Pharm final Book Questions
A 65-year-old woman who has been diagnosed with postmenopausal osteoporosis has no history of fractures and no other pertinent medical conditions. Which is most appropriate for management of her osteoporosis? A. Alendronate B. Calcitonin C. Denosumab D. Raloxifene
A. Alendronate Bisphosphonates are first-line therapy for osteoporosis in postmenopausal women without contraindications. Raloxifene is an alternative that may be less efficacious (especially for nonvertebral and hip fractures), and calcitonin is not recommended. Denosumab is best used for patients at high risk of fractures
A patient has been taking alendronate for postmenopausal osteoporosis for 5 years with a slight increase in bone mineral density and no occurrence of fractures. Risk of which adverse effect might warrant consideration of a drug holiday from alendronate in this patient? A. Atypical femur fractures B. Esophagitis C. Osteosarcoma D. Rhinitis
A. Atypical femur fractures Atypical femur fractures are associated with long-term use of bisphosphonates (greater than 5 years). Therefore, a drug holiday might be considered since the patient has had no fractures. Esophagitis, while a side effect of bisphosphonate therapy, can be prevented with appropriate administration. Osteosarcoma is associated with the parathyroid hormone analogs, and rhinitis is associated with intranasal calcitonin.
Which of the following diabetes medications is most appropriately paired with an adverse effect associated with its use? A. Canagliflozin—urinary tract infections B. Nateglinide—heart failure C. Glipizide—weight loss D. Liraglutide—lactic acidosis
A. Canagliflozin—urinary tract infections Adverse effects of canagliflozin are genital mycotic infections, urinary tract infections, and urinary frequency. Nateglinide may cause hypoglycemia but has not been associated with heart failure. Sulfonylureas are associated with weight gain. Lactic acidosis is a rare but serious side effect of metformin (not liraglutide).
A 63-year-old female patient with anemia secondary to chronic kidney disease and a hemoglobin level of 8.6 g/dL is treated with epoetin alfa. Eight days after the initial dose of epoetin alfa, the patient's hemoglobin is 10.5 g/dL. Which would be the next step in the management of this patient's anemia? A. Discontinue epoetin alfa B. Discontinue epoetin alfa and initiate darbepoetin C. Continue epoetin alfa D. Increase the dose of epoetin alfa
A. Discontinue epoetin alfa Hemoglobin has increased to more than 10 g/dL and more than 1 g/dL in 2 weeks, so epoetin alfa should be discontinued or the dose reduced. Switching to darbepoetin, continuing epoetin alfa, or increasing the dose of epoetin alfa would continue to increase hemoglobin and lead to increased risk of cardiovascular events.
Which is the BEST description of the mechanism of action of dutasteride? A. Dutasteride blocks 5-α reductase. B. Dutasteride blocks α1A receptors. C. Dutasteride blocks PDE-5. D. Dutasteride blocks α1A and α1B receptors.
A. Dutasteride blocks 5-α reductase. Dutasteride blocks 5-α reductase. Dutasteride does not affect α1A receptors, α1B receptors, or PDE-5.
A healthy 2-year-old boy ingested one of his mother's 2 mg clonazepam tablets 1 hour ago. The child presented to the emergency department with CNS depression but a normal heart rate and blood pressure. His bedside glucose check is also normal. Which antidote might be helpful? A. Flumazenil B. Naloxone C. Physostigmine D. Fomepizole
A. Flumazenil Flumazenil is a competitive benzodiazepine antagonist that reverses the CNS depression from benzodiazepines such as clonazepam. After flumazenil administration, resedation usually occurs, since the duration of the benzodiazepine is longer than that of the flumazenil. Naloxone reverses the effects from opioids and clonidine, not benzodiazepines. Physostigmine is the antidote for anticholinergic toxicity. Fomepizole is the antidote for methanol or ethylene glycol toxicity.
Which adverse effect commonly occurs with glucocorticoid therapy? A. Glaucoma B. Hyperkalemia C. Weight loss D. Osteoarthritis
A. Glaucoma Glucocorticoid therapy may cause hypokalemia, not hyperkalemia. Glucocorticoids also cause increased appetite and osteoporosis. Glaucoma is a known potential adverse effect of this class.
A 45-year-old woman presents to the emergency department with a complaint of persistent vomiting. The patient appears intoxicated, but an ethanol level returns as negative and her basic metabolic panel is unremarkable. Which substance did she probably ingest? A. Isopropyl alcohol B. Methanol C. Ethylene glycol D. Ethanol
A. Isopropyl alcohol Isopropyl alcohol produces twice as much CNS depression as ethanol and is known to cause GI distress. Isopropyl alcohol is metabolized to acetone, so a metabolic acidosis does not result (which is in contrast to the acidosis generated by methanol and ethylene glycol). The ethanol level was negative, eliminating ethanol as an ingestion.
HB is a 55-year-old obese female who has had type 2 diabetes for 10 years. She is currently being treated with metformin, but her HbA1c is above goal. She has a history of heart failure and chronic obstructive pulmonary disorder. Her physician would like to add a medication that will not cause any weight gain. Which of the following would be most appropriate to control HB's diabetes? A. Linagliptin B. Glimepiride C. Pioglitazone D. Inhaled insulin
A. Linagliptin Linagliptin is a DPP-4 inhibitor, and this class of medications is effective in lowering HbA1c levels without causing weight gain (they are usually weight neutral). Sulfonylureas (glimepiride) are associated with weight gain and should be avoided in this obese patient. TZDs (pioglitazone) should be avoided in patients with heart failure. Because of the potential for bronchospasm associated with inhaled insulin, it should be avoided in patients with a history of chronic obstructive pulmonary disorder and asthma.
Which of the following drugs for diabetes is LEAST likely to cause weight gain? A. Liraglutide B. Pioglitazone C. Repaglinide D. Insulin glulisine
A. Liraglutide GLP-1 receptor agonists are usually associated with weight loss due to their ability to enhance satiety. All of the other agents are associated with weight gain.
A 27-year-old married woman is asking about treatment options for obesity. She recently stopped taking her birth control medications, as she felt they were contributing to her weight gain. Which medication should be avoided in this patient? A. Phentermine/topiramate B. Orlistat C. Diethylpropion D. Lorcaserin
A. Phentermine/topiramate Although patients should not take any medications to lose weight during pregnancy, the topiramate component of this medication is especially dangerous, since it can be teratogenic. Because this patient stopped her birth control medicine, she is at risk of becoming pregnant and developing birth defects while also on this medication.
An 81-year-old woman presents to the emergency department with progressive weakness, fatigue, confusion, and reports of seeing people in her house who were trying to hurt her but who were not physically present. Her physical exam was positive for pallor but negative for koilonychias or cracking at the corners of the mouth. Which deficiency would be the highest priority in this patient's workup? A. Vitamin B12 B. Iron C. Folate D. Calcium
A. Vitamin B12 Based on the presentation of confusion and hallucinations, vitamin B12 deficiency should be considered the highest priority. Second priority would be to assess folate deficiency, since symptoms are similar to vitamin B12 deficiency. Iron would be the third priority due to the patient's age, even without the presence of koilonychias or cracking of the mouth. Last priority would be to assess age-related deficiencies in calcium, which could lead to fatigue as well as muscle cramps, poor appetite, and abnormal heart rhythms.
Which patient with iron deficiency anemia would need the parenteral form of iron replacement? A. 22-year-old woman with heavy menstrual periods B. 58-year-old man with end stage renal disease on hemodialysis C. 32-year-old woman in the first trimester of pregnancy D. 40-year-old man with a diabetic foot infection
B. 58-year-old man with end stage renal disease on hemodialysis Clinical evidence supports the use of parenteral iron over oral iron in hemodialysis patients due to a significantly greater increase in hemoglobin levels and lower incidence of treatment-related adverse events. Parenteral iron is also preferred in patients who cannot tolerate oral iron or who have iron malabsorption. Patients with heavy menstrual periods, who are pregnant, or who have chronic disease states, such as diabetes, and infections, should be administered an initial trial of oral iron.
A 55-year-old woman with postmenopausal osteoporosis has a past medical history of ethanol abuse, alcoholic liver disease, erosive esophagitis, and hypothyroidism. Which is the primary reason oral bisphosphonates should be used with caution in this patient? A. Age B. Erosive esophagitis C. Liver disease D. Thyroid disease
B. Erosive esophagitis Bisphosphonates are known to cause esophageal irritation and should be used with caution in a patient with a history of erosive esophagitis. Age is not a factor for consideration in bisphosphonate use. Liver disease is not a contraindication to bisphosphonate use, since bisphosphonates are mainly cleared via the kidney. Thyroid disease is not a contraindication to bisphosphonate use, although overaggressive replacement of thyroid may contribute to osteoporosis.
Which is CORRECT regarding finasteride? A. Finasteride is associated with significant hypotension. B. Finasteride is associated with birth defects. C. Finasteride is effective within 2 weeks of initiation. D. Finasteride is renally eliminated.
B. Finasteride is associated with birth defects. Because finasteride inhibits the conversion of testosterone to its active form, it may cause significant developmental defects in the male genitalia of a developing fetus. As such, it is contraindicated in pregnancy. Unlike the α-blockers, the 5-α reductase inhibitors are not associated with hypotension. Finasteride may take up to 12 months before it is effective. Finasteride is metabolized via CYP450 and is not renally eliminated.
A patient with Addison disease treated with hydrocortisone is experiencing dehydration and hyponatremia. Which drug is best to add to the patient's therapy? A. Dexamethasone B. Fludrocortisone C. Prednisone D. Triamcinolone
B. Fludrocortisone To combat dehydration and hyponatremia, a corticosteroid with high mineralocorticoid activity is needed. Fludrocortisone has the greatest mineralocorticoid activity of the agents provided. The other drugs have little or no mineralocorticoid activity.
Which is correct regarding the pharmacokinetics of the bisphosphonates? A. Bisphosphonates are well absorbed after oral administration. B. Food or other medications greatly impair absorption of bisphosphonates. C. Bisphosphonates are mainly metabolized via the cytochrome P450 system. D. Elimination half-life of bisphosphonates ranges from 4 to 6 hours.
B. Food or other medications greatly impair absorption of bisphosphonates. Food and other medications decrease absorption of bisphosphonates, which are already poorly absorbed (less than 1%) after oral administration. Bisphosphonates are cleared from the plasma by binding to bone and being cleared by the kidney (not metabolized by the CYP450 system). The elimination half-life may be years.
Which contributes to osteoporosis with long-term use of glucocorticoids? A. Increased excretion of calcium B. Inhibition of calcium absorption C. Stimulation of the hypothalamic-pituitary-adrenal axis D. Decreased production of prostaglandins
B. Inhibition of calcium absorption Glucocorticoid-induced osteoporosis is attributed to inhibition of calcium absorption and bone formation. Increased intake of calcium plus vitamin D and use of bisphosphonates may be indicated. Glucocorticoids suppress rather than stimulate the hypothalamic-pituitary-adrenal axis. The decreased production of prostaglandins does not play a role in bone formation.
Which of the following statements is correct regarding insulin glargine? A. It is primarily used to control postprandial hyperglycemia. B. It is a "peakless" insulin. C. The prolonged duration of activity is due to slow dissociation from albumin. D. It should not be used in a regimen with insulin lispro or glulisine.
B. It is a "peakless" insulin Insulin glargine has a relatively flat, prolonged hypoglycemic effect. Because of this, it is used for basal glucose control, not postprandial. The prolonged duration is due to its low pH, which leads to precipitation at the injection site and resultant extended action. Insulin glargine is often used for basal control in a regimen where insulin lispro, glulisine, or aspart are used for mealtime glucose control. [Note: Glargine should not be combined with other insulins in the same syringe, as it may alter the pharmacodynamic properties of the medication.]
A 3-year-old boy is brought to the emergency department by his mother, who reports that he has been crying continuously and "does not want to play or eat" for the past few days. She also states that he has not had regular bowel movements, with mostly constipation and occasional diarrhea, and frequently complains of abdominal pain. The child now has an altered level of consciousness, is difficult to arouse, and begins to seize. The clinician rules out infection and other medical causes. Upon questioning, the mother states that the house is in an older neighborhood, that her house has not been remodeled or repainted since the 1940s, and that the paint is chipping around the windows and doors. The child is otherwise breathing on his own and urinating normally. Which toxin would you expect to be producing such severe effects in this child? A. Iron B. Lead C. Carbon monoxide D. Cyanide
B. Lead Lead poisoning is common among children in older homes painted before lead was removed from paint. Paint chips with lead are easily ingested by toddlers, and excessively high lead levels can lead to the signs and symptoms described plus clumsiness, confusion, headaches, coma, constipation, intestinal spasms, and anemia. Death is rare when chelation therapy is instituted. Iron can produce abdominal pain, but more often would cause diarrhea, vomiting, and volume loss. Carbon monoxide would affect the entire household, depending on the source. Clinical effects from carbon monoxide would include headache, nausea, and CNS depression. If he had cyanide poisoning, death would have occurred quickly following respiratory arrest of oxidative phosphorylation and production of adenosine triphosphate, but this child has been exhibiting symptoms over several days.
Which of the following statements is characteristic of metformin? A. Metformin contains a boxed warning due to the potential for increased risk of myocardial infarction. B. Metformin decreases hepatic glucose production. C. Metformin can be used safely in patients with renal dysfunction. D. Weight gain is a common adverse effect.
B. Metformin decreases hepatic glucose production. Metformin works by inhibiting hepatic gluconeogenesis. The primary adverse effects associated with metformin are gastrointestinal and in rare cases, lactic acidosis. Metformin does not carry a warning for increased risk of myocardial infarction (this is the case for rosiglitazone). Metformin is contraindicated in renal dysfunction due to the risk of lactic acidosis. Unlike the sulfonylureas and insulin, weight gain is not an adverse effect, and some patients actually lose weight due to GI side effects.
Which is CORRECT regarding the mechanism of action of phosphodiesterase-5 (PDE-5) inhibitors? A. PDE-5 inhibitors increase prostaglandin production. B. PDE-5 inhibitors enhance the effect of nitric oxide. C. PDE-5 inhibitors cause vasoconstriction of the erection chamber. D. PDE-5 inhibitors antagonize cyclic GMP.
B. PDE-5 inhibitors enhance the effect of nitric oxide. PDE-5 inhibitors enhance the effect of nitric oxide by preventing the breakdown of cGMP. PDE-5 inhibitors do not affect prostaglandin production. Although blood is drawn to the erection chamber, PDE- 5 inhibitors allow for this via vasodilation, not vasoconstriction. PDE-5 inhibitors prevent the breakdown of cGMP but do not antagonize its action.
After completing his last cycle of chemotherapy, a 68-year-old man received a dose of pegfilgrastim prophylactically to reduce his risk of neutropenia. Twenty-four hours later, he returned to clinic to receive an additional dose of pegfilgrastim and was told he did not need another dose. Which would explain the rationale behind this recommendation? A. Absolute neutrophil count is above 1000/μL B. Pegfilgrastim is given as single dose C. Next dose of pegfilgrastim is due 72 hours after the first dose D. Next dose of pegfilgrastim is due 48 hours after the first dose
B. Pegfilgrastim is given as single dose Pegfilgrastim is a pegylated form of G-CSF and has a longer half-life; therefore, it is administered as a single dose with no additional doses needed. Monitoring of the ANC is not necessary with pegfilgrastim due to the pharmacokinetics of the drug.
Which best describes the mechanism of action of denosumab in the treatment of osteoporosis? A. Parathyroid hormone analog B. RANKL inhibitor C. Selective estrogen receptor modulator D. Vitamin D analog
B. RANKL inhibitor Denosumab is a monoclonal antibody that targets receptor activator of nuclear factor kappa- B ligand (RANKL) and inhibits osteoclast formation and function.
Which class of oral diabetes drugs is paired most appropriately with its primary mechanism of action? A. DPP-4 inhibitor—inhibits breakdown of complex carbohydrates B. SGLT2 inhibitor—increases urinary excretion of glucose C. Sulfonylurea—increases insulin sensitivity D. Thiazolidinedione—decreases hepatic gluconeogenesis
B. SGLT2 inhibitor—increases urinary excretion of glucose SGLT2 inhibitors work by inhibiting the sodium-glucose cotransporter 2 (SGLT2), resulting in decreased reabsorption of glucose in the kidney and increased urinary excretion. Sulfonylureas work primarily by increasing insulin secretion through stimulation of the β cells in the pancreas. DPP-4 inhibitors work by inhibiting breakdown of incretins, thereby increasing postprandial insulin secretion, decreasing postprandial glucagon, etc. TZDs work primarily by increasing insulin sensitivity.
A 27-year-old woman presents to the emergency department 6 hours after reportedly ingesting 20 tablets of acetaminophen 500 mg. An acetaminophen level is drawn, but it has to be sent out to another lab and will not return for another 6 hours. What is the most appropriate next step in management of this patient? A. Administer a dose of activated charcoal. B. Start empirical N-acetylcysteine therapy. C. Wait for the level to return and then decide what to do. D. Draw a NAPQI level.
B. Start empirical N-acetylcysteine therapy. N-acetylcysteine should be started empirically on the basis of the history, and then, once the level returns and is plotted on the Rumack-Matthew nomogram, a final decision on whether to continue therapy can be made. Activated charcoal would not be of any benefit 6 hours post-acetaminophen ingestion. The optimal time frame to give N-acetylcysteine is within 8 to 10 hours postingestion. So, waiting on the level to return would put the patient more than 12 hours postingestion. Therefore, initiation of N-acetylcysteine therapy should happen, if possible during the optimal time frame. Clinicians are unable to draw a NAPQI level and therefore cannot utilize this to guide therapy.
Which describes an important difference between terazosin and tamsulosin? A. Terazosin blocks α1A receptors, whereas tamsulosin blocks α1A and α1B receptors. B. Terazosin blocks α1A and α1B receptors, whereas tamsulosin blocks α1A receptors. C. Terazosin blocks 5-α reductase, whereas tamsulosin blocks PDE-5. D. Terazosin must be taken with food, whereas tamsulosin can be taken on an empty stomach.
B. Terazosin blocks α1A and α1B receptors, whereas tamsulosin blocks α1A receptors. Tamsulosin is more selective for the α1A receptor, found in the prostate. Terazosin blocks α1A; however, terazosin also blocks α1B. Neither one blocks 5-α reductase nor PDE-5. Tamsulosin should be taken with food, while terazosin does not need to be taken with food.
A 47-year-old man with a history of a seizure disorder, maintained on phenytoin, presented to the emergency department with salicylate toxicity. The salicylate level was 50 mg/dL (15 to 35 mg/dL therapeutic range) and the phenytoin level was 15 mg/L (10 to 20 mg/L therapeutic range). What therapy can be considered to enhance the elimination of salicylate without impacting the phenytoin? A. Multiple doses of activated charcoal B. Urinary alkalinization C. Whole bowel irrigation D. Urinary acidification
B. Urinary alkalinization Urinary alkalinization enhances the elimination of the salicylate but does not affect the therapeutic phenytoin level. Multiple doses of activated charcoal would lower the concentration of both medications, rendering the phenytoin subtherapeutic. Whole bowel irrigation is another GI decontamination modality involving administration of large quantities (up to 2 L/h in adults) of a polyethylene glycol-balanced electrolyte solution via a nasogastric tube until the patient generates clear rectal effluent.
Which BEST describes the mechanism of action of alprostadil? A. Alprostadil blocks cGMP. B. Alprostadil blocks nitric oxide. C. Alprostadil increases PDE-5. D. Alprostadil increases cAMP.
C. Alprostadil increases PDE-5. Through an unknown mechanism, alprostadil (a synthetic prostaglandin) increases levels of cAMP, causing smooth muscle relaxation. Alprostadil does not affect cGMP, nitric oxide, or PDE-5.
A 5-year-old boy is brought in to the healthcare facility for being irritable and failure to thrive. He is drowsy, and his vital signs are normal. The doctor diagnoses him with lead toxicity when the blood lead level returns as 75 μg/dL. Which chelator regimen should be started? A. Dimercaprol B. Calcium disodium edetate C. Both dimercaprol and calcium disodium edetate D. Succimer
C. Both dimercaprol and calcium disodium edetate Dual parenteral therapy with dimercaprol and calcium disodium edetate is indicated if encephalopathy is present, or if the lead level is greater than 70 μg/dL in a child. Dimercaprol intramuscular therapy is initiated 4 hours prior to the intravenous administration of calcium disodium edetate when both medications are required. Succimer (dimercaptosuccinic acid, DMSA) is utilized when the lead level is greater than 45 μg/dL but less than 70 μg/dL, without encephalopathy.
A patient is worried about starting terazosin because he is very sensitive to side effects of medications. Which adverse effect would be most expected in this patient? A. Erectile dysfunction B. Gynecomastia C. Dizziness D. Vomiting
C. Dizziness Because of the α-blocking properties, terazosin commonly causes dizziness (this may be related to orthostatic hypotension). ED and gynecomastia would be unexpected with α-blockers. While most any drug may cause nausea and vomiting, terazosin is much more likely to cause dizziness.
A 45-year-old man presented to the emergency department 18 hours after ingesting an unknown product. On presentation, he is tachycardic, hypertensive, tachypneic, and complaining of flank pain. A metabolic panel is obtained, and the patient has a large anion gap acidosis, an increased creatinine, and hypocalcemia. Which substance was most likely ingested? A. Methanol B. Acetaminophen C. Ethylene glycol D. Iron
C. Ethylene glycol Ethylene glycol produces a metabolic acidosis from the toxic metabolites. The formation of calcium oxalate crystals, which can be found on urinalysis, leads to hypocalcemia and renal failure. The treatment regimen for this patient would include intravenous fomepizole, if some of the parent compound was still present, and hemodialysis. Methanol may produce a metabolic acidosis as well, but its target organ of toxicity is the eyes instead of the kidneys as with ethylene glycol. Acetaminophen toxicity may produce upper quadrant pain within the first 24 hours, but vital sign abnormalities are not usually found during this time frame. Iron toxicity may also produce a metabolic acidosis and tachycardia. However, hypocalcemia does not occur.
A child with severe asthma is treated with high-dose inhaled corticosteroids. Which adverse effect is of particular concern? A. Hypoglycemia B. Hirsutism C. Growth suppression D. Cushing syndrome
C. Growth suppression Corticosteroids may retard bone growth. Chronic use of the medication may lead to growth suppression, so linear growth should be monitored periodically. Hyperglycemia, not hypoglycemia, is a possible adverse effect. Hirsutism and Cushing syndrome are unlikely with the dose that the child receives via inhalation.
Which drug would be beneficial to reduce the frequency of painful crises in a patient with sickle cell disease? A. Epoetin alfa B. Filgrastim C. Hydroxyurea D. Sargramostim
C. Hydroxyurea Clinical evidence supports the use of hydroxyurea for reducing the frequency and severity of painful sickle cell crises during the course of sickle cell disease. Epoetin alfa helps increase hemoglobin and red blood cell production in anemias secondary to chronic kidney disease, HIV, bone marrow disorders, and other disorders. Filgrastim and sargramostim stimulate granulocyte production in the marrow to increase the neutrophil counts and reduce the duration of severe neutropenia.
MC is a patient with type 2 diabetes currently being treated with insulin detemir. The physician determines that MC needs additional insulin therapy for control of postprandial glucose. Which agent is most appropriate to add at this time? A. Insulin degludec B. NPH insulin C. Insulin lispro D. NPH/regular 70/30 insulin
C. Insulin lispro Insulin lispro is a rapid-acting insulin that has an onset of action within 15 to 30 minutes. Rapid-acting insulins are administered to mimic the prandial (mealtime) release of insulin and control postprandial glucose levels. Insulin degludec is a long-acting insulin used to control fasting glucose levels. NPH insulin is an intermediate-acting insulin also used for basal (fasting) control. NPH/regular 70/30 insulin is a mixture of NPH (intermediate-acting) and regular (short-acting) insulin. The patient is already on a long-acting insulin (detemir) for basal control, and another insulin for basal control is not warranted.
Which is the most appropriate initial oral agent for management of type 2 diabetes in patients with no other comorbid conditions? A. Glipizide B. Empagliflozin C. Metformin D. Pioglitazone
C. Metformin
A 38-year-old obese man with depression is considering a weight loss medication following several failed attempts with diet and exercise. Which medication could be considered in this individual? A. Liraglutide B. Bupropion + naltrexone C. Orlistat D. Lorcaserin
C. Orlistat Only orlistat has not been associated with suicidal ideation. All of the other drugs listed may cause suicidal ideation and would not be advisable for an individual with depression. Also, with a history of depression, the patient may be taking a medication that could increase serotonin levels. The addition of lorcaserin, a serotonin receptor agonist, could lead to serotonin syndrome further excluding it from the list of possible options.
A 64-year-old woman with a history of type 2 diabetes is diagnosed with heart failure. Which of the following medications would be a poor choice for controlling her diabetes? A. Exenatide B. Glyburide C. Pioglitazone D. Insulin
C. Pioglitazone The TZDs (pioglitazone and rosiglitazone) can cause fluid retention and lead to a worsening of heart failure. They should be used with caution and dose reduction, if at all, in patients with heart failure. Exenatide, glyburide, and insulin do not have precautions for use in heart failure patients.
Which is appropriate for treatment of congenital adrenal hyperplasia in a child? A. Adrenocorticotropic hormone (ACTH) B. Ketoconazole C. Prednisone D. Spironolactone
C. Prednisone Congenital adrenal hyperplasia is seen in infancy and childhood. Because cortisol synthesis is decreased, feedback inhibition of adrenocorticotropic hormone (ACTH) formation and release is also decreased, resulting in enhanced ACTH formation. This in turn leads to increased levels of adrenal androgens and/or mineralocorticoids. The treatment is to administer a glucocorticoid, such as hydrocortisone (in infants) or prednisone, which restores the feedback inhibition. The other options are inappropriate.
A 70-year-old woman is being started on ibandronate once monthly for the treatment of osteoporosis. Which is important to communicate to this patient? A. Take this medication with orange juice to increase absorption. B. Take this medication after meals to minimize stomach upset. C. Remain upright for at least 60 minutes after taking this medication. D. Adverse effects may include blood clots and leg cramps.
C. Remain upright for at least 60 minutes after taking this medication. Patients need to remain upright for 60 minutes after ibandronate (30 minutes for other bisphosphonates). Ibandronate should be given on an empty stomach with plain water only. Bisphosphonates, unlike raloxifene, are not associated with blood clots and leg cramps.
Use of which agent for osteoporosis should be limited to no more than 2 years? A. Calcitonin B. Denosumab C. Teriparatide D. Zoledronic acid
C. Teriparatide Use of the recombinant parathyroid hormone teriparatide should be limited to 2 years. Use beyond 2 years has not been studied, and is not recommended. The other agents do not have such limitations.
A 70-year-old man with BPH and an enlarged prostate continues to have urinary symptoms after an adequate trial of tamsulosin. Dutasteride is added to his therapy. In addition to tamsulosin, he is also taking hydrochlorothiazide, testosterone, and vardenafil as needed before intercourse. Which of his medications could have an interaction with dutasteride? A. Hydrochlorothiazide B. Tamsulosin C. Testosterone D. Vardenafil
C. Testosterone Because dutasteride prevents the conversion of testosterone to the more active form, DHT, these medications have an interaction. Essentially, dutasteride prevents testosterone from "working." Hydrochlorothiazide does not interfere with the metabolism of dutasteride, and dutasteride does not have any effect on the blood pressure-lowering effects of hydrochlorothiazide. Tamsulosin is appropriate in combination with a 5-α reductase inhibitor when the prostate is enlarged. Vardenafil is only prescribed as needed, and the two drugs do not have a pharmacokinetic interaction.
When selecting between the available PDE-5 inhibitors for treatment of ED, which is an important consideration? A. Tadalafil has the shortest half-life of the PDE-5 inhibitors. B. Sildenafil should be given with food to increase absorption. C. Vardenafil ODT doses are not equal to film-coated vardenafil doses. D. Avanafil should be taken at least 1 hour before intercourse.
C. Vardenafil ODT doses are not equal to film-coated vardenafil doses. The ODT dosage form of vardenafil provides a high systemic concentration of vardenafil, which is higher than that provided by the film-coated tablets. As such, the doses are not interchangeable. Tadalafil has the longest half-life of all PDE-5 inhibitors. Food may delay sildenafil absorption. Avanafil has the quickest onset of action and may be taken 30 minutes before intercourse.
A 70-year-old woman is being treated with raloxifene for osteoporosis. Which is a concern with this therapy? A. Breast cancer B. Endometrial cancer C. Venous thrombosis D. Hypercholesterolemia
C. Venous thrombosis Raloxifene can increase the risk of venous thromboembolism. Unlike estrogen and tamoxifen, raloxifene does not result in an increased incidence of endometrial cancer. Raloxifene lowers the risk of breast cancer in high-risk women, and it also lowers LDL cholesterol.
A 50-year-old migrant field worker comes to the emergency department and complains of diarrhea, tearing, nausea and vomiting, and sweating. The clinician notices that he looks generally anxious and has fine fasciculations in the muscles of the upper chest as well as pinpoint pupils. Which antidote should he receive first? A. N-acetylcysteine B. Sodium nitrite C. Deferoxamine D. Atropine
D. Atropine Atropine is appropriate for this patient, who has symptoms consistent with organophosphate (insecticide) poisoning. The mnemonic DUMBBELS (diarrhea, urination, miosis, bronchorrhea/bradycardia, emesis, lacrimation, salivation) can be used to remember the signs and symptoms of cholinergic toxicity. An anticholinergic antidote, atropine, controls these muscarinic symptoms, whereas the antidote pralidoxime treats the nicotinic symptoms like fasciculations (involuntary muscle quivering or twitching). N-acetylcysteine is the antidote for acetaminophen overdose and acts as a sulfhydryl donor. Sodium nitrite is one of the antidotes included in the old cyanide antidote kit (sodium nitrite and sodium thiosulfate). Deferoxamine is the chelating agent for iron.
A 41-year-old male jeweler presents to the emergency department after he was found unconscious on the floor of the shop by a coworker. The coworker states that the patient complained of being cold this morning around 8 AM (the central heat was broken, and the outdoor temperature was 34°F) and that since noon, he had been complaining of headache, drowsiness, confusion, and nausea. The clinician notices that he has cherry red skin. What is the most likely toxin causing his signs and symptoms? A. Ethylene glycol B. Cyanide C. Acetaminophen D. Carbon monoxide
D. Carbon monoxide Although watch makers and other professionals who use electroplating may be at higher risk for cyanide exposure because many plating baths use cyanide-containing ingredients (for example, potassium cyanide), this patient shows signs of carbon monoxide poisoning, such as cherry red skin, headache, confusion, nausea, and drowsiness leading to unconsciousness. The history also leads us to believe that this person may have been using a space heater to stay warm, which would be consistent with the description. A carboxyhemoglobin level should be obtained to confirm the exposure. Cyanide in low doses from such an occupational exposure can present with loss of consciousness, flushing, headache, and confusion. Chronically, workers may develop a rash after handling cyanide solutions. Also, an odor of bitter almonds may be present. An arterial blood gas and a venous blood gas could be obtained and compared to determine if cyanide is present (a lack of oxygen extraction would be present on the venous side). Ethylene glycol toxicity may cause alterations in mental status, but the history did not include anything suggesting a toxic alcohol ingestion. Acetaminophen toxicity is not consistent with this presentation.
Which drug is an H1-receptor antagonist that also has serotonin receptor antagonism on the appetite center, with the ability to stimulate appetite? A. Hydroxyzine B. Loratadine C. Diphenhydramine D. Cyproheptadine
D. Cyproheptadine Cyproheptadine has significant serotonin antagonism and is known to increase appetite.
KD is a 69-year-old male with type 2 diabetes and chronic pancreatitis. Which of the following diabetes medications is contraindicated in this patient? A. Glipizide B. Insulin lispro C. Metformin D. Dulaglutide
D. Dulaglutide Dulaglutide is a GLP-1 receptor agonist. Although infrequent, GLP-1 receptor agonists have been associated with pancreatitis and should be avoided in patients with chronic pancreatitis. Glipizide, insulin lispro, and metformin have not been associated with an increased risk of pancreatitis.
A 60-year-old woman presents to her primary care physician complaining of dizziness and fatigue. Following laboratory testing, the patient is diagnosed with iron deficiency anemia, and oral iron supplementation is needed. Which would be the most appropriate dosing regimen for the patient? A. Ferrous fumarate 325 mg once daily B. Ferrous gluconate 256 mg once daily C. Polysaccharide-iron complex 150 mg two to three times daily D. Ferrous sulfate 325 mg two to three times daily
D. Ferrous sulfate 325 mg two to three times daily The recommended dose of iron supplementation in iron deficiency anemia is typically about 150 mg of elemental iron in two to three divided doses. Extended-release formulations (such as polysaccharide- iron complex) may be dosed once daily. Ferrous sulfate 325 mg contains approximately 65 mg of elemental iron, ferrous fumarate 325 mg contains about 107 mg elemental iron, ferrous gluconate 256 mg contains approximately 30 mg elemental iron, and polysaccharide-iron complex 150 mg contains 150 mg elemental iron.
A fellow health care provider is concerned about prescribing orlistat to adolescent patients. Many of his adolescent patients are stopping the medication during the first month of treatment. Which side effect is the most likely reason the adolescents are stopping orlistat? A. Valvulopathy B. Suicidal ideation C. Drowsiness D. Flatulence
D. Flatulence Flatulence is a very common side effect with orlistat, along with several other GI disturbances. For adolescents, these side effects may be embarrassing and difficult to manage. It is important to counsel patients about these gastrointestinal side effects with orlistat and recommend a low-fat diet as well as cholestyramine to counteract the effects should they become bothersome. The other side effects listed have been seen with other obesity medications, but not with orlistat.
Corticosteroids are useful in the treatment of which of the following disorders? A. Cushing syndrome B. Diabetes C. Hypertension D. Inflammatory bowel disease
D. Inflammatory bowel disease Corticosteroids can increase blood pressure and glucose and are not used in the treatment of hypertension or diabetes. Cushing syndrome is an excess secretion of glucocorticoids. Dexamethasone may be used in the diagnosis of Cushing syndrome, but not its treatment. Corticosteroids reduce inflammation and can be used in the management of inflammatory bowel disease.
Which is an appropriate treatment for a nutritional anemia that presents as a hunger for ice and/or upward curvature of the fingernails? A. Vitamin B12 (cyanocobalamin) B. Folic acid C. Vitamin D D. Iron
D. Iron Vitamin B12, folic acid, and iron deficiencies all contribute to anemia, but iron deficiency is associated with pica (hunger for ice or dirt) and koilonychias (upward curvature of toenails/fingernails). Vitamin D deficiency does exist but does not cause anemia.
A 15-year-old girl presents to the emergency department with CNS depression. She is slightly bradycardic and slightly hypotensive. Upon further questioning, the mother admits that the patient was found with an open bottle of clonidine. Which antidote might be beneficial for this patient? A. Flumazenil B. Atropine C. Deferoxamine D. Naloxone
D. Naloxone Naloxone has a reversal rate of the CNS effects of approximately 50% in clonidine ingestions. Flumazenil reverses benzodiazepines and has no effect on clonidine. Atropine is an anticholinergic agent and would not improve the CNS depression. Deferoxamine is the chelator for iron.
A patient who is taking a PDE-5 inhibitor for ED is diagnosed with angina. Which antianginal medication would be of particular concern in this patient? A. Metoprolol B. Diltiazem C. Amlodipine D. Nitroglycerin
D. Nitroglycerin Nitrates, such as nitroglycerin, can cause life-threatening hypotension when taken with PDE- 5 inhibitors. While metoprolol, diltiazem, and amlodipine may all lower blood pressure, the interaction with PDE- 5 inhibitors is not relevant.
56-year-old woman is discovered to have megaloblastic anemia. Her past medical history is significant for alcoholism. Which would be the best treatment option for this patient? A. Oral vitamin B12 B. Parenteral vitamin B12 C. Oral folic acid D. Oral vitamin B12 with oral folic acid
D. Oral vitamin B12 with oral folic acid The patient has a history of alcoholism, which would suggest folic acid deficiency anemia. However, folic acid administration alone reverses the hematologic abnormality and masks possible vitamin B12 deficiency, which can then proceed to severe neurologic dysfunction and disease. The cause of megaloblastic anemia needs to be determined in order to be specific in terms of treatment. Therefore, megaloblastic anemia should not be treated with folic acid alone but, rather, with a combination of folic acid and vitamin B12.
A patient has been taking ferrous sulfate 325 mg twice daily for two weeks and is complaining of a bad taste after each dose. Which once-daily, oral iron formulations would improve tolerability and provide a similar total daily dose of elemental iron as twice-daily ferrous sulfate? A. Ferric ammonium citrate 25 mg B. Ferrous gluconate 100 mg C. Ferrous sulfate, anhydrous 142 mg D. Polysaccharide-iron complex 150 mg
D. Polysaccharide-iron complex 150 mg Once-daily polysaccharide-iron complex (150 mg = 150 mg elemental iron) is tasteless and odorless, with a similar total daily dose of elemental iron as ferrous sulfate 325 mg twice daily (130 mg elemental iron/day). Once-daily ferric ammonium citrate 25 mg (4.5 mg elemental iron) is less bioavailable than twice-daily ferrous sulfate. Ferrous sulfate and ferrous gluconate have similar tolerability, but once-daily ferrous gluconate has less elemental iron (12 mg elemental iron). Ferrous sulfate, anhydrous has better tolerability with the extended-release formulation, but has less elemental iron (43 mg elemental iron) administered once daily compared to twice daily ferrous sulfate.
A 52-year-old woman has a history of rheumatoid arthritis, diabetes, hypertension, and heartburn. Her daily medications include methotrexate, prednisone, metformin, hydrochlorothiazide, and lisinopril, and calcium carbonate as needed for heartburn symptoms. She is worried about the risk of osteoporosis as she approaches menopause. Which of her medications is most likely to contribute to the risk of developing osteoporosis? A. Calcium carbonate B. Hydrochlorothiazide C. Lisinopril D. Prednisone
D. Prednisone Glucocorticoids (for example, prednisone at a dose of ≥ 5 mg per day for greater than 3 months) are a significant risk factor for osteoporosis. The other medications have not been shown to increase the risk of osteoporosis, and calcium carbonate and hydrochlorothiazide (diuretic that increases calcium retention) may be beneficial for patients at risk of osteoporosis.
Which osteoporosis medication works by preferentially stimulating activity of osteoblasts? A. Denosumab B. Ibandronate C. Raloxifene D. Teriparatide
D. Teriparatide Teriparatide is a parathyroid hormone analog that has anabolic effects on bone through stimulation of osteoblast activity. The other medications work primarily by inhibiting osteoclast activity (inhibition of bone resorption).
Which agent is administered once yearly to treat osteoporosis? A. Abaloparatide B. Denosumab C. Risedronate D. Zoledronic acid
D. Zoledronic acid Zoledronic acid is administered intravenously once per year. Abaloparatide is a daily subcutaneous injection. Denosumab is administered every 6 months, and risedronate is administered daily, weekly, or monthly.
