease treated for 2-12 weeks Upper GI symptoms without endoscopy (asymptomatic for 3 consecutive days) Stress ulcer prophylaxis treated beyond intensive care unit admission Uncomplicated Helicobacter pylori infection treated for 2 weeks (asymptomatic) PPI use should be continued in patients with the following conditions: Barret esophagus Chronic NSAID use with bleeding risk Severe esophagitis Documented history of bleeding GI ulcer

Today's Patient is a 64 year old white man with NYHA HFrEF stable while managed with enalapril and carvedilol, but now has developed angioedema.You recommend switching from enalapril to valsartan, but he asks you about Entresto because the advertisements on television and social media encouraged him to ask his Dr about Entresto.You advise him that: A) Valsartan is more effective than Entresto B) Patients with a history of angioedema should NOT take Entresto! C) He should start Entresto as soon as possible and definitely within 24 hours of his last dose of enalapril. D) Entresto is contraindicated for use with carvedilol

B) Patients with a history of angioedema should NOT take Entresto!

The mechanism of action of penicillin allergy toxicity is best described as: A) Cell walls in human skin are destroyed by penicillin resulting in the characteristic rash seen in penicillin allergy. B) Penicillin breakdown products form haptens which bind to cell surface proteins to form an antigen. The major breakdown product results from the degredation of the 4 member ring structure, and the minor breakdown product results from the degredation of the 5 member ring. C) Penicillin breakdown products act to release beta lactamase which results in the allergic reaction. D) Susceptible bacteria release allergic components in an effort to convince the patient to stop taking their medicine.

B) Penicillin breakdown products form haptens which bind to cell surface proteins to form an antigen. The major breakdown product results from the degredation of the 4 member ring structure, and the minor breakdown product results from the degredation of the 5 member ring.

Therapeutically useful anti-arrythmic medications: A) Open the sodium channel and enhance conduction. B) Reduce conduction and excitability and increase the refractory period to a greater extent in depolarized tissue than in normally polarized tissue. C) Shorten the refractory period to cancel out blocked impulses D)Activate the sympathetic nervous system to enhance contractility

B) Reduce conduction and excitability and increase the refractory period to a greater extent in depolarized tissue than in normally polarized tissue.

Ascites Treatment- which statement is most correct? A) Spironolactone is classified as an angiotensin receptor antagonist B) Spironolactone is combined with a loop diuretic C) The furosemide dose is 100 mg day to 40 mg per day for Spironolactone D) No answer text provided.

B) Spironolactone is combined with a loop diuretic

When used to manage portal hypertension the dosing strategy for beta adrenergic antagonists is best described as: A) start at the maximum or target dose and down titrate once pressure is under control B) start with the lowest recommended starting dose, and titrate towards the target efficacy dose while carefully monitoring heart rate. C) start with metoprolol XL and switch to immediate release once target heart rate is reached.

B) start with the lowest recommended starting dose, and titrate towards the target efficacy dose while carefully monitoring heart rate.

An INR is measured two days after a warfarin dose increase. Why didn't this lab value predict that the new dose was too high? A. The INR should only be used to monitor low molecular weight heparins B. The half life of warfarin is approximately 40 hours. The half life of Factor II is 72 hours, and Factor X half life is 40 hours. The INR was measured at best after only one half life, probably less than one half life. We were no where near the maximum inhibition of clotting factors. The INR should have been repeated after 5-7 days at the new dose. C. The INR should have been measured one half hour before, and two hours after the dose increase. D. All of the above

B. The half life of warfarin is approximately 40 hours. The half life of Factor II is 72 hours, and Factor X half life is 40 hours. The INR was measured at best after only one half life, probably less than one half life. We were no where near the maximum inhibition of clotting factors. The INR should have been repeated after 5-7 days at the new dose.

Which statement is NOT correct? A) Digoxin interferes with Na-K ATP'ase in cardiac tissue. The resulting increase in intracellular sodium acts to inhibit the efflux of calcium. B) Digoxin has a very narrow therapeutic index, adverse effects can be frequent and severe if patients are not monitored carefully. C) Digoxin acts as a vagolytic D) Digoxin is rarely considered a first line drug due to its narrow therapeutic window, and lack of benefit on mortality. However in carefully selected patiients adding digoxin can improve cardiac contractility, reduce hospitalizations and reduce patient symptoms of heart failure.

C) Digoxin acts as a vagolytic Digoxin interferes with Na-K ATP'ase in cardiac tissue. The resulting increase in intracellular sodium acts to inhibit the efflux of calcium. Digoxin has a very narrow therapeutic index, adverse effects can be frequent and severe if patients are not monitored carefully. Digoxin is rarely considered a first line drug due to its narrow therapeutic window, and lack of benefit on mortality. However in carefully selected patiients adding digoxin can improve cardiac contractility, reduce hospitalizations and reduce patient symptoms of heart failure. Digoxin acts as a vagoTONIC.

Which one of the following drugs used in HF is associated with clinically or physiologically useful inotropic effects? A) Nesiritide B) Lisonopril C) Dobutamine D) Valsartan

C) Dobutamine

A 54-year-old woman presents with signs and symptoms consistent with an early stage of rheumatoid arthritis. You decide to initiate NSAID therapy.Which of the following patient characteristics is the most compelling reason for avoiding celecoxib in the treatment of her arthritis? A) History of alcohol abuse B) History of gout C) History of myocardial infarction D) History of osteoporosis

C) History of myocardial infarction Celecoxib is a COX-2-selective inhibitor. COX-2 inhibitors have the advantage over nonselective NSAIDs of reduced gastrointestinal toxicity, BUT clinical data suggest that they are more likely to cause arterial thrombotic events. A history of myocardial infarction would be a compelling reason to avoid a COX-2 inhibitor.

A 63-year-old man is undergoing radiation treatment as an outpatient for metastatic bone cancer. His pain is treated with a fixed combination of oxycodone plus acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse.The most appropriate oral medication for his increasing pain is A) Buprenorphine B) Codeine plus aspirin C) Hydromorphone D) Tramadol

C) Hydromorphone In most situations, pain associated with metastatic carcinoma ultimately necessitates the use of an opioid analgesic that is equivalent in strength to morphine, so hydromorphone, oxymorphone, or levorphanol would be indicated. The combination of codeine plus salicylate would not be as effective as the original drug combination. Propoxyphene and Tramadol are less active than the original. Buprenorphine, a mixed agonist-antagonist, is not usually recommended for cancer-associated pain because it has a limited maximum analgesic effect ("ceiling") and because of possible dysphoric and psychotomimetic effects.

When selecting an opioid for a patient claiming an allergy to codeine: A) Choose Morphine the active metabolite of codeine. B) All patients claiming an allergy to codeine should not receive an analgesic. C) If there is a compelling reason to use an opioid you could choose an opioid such as fentanyl or meperidine because these opioids are chemically distinct from codeine. D) There is no risk of allergic reactions from opioids

C) If there is a compelling reason to use an opioid you could choose an opioid such as fentanyl or meperidine because these opioids are chemically distinct from codeine.

The main advantage of ketorolac over other NSAIDs is that ketorolac: A) Can be combined safely with an opioid such as codeine B) Does not prolong bleeding time C) Is available in a parenteral formulation for intramuscular or intravenous injection. D) Is less likely to cause acute renal failure in patients with some preexisting degree of renal impairment

C) Is available in a parenteral formulation for intramuscular or intravenous injection.

An 18-month-old boy dies from an accidental overdose of acetaminophen. Which of the following is the most likely cause of this patient's death? A) Arrhythmia B) Hemorrhagic stroke C) Liver failure D) Ventilatory failure

C) Liver failure

All of the following are properties of opioids EXCEPT A) Oral absorption of opioids is significantly less than SC or IV B) Unlike many other medications there is no plateau effect C) Long acting agents, and dose forms are easy and safe to titrate D) NSAIDs and acetaminophen may be just as effective as mild to moderate opioid agonists

C) Long acting agents, and dose forms are easy and safe to titrate

On your way to the next MCQ Exam, you experience that feeling that an attack of diarrhea is imminent. Stopping at a drugstore, which one of the following antidiarrheal drugs could you buy without a prescription even though it is related chemically to the strong opioid analgesic meperidine? A) Aluminum hydroxide B) Diphenoxylate C) Loperamide D) Magnesium hydroxide

C) Loperamide Aluminum hydroxide is constipating but not related chemically to meperidine; magnesium hydroxide is a strong laxative. The 2 antidiarrheal drugs structurally related to opioids are diphenoxylate and loperamide. Loperamide is available over-the-counter; diphenoxylate is mixed with atropine, and the product (Lomotil, others) requires a prescription.

Portal Hypertension: Beta adrenergic antagonists are used to reduce portal pressure by reducing portal venous inflow reducing cardiac output thus reducing splanchnic blood flow.Which statement is most correct? A) Metoprolol is preferred B) Non selective BB are preferred as use results in reduction of varices and improved mortality C) Non selective BB are preferred as use results in reduction of variceal bleeding and risk of rebleeding D) Beta agonists such as isoproterenol are used to reduce portal pressure, and reduce risk of rebleeding

C) Non selective BB are preferred as use results in reduction of variceal bleeding and risk of rebleeding

Which statement about the mechanism of action of amiodarone is NOT correct? A) prolongs the action potential duration (and the QT interval on the ECG) by blockade of K Channels B) blocks inactivated sodium channels C) Reverses electrolyte imbalances, restores patency of coronary arteries, and balances pH D) has weak adrenergic and calcium channel-blocking actions

C) Reverses electrolyte imbalances, restores patency of coronary arteries, and balances pH

ACE inhibitors should be used with caution in patients with A) Diastolic blood pressure > 90 mm Hg B) Serum Na >145 meq/L C) Serum K > 5 mEq/L D) Serum Creatinine > 1.2 mEq/L

C) Serum K > 5 mEq/L Remember, hyperkalemia is a common adverse effect!

A young man is brought to the emergency department in an anxious and agitated state. He informs the attending physician that he uses "street drugs" and that he gave himself an intravenous "fix" approximately 12 h ago. After an initial period of contentment and relaxation, he now has chills and muscle aches and has also been vomiting. His symptoms include hyperventilation and hyperthermia. You note that his pupil size is larger than normal.What is the most likely cause of these signs and symptoms? A) The patient had injected dextroamphetamine B) The patient has overdosed with an opioid C) The signs and symptoms are those of the opioid abstinence syndrome D) The patient has hepatitis B

C) The signs and symptoms are those of the opioid abstinence syndrome The signs and symptoms are those of withdrawal in a patient physically dependent on an opioid agonist, especially morphine or heroin. They usually start within 6-10 h after the last dose; their intensity depends on the degree of physical dependence, and peak effects usually occur at 36-48 h. Mydriasis is a prominent feature of the abstinence syndrome; other symptoms include rhinorrhea, lacrimation, piloerection, muscle jerks, and yawning. An overdose of dextroamphetamine would not produce an initial feeling of contentment and relaxation.

Identify the correct initial starting dose. A) In heart failure start oral digoxin at 250 mcg per day, increase the dose by 125 mcg per day on alternating days until the daily oral dose exceeds 1000 mcg per day. B) The usual initial oral dose of metoprolol XL for heart failure is 50-100 mg twice a day. C) The usual initial dose of lisinopril for heart failure is 5 mg orally once a day. The usual maintenance dose ranges from 5-20 mg daily. D) In heart failure start oral furosemide at 200-400 mg every 6 hours.

C) The usual initial dose of lisinopril for heart failure is 5 mg orally once a day. The usual maintenance dose ranges from 5-20 mg daily. Initial management: ACE (& diuretics for symptoms) ACE> Beta blockers (both reduce mortality)

You should prescribe a newly approved drug when: A) A paid speaker tells you how much success she has with this new drug while the drug rep buys you an expensive dinner. B) Whenever a new drug has a unique mechanism of action. C) Use newly approved drugs once they have demonstrated superior safety and/or superior clinical outcomes. D) Improvements in laboratory values always result in improvements in clinical outcomes.

C) Use newly approved drugs once they have demonstrated superior safety and/or superior clinical outcomes.

All of the following medications are commonly associated with constipation except? A) Vincristine B) Verapamil C) Vancomycin D) Vareicline

C) Vancomycin This would cause diarrhea!

Which of the following drugs would be the most appropriate choice for rate control in a 69-year-old woman with atrial fibrillation and asthma? A) a dihydropyridine calcium channel blocker B) a beta blocker C) a nondihydropyridine calcium channel blocker D) amiodarone

C) a nondihydropyridine calcium channel blocker Diltiazem and verapamil are preferred over beta blockers for rate control in patients with asthma because beta blockers can precipitate bronchoconstriction and bronchospasm. Unlike diltiazem and verapamil, the dihydropyridine calcium channel blockers (all the other calcium channel blockers ) do not have rate-controlling activity.

Which statement is correct? A. Adverse events are always reported in published trials. B. Spontaneous reporting is the most reliable method for reporting adverse events. C. Adverse events should be reported in the abstract, results and discussion sections of every paper that claims a benefit to treatment. D. Patients who withdraw from a study because of adverse effects should not be included in the results

C. Adverse events should be reported in the abstract, results and discussion sections of every paper that claims a benefit to treatment.

How likely is that the described event (too high of warfarin dose increase) is an adverse drug reaction? A. Unlikely B. Possible C. Probable or Definite D. None of the above

C. Probable or Definite Right- I would classify this event as Probable since there is no re-challenge. When we re-challenge by prescribing a lower dose if the patient reaches a target response I would classify as definite

PMH: your patient has stage 2 hypertension and is at risk for type 2 diabetes. At the follow up appointment you note that He/she has lost a small amount of weight, has an improved diet, and has begun to exercise on a regular basis. You noted a small decrease in blood pressure. After confirming your diagnosis you initiated treatment with an ACE Inhibitor. On the next follow up appointment you note that blood pressure was reduced by about 10 mmHg after 2 months of treatment. Based on your interview and the patients response you are confident that patient adherence to diet, exercise and medication is high. Your patient is unaware of any side effects from the ACE inhibitor. However blood pressure remains elevated. You decide it is time to change therapy for hypertension. Your next step should be to: Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic. Keep raising the dose of ACE inhibitor until the patients reaches blood pressure goal. Stop the ACE inhibitor and initiate treatment with a calcium channel antagonist. Stop the ACE inhibitor and initiate treatment with the newest medication available.

Continue diet, exercise and ACE inhibitor therapy. Add a medication having a different mechanism of action and different side effects such as a thiazide diuretic.

Which classes of antihypertensive medications are most effective in low renin or volume-expanded forms of hypertension? A) Aldosterone anatagonists B) ACE inhibitors C) Thiazide Diuretics D) Aldosterone antagonists andThiazide Diuretics

D) Aldosterone antagonists and Thiazide Diuretics Thiazides, loops, and potassium-sparing diuretics (including aldosterone antagonists) are most effective in low renin patient populations (African Americans, elderly patients). ACE inhibitors are more effective in high-renin patients (white patients, comparatively).

One of the following statements about the mechanism of action of anti-arrythmic agents is NOT correct. Identify the incorrect statement. A) Block sodium channels B)Block Calcium Channels C)Block Potassium Channels D) Block Premium Cable TV Channels

D) Block Premium Cable TV Channels

Which statement about CDI is NOT correct? A) C difficile is a Gram-positive, spore forming rod B) Primary cause of hospital-associated diarrhea in US C) Overgrowth in gut supported by antibiotic use D) Caused by Bacteroides fragilis

D) Caused by Bacteroides fragilis

The treatment of choice for urgent conversion of symptomatic unstable atrial fibrillation is: A) IV magnesium sulfate B) IV amiodarone C) IV digoxin D) DC cardioversion

D) DC cardioversion If the patient was stable, you would give Beta blockers or non DHP Calcium channel blockers

A 55-year-old woman with type 1 diabetes of 40 years' duration complains of severe bloating and abdominal distress, especially after meals. Evaluation is consistent with diabetic gastroparesis. Which of the following is a prokinetic drug that could be used in this situation? A) Alosetron B) Cimetidine C) Loperamide D) Metoclopramide

D) Metoclopramide Alosetron is a 5HT3 receptor blocker, cimetidine is a H2 receptor blocker, loperamide is an opioid only metoclopramide is considered a prokinetic agent (ie, one that increases propulsive motility in the gut).

Which of the following is NOT a primary risk factor for PONV? (Post-Operative Nausea and Vomiting) A) Female Gender B) Non-smoker C) History of PONV and/or Motion Sickness D) Riding a rental bicycle without wearing a helmet. E) Postoperative use of opioid analgesics

D) Riding a rental bicycle without wearing a helmet.

A 55-year-old pharmacology professor is brought to the emergency department 2 h after the onset of severe chest pain during a stressful question and answer session. He has a history of poorly controlled mild hypertension and elevated blood cholesterol but does not smoke. ECG changes (ST elevation) and cardiac enzymes confirm the diagnosis of myocardial infarction. The decision is made to attempt to open his occluded artery.If this patient undergoes a percutaneous coronary angiography procedure and placement of a stent in a coronary blood vessel, he will need to be on dual antiplatelet therapy, for example aspirin and clopidogrel for at least a year. Which response most accurately describes the mechanism of action of clopidogrel? A) Clopidogrel directly binds to the platelet ADP receptors B) Clopidogrel irreversibly inhibits cyclooxygenase C) Clopidogrel facilitates the action of antithrombin III D) The active metabolite of clopidogrel binds to and inhibits the platelet ADP receptors

D) The active metabolite of clopidogrel binds to and inhibits the platelet ADP receptors Clopidogrel is a prodrug that is activated by CYP2C9 and CYP2C19. It IRREVERSIBLY binds to the ADP receptor on the surface of platelets that serves as a key role in platelet aggregation. Aspirin and clopidogrel help prevent platelet-induced occlusion of coronary stents.

Loop diuretics such as furosemide

Decrease preload by decreasing vascular fluid volume

A 16-year-old girl comes to the emergency department suffering from the effects of an aspirin overdose. Which of the following syndromes is this patient most likely to exhibit as a result of this drug overdose? A) Bone marrow suppression and possibly aplastic anemia B) Fever, hepatic dysfunction, and encephalopathy C) Rapid, fulminant hepatic failure D) Rash, interstitial nephritis, and acute renal failure E) Hyperthermia, metabolic acidosis, and coma

E) Hyperthermia, metabolic acidosis, and coma Salicylate intoxication is associated with metabolic acidosis, dehydration, and hyperthermia. If these problems are not corrected, coma and death ensue.

Adverse drug reactions do not result in patient harm. True or False?

False

Always start treatment with more than one drug at a time. True False

False

Most adverse reactions are caused by exotic medications rather than by anticoagulants or by insulin. True or False?

False

Most important adverse effect from NSAIDs is

GI bleeding

advantages and disadvantages to PPIs are

Most potent inhibitors of acid secretion, good efficacy/safety, long duration of action, but expensive

Aprepitant

NK 1 receptor antagonists

List at least 5 examples of prescription and non prescription medications associated with liver injury.

OTC Medications: Alcohol, acetaminophen (high doses), NSAIDs especially diclofenac (some NSAIDS are safer than others) Rx Medications: Seizure meds almost all esp -Phenytoin; INH; Statins (high doses) Amiodarone Allopurinol Methotrexate Antipsychotics

Clinical benefit of: ACE inhibitors

Particularly useful in patients with CKD, DM, HF, and post-MI.

Reverses warfarin

Phytonadione

Advantages and disadvantages of antacids

Prompt acting but short duration of action

Clinical benefit of: Beta Adrenergic Antagonists

Reduce mortality after MI and in HF. Prevent reflex tachycardia associated with use of vasodilators.

Reserve unproven and off-label use for situations when your patients is unable to use recommended and proven treatments. True False

True

Clinical benefit of: Calcium Channel Antagonists

Use of short acting agents in this class is associated with increased risk of MI and an increase in mortality

The preferred antiviral drug for treatment of seasonal influenza in hospitalized patients is: peramivir oseltamivir zanamivir rimantadine

oseltamivir MOA: Neuroaminidase inhibitor that prevents the release of mature virion

strong opioid agonists

activates inhibitory pathways for pain suppression and inhibits pathways for appreciation and transmission of pain

Antiviral prophylaxis can be considered for which of the following persons exposed to influenza: a 75-year-old man with severe immune deficiencies a 4-year-old child with asthma who received the influenza vaccine one week ago a 29-year-old pregnant woman all are correct

all are correct Those who are immunocompromised, pregnant, have underlying respiratory conditions, those not previously vaccinated

Codeine

methylmorphine is a pro-drug that must be metabolized via cytochrome p450 2D6 enzymes to the active compound morphine

phenanthrenes

morphine, hydromorphone, codeine, hydrocodone, oxycodone, oxymorphone

Most important adverse effect from opioids is

respiratory depression