1.4 pt 3

RT is a patient with a past medical history of hypertension, dyslipidemia, diabetes, gout, angina, Hepatitis B and HIV. Medications include lisinopril, pitavastatin, metformin, allopurinol and Atripla. RT has been on Atripla for 5 months. Viral load is undetectable and CD4 count is 500 cells/mm3. RT has been having vivid nightmares, hallucinations and suicidal ideation. The infectious disease provider consults the pharmacy department for specific sources of drug and health information for possible drug-induced causes of RTs symptoms. Based upon your drug information literature review, what is the medication cause of RT's symptoms?

• Pitavastatin

• Metformin

• Allopurinol

• Efavirenz

Answer explanation

Explanation: The correct answer is (D). Efavirenz is part of the HAART regimen Atripla. Vivid dreams and nightmares occur commonly with efavirenz therapy. Hallucinations, psychosis, depression and suicidal ideation have been reported. CNS effects tend to occur between 1 and 3 hours after each dose. They may stop within a few days or weeks, but can persist for months or years, and may be associated with high efavirenz serum concentrations. Answers (A), (B) and (C) are incorrect. Pitavastatin, metformin and allopurinol are not associated with vivid nightmares, hallucinations and suicidal ideation. 85% of users answered correctly

SS is a 55-year-old African American woman newly diagnosed with acute lymphoblastic leukemia (ALL). Her physician has recommended she receive part A hyper-CVAD regimen (cyclophosphamide, vincristine, doxorubicin, and dexamethasone). What baseline examination should she receive prior to initiating doxorubicin on day 4?

• CT scan to assess distant site involvement

• Lumbar puncture to determine CNS disease

• 24-Hour urine collection to determine renal function

• MUGA scan to determine left ventricular ejection fraction (LVEF)

Answer explanation

Explanation: The correct answer is (D). Prior to initiating doxorubicin, obtain an ECG and LVEF (via an ECHO or MUGA scan) to determine baseline cardiac function. The incidence of irreversible myocardial toxicity increases as the total cumulative (lifetime) dosages approach 450 to 500 mg/m2. Choice (A) is incorrect. CT scan to assess distant site involvement is not necessary. Choice (B) is incorrect. Although a lumbar puncture should be done in the initial work for ALL, it does not need to be accessed prior to initiating doxorubicin. Choice (C) is incorrect. Doxorubicin is hepatically metabolized; this is not necessary prior to initiating doxorubicin. 69% of users answered correctly

TR is a patient presenting for follow-up to his primary-care provider. His LDL-C is at goal; however, his HDL is 32 mg/dL. The provider would like to start treatment with niacin to increase his HDL-C. TR has a past medical history of hypertension, angina and diabetes. Medications include metoprolol, aspirin and metformin. Social and family history are negative. Basic metabolic panel and complete blood count labs are within normal limits. Select the potential contraindication (drug interaction) if niacin is added to TR's regimen.

• Metoprolol

• Aspirin

• Metformin

• There are no known interactions where it is recommended to avoid concomitant use

Answer explanation

Explanation: The correct answer is (D). There are no known interactions where it is recommended to avoid concomitant use. However, niacin may impact statin levels. Cases of rhabdomyolysis have occurred during concomitant use of niacin and a statin. With concurrent use or if symptoms suggestive of myopathy occur, monitor creatine phosphokinase (CPK). There are patients that will require therapy with niacin and a statin because monotherapy did not achieve the cholesterol goal. Answer (A) is incorrect. Metoprolol does not interact with niacin. Answer (B) is incorrect. Aspirin does not interact with niacin. Answer (C) is incorrect. Metformin does not interact with niacin. 50% of users answered correctly

RJ, an aspiring baseball player, states that he has been taking nutraceuticals and dietary supplements so as to avoid prescription drugs that are prohibited in organized baseball. He asks you what your opinion is about this. Of the following, your best response would be:

• This is a good plan for maintaining nutrition but avoiding prohibited substances.

• This is a good plan for avoiding prohibited substances but will not improve his performance.

• This is not a good plan. Many prohibited substances are components of dietary supplements and nutraceuticals.

• This is not a good plan. Many nutraceuticals and dietary supplements can be identified in the urine.

Answer explanation

Explanation: The correct answer is (C). Choices (A) and (B) are incorrect. This is an incorrect thought process. Many prohibited substances such as stimulants and anabolic steroids can be components of "dietary supplements" as this is an unregulated industry. Choice (D) is incorrect. One should never condone the practice of taking ergogenic aids. 64% of users answered correctly

LM is an 18-year-old woman who is leaving for her first semester of college next month. She would like to know what vaccinations she needs before going to college. Her vaccination record shows the following: DTaP at 2, 4, 6, and 15 months, and 5 years; Hib (ActHIB) at 2, 4, and 6 months; PCV at 2, 4, 6, and 15 months; IPV at 2, 4, and 6 months, and 5 years; MMR at 15 months and 5 years; Varicella at 15 months and 5 years; Hep A at 12 and 18 months; Hep B at 11 years, 11 years 2 months, and 11 years 6 months; Tdap at 15 years. LM does not have any medical conditions and is not allergic to any medications or vaccines. What vaccines should LM receive today?

• MCV and HPV

• Tdap, MCV, and HPV

• Tdap and MCV

• MPSV and HPV

Answer explanation

Explanation: The correct answer is (A). LM has not received the MCV or HPV vaccines. College freshman should receive the MCV vaccine if they have not previously been vaccinated. The HPV vaccine is recommended at age 11 to 12 years; however it can be given in adult women up to the age of 26 who have not previously been vaccinated. 49% of users answered correctly

DA has been diagnosed with chronic HCV genotype 1. His past medical and social histories include a history of IV drug abuse, alcoholism, a wife (married 30 years) with chronic HCV, and a blood transfusion in 2002. During your patient counseling session, DA asks you how he most likely acquired HCV. You correctly tell him

• Blood transfusion in 2002

• Sexually transmitted from his wife

• Intravenous drug abuse

• Alcoholism

Answer explanation

Explanation: The correct answer is (C). Contact with blood contaminated with the HCV virus is the most common route of transmission with intravenous drug use being the number one method of transmission. 80% 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. To manage hypokalemia and fluid overload, furosemide is increased to 40 mg twice daily and spironolactone is initiated at 25 mg once daily. UK is approaching euvolemia and the medical team anticipates another day of aggressive diuresis prior to achieving euvolemia.

• Initiate beta-blocker therapy immediately.

• Initiate beta-blocker therapy once euvolemia is achieved.

• Initiate non-dihydropyridine calcium-channel blocker immediately.

• Initiate positive inotrope daily.

Answer explanation

Explanation: The correct answer is (B). Given the mortality benefit associated with beta blockers in heart failure, this medication should be a part of the patient's medical regimen. However, beta blockers should only be initiated once euvolemia is obtained. In addition, it is important to only use one of three beta blockers shown to reduce mortality. Answer (A) is incorrect. Given the mortality benefit associated with beta blockers in heart failure, this medication should be a part of the patient's medical regimen. However, beta blockers should only be initiated once euvolemia is obtained. Answer (C) is incorrect. Calcium-channel blockers do not have a major role in the management of systolic heart failure. They would only be utilized after all other agents have been initiated and titrated to goal doses. Answer (D) is incorrect. The positive inotrope (digoxin) is indicated for patients who remain symptomatic despite standard HF therapy with both an ACE inhibitor and a beta blocker. A lower digoxin dose should be initiated in an elderly patient to achieve a serum digoxin concentration less than 1 ng/mL. 69% of users answered correctly.

A patient presents a new prescription to you for tamoxifen. Her doctor said he was prescribing it as adjuvant treatment for breast cancer following her surgery last month. You review her medication profile and document that she is also taking metoprolol, hydrochlorothiazide, and Prozac. Select the appropriate assessment of potential drug interactions for this patient.

• There are no clinically significant drug interactions to alter her medication regimen.

• You explain that a number of SSRIs including Prozac have been documented to decrease the effectiveness of tamoxifen by interfering with its metabolism to an active metabolite. You will call the patient's physician to consider alternative antidepressant options.

• You explain that hydrochlorothiazide has been documented to decrease the effectiveness of tamoxifen by interfering with its metabolism to an active metabolite. You will call the patient's physician to consider alternative diuretic.

• You explain that metoprolol has been documented to decrease the effectiveness of tamoxifen by interfering with its metabolism to an active metabolite. You will call the patient's physician to consider alternative beta-blocker.

Answer explanation

Explanation: The correct answer is (B). SSRIs that are strong inhibitors of the cytochrome P450 system have been documented to decrease the effectiveness of tamoxifen by decreasing the metabolism of tamoxifen to its potent metabolite endoxifen. It would be appropriate to notify the patient's physician and discuss alternative antidepressant options. Choice (A) is incorrect. There is a potentially clinically significant drug interaction between tamoxifen and Prozac (fluoxetine). Choice (C) is incorrect. Hydrochlorothiazide has not been shown to interfere with the activation of tamoxifen. Choice (D) is incorrect. Metoprolol has not been shown to interfere with the activation of tamoxifen. 73% of users answered correctly.

UT is a 33-year-old patient presenting with nervousness, irritability, and bouts of crying, dizziness, and lightheadedness. UT has a past medical history of allergic rhinitis, depression, and elbow tendinitis. Medications include loratadine, paroxetine, and meloxicam. UT's provider is completing a complete evaluation of her to identify the cause of the symptoms. UT has been feeling well (depression symptoms) and has tolerated medications well. She just returned from a 5-day cruise to the Bahamas. The symptoms started during the 3rd day of the cruise. She went on the cruise with six other people. The other people are fine and are not exhibiting any signs or symptoms.

• Drug interaction between loratadine and paroxetine, leading to supratherapeutic levels of paroxetine

• Drug interaction between meloxicam and paroxetine, leading to supratherapeutic levels of paroxetine

• Ineffectiveness of paroxetine

• Abrupt discontinuation of paroxetine

Answer explanation

Explanation: The Correct Answer is: D Abrupt discontinuation of SSRIs may lead to the following symptoms: nervousness, anxiety, irritability, bouts of crying or tearfulness, dizziness, lightheadedness, insomnia, confusion, trouble concentrating, nausea, and vomiting; effects are most common with paroxetine (D) because of its short half-life and least common with fluoxetine because of its long half-life. A clinically significant drug interaction between UT medications (A and B) is not expected to occur. SSRIs are excellent choices for treatment of depression (C). Antidepressant drugs produce a response in about 50-60% of adults with major depression and a remission in about 30%; with multiple courses and/or multiple drugs, 80% of patients will respond. UT has already responded to the medication; therefore, it is unlikely the medication is no longer effective. 50% of users answered correctly.

CC is a 64-year-old man with a history of chronic kidney disease and heart failure. His baseline SCr is 1.6 mg/dL, with a corresponding CrCl of approximately 50 mL/min. Today, he is brought by ambulance to the emergency room with dyspnea at rest and lower extremity edema all the way up to his thighs. His laboratory analysis shows a SCr of 3.2 mg/dL, and he does not recall urinating at all in the past 24 hours. Which of the following statements is true regarding the estimation of CC's kidney function today?

• Patient's CrCl is essentially zero, as his is not making urine.

• Patient's CrCl is approximately 25 mL/min.

• Patient's CrCl is still approximately 50 mL/min.

• Patient has AKI, and so we cannot estimate his CrCl.

• Wait to calculate patient's CrCl until after giving diuretics.

Answer explanation

Explanation: The correct answer is (A). Clearance is defined as the volume of solvent cleared of solute per unit time. If the patient is not urinating, his clearance is essentially zero. Answer (B) is incorrect. This answer seems appropriate given that the patient's SCr has doubled. Doubling of the SCr would cause the CrCl to decrease by one-half, from 50 mL/min to 25 mL/min. However, the SCr is the amount of creatinine in the serum at the time. If the patient stops urinating the GFR is zero, but the SCr will not reflect this change until more SCr is made and accumulates in the serum. The laboratory value lags behind the clinical situation. Answer (C) is incorrect. The patient's CrCl on presentation was approximately 50 mL/min. Now that he is not urinating and his SCr has started to increase, this value is no longer valid. This baseline value would be a good reference point and goal to achieve during his recovery from AKI. Answer (D) is incorrect. While it is true that our equations to quantify kidney function are not very accurate during AKI, we must use the information and our professional judgment to recommend appropriate drug therapy for this patient. Answer (E) is incorrect. While diuretics may be able to convert anuria/oliguria to nonoliguria, the patient may require other pharmacotherapy in the meantime. For instance, the patient may require inotropes for his heart failure before diuresis can be attempted. 58% of users answered correctly