1.4 pt 2

Which opioid is associated with both proconvulsant and pro-dysrhythmic activity in overdose?

• Meperidine

• Methadone

• Hydrocodone

• Heroin

• Propoxyphene

Answer explanation

Explanation: The correct answer is (E). Propoxyphene is associated with seizures and QRS interval prolongation due to sodium channel-blocking properties particularly in doses >10 mg/kg. Choice (A) is incorrect. Seizures are associated with accumulation of the meperidine metabolite normeperidine, but dysrhythmias are not a frequent adverse effect in overdose. Choice (B) is incorrect. Methadone is associated with pro-dysrhythmic properties even in therapeutic levels as it can prolong QT/QTc interval potentially precipitating torsade de pointes, but seizures are not a frequent adverse effect. Choice (C) is incorrect. Hydrocodone is not commonly associated with intrinsic proconvulsant or prodysrhythmic activity in overdose. Choice (D) is incorrect. Heroin is not commonly associated with intrinsic proconvulsant or pro-dysrhythmic activity in overdose. 19% of users answered correctly

UK is a 66-year-old woman with a history of ischemic cardiomyopathy who presents to urgent care with symptoms consistent with NYHA class IV HF. Past medical history includes hypertension, hyperlipidemia, diabetes mellitus, myocardial infarction and hypothyroidism. UK complains of progressive weight gain (~8 lb. increase since her previous visit 3 months ago), shortness of breath at rest, 1 pillow orthopnea and occasional paroxysmal nocturnal dyspnea (PND). Her physical examination is positive for 1+ pitting edema in her ankles. Vital signs include BP 112/73 mm Hg and HR 88 bpm. Laboratory results include potassium 3.7 mmol/L, BUN 35 mg/dL and serum creatinine 1.4 mg/dL. UK's current medications are levothyroxine 0.05 mg daily, furosemide 20 mg twice daily, lisinopril 20 mg daily, atorvastatin 40 mg daily, aspirin 81 mg daily, insulin glargine 46 units at bedtime and insulin aspart 6 units before meals. Which of the following is the best treatment option to manage UK's hypokalemia and fluid overload?

• Continue furosemide 20 mg twice daily.

• Increase furosemide to 80 mg twice daily.

• Initiate spironolactone 25 mg once daily.

• Increase furosemide to 40 mg twice daily and initiate spironolactone 25 mg once daily.

Answer explanation

Explanation: The correct answer is (D). While the addition of a potassium supplement could be considered, the addition of spironolactone along with the diuretic dose increase would provide additional mortality benefit as well as result in potassium retention. When added to standard HF therapy in patients with NYHA class III or IV HF symptoms, spironolactone has been shown to reduce mortality. Answer (A) is incorrect. UK is experiencing fluid overload based upon signs and symptoms and the current loop diuretic dose is inadequate. Answer (B) is incorrect. Increasing the furosemide dose alone is inappropriate as it will worsen UK's relatively low serum potassium. Answer (C) is incorrect. Spironolactone alone at the low doses used to reduce mortality in HF does not commonly result in clinically meaningful diuresis. 60% of users answered correctly

An 82-year-old patient who is taking 2 mg of terazosin for BPH comes into the pharmacy complaining of dizziness and generalized muscle weakness and persistent LUTS. What would you recommend to his physician?

• Add finasteride 5 mg daily to his regimen.

• Switch his terazosin to doxazosin 4 mg.

• Switch his terazosin to tamsulosin 0.4 mg daily.

• Lower the dose of his terazosin to 1 mg.

• Add saw palmetto twice daily.

Answer explanation

Explanation: The correct answer is (C). Tamsulosin may afford better tolerability for this patient and would be expected to provide symptom relief relatively quickly, often within 1 week of therapy, as it does not require titration. Choice (A) is incorrect. The patient is complaining of dizziness associated with his ?-blocker therapy. Adding finasteride will not ameliorate this and, if a 5ARI were added, it may take several months to show benefit in symptom reduction. Choice (B) is incorrect. Exchanging one long-acting, second-generation agent for another would not be ideal and this patient may continue to experience the same side effects. Choice (D) is incorrect. Lowering his dose of terazosin may improve tolerability; however, he is still experiencing symptoms of BPH. If his dose was lowered, he would likely continue to experience his symptoms. Choice (E) is incorrect. Based on lack of clinical outcomes, phytotherapy is not recommended by the American Urological Association for treatment of BPH. 79% of users answered correctly

ER is a newly diagnosed HIV patient. He presents with a HAART prescription consisting of emtricitabine, tenofovir and efavirenz. His provider told him that he has to take an over-the-counter supplement with the tenofovir. ER does not recall the name of the supplement and would like for you to recommend the name and store brand to save money. What supplement should a patient receiving tenofovir take?

• St John's wort

• Glucosamine

• Kava Kava

• Calcium and vitamin D

Answer explanation

Explanation: The correct answer is (D). Tenofovir can decrease bone density and cause osteomalacia, even in adolescents; patients taking tenofovir should be monitored for bone loss and should take calcium and vitamin D supplements. Answer (A) is incorrect. St. John's wort is most commonly used for depression and conditions that go along with depression such as anxiety, tiredness, loss of appetite and trouble sleeping. There are numerous drug interactions with St John's wort (including HIV drug interactions); therefore, extreme caution should be employed before taking St John's wort with HAART. Answer (B) is incorrect. Glucosamine is used for osteoarthritis. The patient's medications are not known to cause osteoarthritis. Answer (C) is incorrect. Kava is used to calm anxiety, stress, restlessness, and treat sleep problems (insomnia). Several cases of liver damage and some deaths have been traced to kava. As a result, kava has been banned from the market in Switzerland, Germany and Canada, and several other countries are considering similar action. The patient's medications are not causing anxiety or related symptoms. 90% of users answered correctly.

The administration of which of the following agents would be indicated in the setting of tricyclic antidepressant overdose associated with seizures or QRS interval >115 ms?

• Sodium bicarbonate

• Flumazenil

• Physostigmine

• Procainamide

• Both a and c

Answer explanation

Explanation: The correct answer is (A). Serum alkalinization with a goal of establishing a systemic pH between 7.45 and 7.55 is indicated in the setting of tricyclic antidepressant (TCAD) toxicity with evidence of widening QRS interval and/or seizure activity. Mechanisms by which sodium bicarbonate administration may provide benefit are as follows: 1. Increased systemic sodium levels may overcome blocked sodium channels and/or increased systemic pH results in increased nonionized TCAD, decreasing ligand receptor interaction between ionized TCAD and the sodium channel. 2. Wide complex dysrhythmia and hypotension can be reversed by administration of sodium bicarbonate in suicient dose. Seizures will not respond to this sodium bicarbonate therapy, and should be treated with standard measures, but if seizures occur in the setting of TCAD overdose sodium bicarbonate therapy is warranted because they indicate significant toxicity. 3. Other potential therapies could include administration of hypertonic 3% saline to increase systemic sodium levels or hyperventilation to increase systemic pH; however, these have not been found to provide the same level benefit as treatment with sodium bicarbonate. Choice (B) is incorrect. Administration of flumazenil may precipitate generalized seizures in the setting of TCAD overdose and is contraindicated. Choice (C) is incorrect. Physostigmine is a cholinesterase inhibitor and can reverse some anticholinergic symptoms of TCAD poisoning. Historically, it has been utilized to treat TCAD-induced antimuscarinic symptoms. However, use has been abandoned as physostigmine is associated with increased incidence of dysrhythmia, bradycardia, asystole, and seizures. Choice (D) is incorrect. Procainamide is a class IA antidysrhythmic agent and has a mechanism of action that blocks cardiac fast sodium channels. These are the same channels antagonized in TCAD poisoning leading to QRS prolongation, and utilization may worsen cardiac toxicity. As such, administration of agents with sodium channel-blocking properties (class IA and IC anti-dysrhythmics) is an absolute contraindication in TCAD poisoning. Choice (E) is incorrect. 36% of users answered correct

Select the item that should be part of an evaluation of erectile dysfunction.

• A sexual history from the patient and partner

• A medical history

• A physical examination

• A psychosocial assessment

• All of the above

Answer explanation

Explanation: The correct and best answer is (E). All of the above items are part of a comprehensive workup for ED. Choice (A) is correct. An important part of the evaluation, the sexual history should identify the duration, frequency, quality, and duration of erections and consider the nature of the sexual relationship. Choice (B) is correct). The history should particularly focus on identifying potentially modifiable risk factors such as hypertension, diabetes, and dyslipidemia. Choice (C) is correct. The physical examination is necessary to identify hypogonadism or neurological conditions that could result in ED. Choice (D) is correct. Psychosocial issues can be the cause or may complicate the management of ED. 93% of users answered correctly

RT is a 35-year-old pharmaceutical representative. His territory is the Southeastern United States. He has a past medical history of partial epilepsy and allergic rhinitis. Medications include carbamazepine and cetirizine. RT travels a lot for his job (air and land travel). His seizures have been well controlled until recently. He cannot identify any risk factors for the increase in seizures and states that he has been 100% adherent with medicine. The past few weeks has been unseasonal as it has been 100 degrees F and very humid. His provider has evaluated RT for treatable causes of his increase in seizures. All labs and evaluation have been within normal limits. RT's carbamazepine level was 8.1 mcg/mL. The provider orders a pharmacotherapy consult for evaluation.

• RT has partial epilepsy and carbamazepine is not effective for partial seizures.

• There is a drug interaction between cetirizine and carbamazepine leading to subtherapeutic levels of carbamazepine.

• RT has a supratherapeutic carbamazepine level. Supratherapeutic AED levels may cause a seizure.

• Storing carbamazepine tablets in humid conditions can cause concretion of the tablets, resulting in poor bioavailability and therapeutic failure.

Answer explanation

Explanation: The correct answer is (D). Storing carbamazepine tablets in humid conditions can cause concretion of the tablets, resulting in poor bioavailability and therapeutic failure. Answer (A) is incorrect. Carbamazepine is effective for partial epilepsy. Answer (B) is incorrect. There is not a known drug interaction between carbamazepine and cetirizine that would lead to low carbamazepine levels. Additionally, the carbamazepine level is within the expected range. Answer (C) is incorrect. Supratherapeutic levels of AEDs may cause a seizure; however, the carbamazepine therapeutic level is 6-10 mcg/ml. 77% of users answered correctly

A 57-year-old man with recently diagnosed limited-stage small-cell lung cancer presents to clinic for treatment. Which of the following would be a rational therapy for this gentleman?

• Surgery followed by four cycles of cisplatin + etoposide

• Six cycles of cisplatin + pemetrexed

• Concurrent radiation therapy and cisplatin + etoposide

• Six cycles of carboplatin + paclitaxel

Answer explanation

Explanation: The correct answer is (C). For limited-stage SCLC to maximize survival, one should utilize concurrent radiation therapy and cisplatin + etoposide. Answer (A) is incorrect. Surgery is not a primary treatment option in SCLC. Answer (B) is incorrect. Cisplatin + pemetrexed is a regimen utilized in NSCLC, not in SCLC. Answer (D) is incorrect. Carboplatin + paclitaxel is a regimen utilized in NSCLC, not in SCLC. 42% of users answered correctly

HM is a 63-year-old critically ill, morbidly obese man (BMI 42 kg/m2) with severe acute pancreatitis in whom enteral nutrition has failed. On day 7 of hospitalization, PN is initiated. HM weighs 150 kg; ideal body weight is 82 kg. The PN regimen consists of 1800 kcal/d and 205 g protein per day. What is the most appropriate assessment of this PN regimen?

• Appropriate calories and protein

• Appropriate calories; too few protein

• Appropriate protein; too few calories

• Too few calories; too much protein

Answer explanation

Explanation: The correct answer is (A). According to the SCCM/ASPEN nutrition support guidelines for the critically ill, when BMI is >30 kg/m2, goal calories are 11 to 14 kcal/kg actual body weight per day or 22 to 25 kcal/kg ideal body weight per day. HM's regimen provides 12 kcal/kg actual body weight per day and 22 kcal/kg ideal body weight per day, both of which follow the recommendations. Protein should be provided at ? 2 g/kg ideal body weight per day for BMI 30 to 40 kg/m2 and at ? 2.5 g/kg ideal body weight per day for BMI >40 kg/m2. HM's regimen provides 2.5 g/kg ideal body weight per day. 44% of users answered correctly

JR is a long-distance cyclist that recently suffered a transient ischemic attack (TIA). He reported to the emergency department (ED) where he related no prescription drug use. His vitals in the ED were: BP 164/90 mm Hg, RR 20 breaths/min, HR 52 beats/min and regular, temperature 99°F. His BUN was 18 mg/dL and his Scr was 1.1 mg/dL. Of note, his hemoglobin was 19 g/dL and his hematocrit was 57.2%. He was assessed as being well hydrated but not fluid overloaded. He was no longer suffering from any neurologic deficit. He did not lose consciousness. A urine test using isoelectric focusing would likely be positive for which exogenously administered substance?

• Testosterone

• Recombinant human growth hormone

• Recombinant erythropoietin

• Recombinant human chorionic gonadotropin

Answer explanation

Explanation: The correct answer is (C). Stimulating erythropoiesis increases RBC mass, which if le unabated, can increase to the point of worsened HTN, increased fluid volume, and thromboembolic events including stroke and TIA. Isoelectric focusing takes advantage of the extra sugar molecules on the recombinant product and this glycosylation allows for separation of exogenous and endogenous erythropoietin in a pH-gradient electrical field, thus, differing isoform patterns. Choice (A) is partially correct. Testosterone can stimulate endogenous erythropoiesis, but has not been associated with thromboembolic events and stroke. Advanced technological testing for testosterone involves carbon isotope ratio testing or isotope ratio mass spectrometry. Choice (B) is incorrect. Because recombinant HGH does not contain glycosylation process, isoelectric focusing method developed for recombinant erythropoietin cannot be directly applied to HGH. No definitive test exists currently to detect HGH. Additionally, it has not been associated with embolic events. Choice (D) is incorrect. Isoelectric focusing is not the method used to test for human chorionic gonadotropin nor is it associated with stroke or TIA. 58% of users answered correctly.