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WorksheetsExam 3 Pharmacotherapy
Total questions: 84
Worksheet time: 3hrs 48mins
When should you recommend an alternate contraceptive than a COC in a patient with migraines?
Migraine with aura
Migraine without aura
Both
Neither
Select all of the following that could be acceptable interventions for migraine patients:
Yoga or regular physical activity
Use of fexofenadine or loratadine instead of pseudoephedrine for allergies
Switching B-A-C to a single-agent NSAID or Tylenol
Switching nifedipine po to diltiazem or verapamil if possible
When are opiates indicated for migraine management?
Severe pain not requiring emergency admission
Severe pain requiring emergency admission and IV administration
Low dose maintenance for prevention
Never
Which of the following could be considered a rescue medication option for migraines in the following cases?
Supplemental oxygen
Intranasal dihydroergotamine (DHE) in a hyperglycemic diabetic patient admitted for pneumonia
Naratriptan dosed 2 hours ago without symptom resolve
Sumatriptan for a patient with a 10/10 migraine related to cocaine use and beta blocker noncompliance
Which of the following is an unsuitable or incorrect case?
Onset of migraine treated with eletriptan in a patient receiving ketoconazole IV for Mucormycosis
Patient complains of migraine unresolved by a single dose of sumatriptan 2 hrs ago. NP recommends re-dosing sumatriptan
Zolmitriptan co-treated with prochlorperazine
Lasmiditan given to a tachycardic bacteremia patient
A patient is receiving a new prescription for Naratriptan. Which of the following are acceptable counseling points?
You can repeat the dose in 4 hours if not resolved.
You may experience nausea and dizziness. If it becomes a problem, we can ask your PCP for some chlorperazine.
Try not to take illicit substances with this medication.
Rizatriptan and propranolol can be initiated at normal doses
Which of the following is an incorrect statement?
Frovatriptan is the longest half life -triptan
-triptans utilize serotonin 1B and 1D agonism for antimigraine effects
-triptans are generally safe to use in pregnancy
Asymptomatic blood pressure of 142/82 is not a reason to avoid -triptans
Which of the following patients are a candidate for intranasal sumatriptan or DHE?
Patient complaining of a 9/10 migraine not resolved by at-home Tylenol #3
Patient admitted 3 days ago for cerebral infarction currently doing well (exc. migraine of course)
Patient closely monitored for unstable angina and suspected IHD
Patient presenting with bp 183/99 following antihypertensive noncompliance
In which of the following patients would insurance possibly cover a -gepant or lasmiditan?
Patient is pregnant, therefore C/I both -triptans and ergot alkaloids
Patient has tried SQ sumatriptan for several months without resolve
Patient is taking rizatriptan and propranolol concomittantly, warranting a lower initial dose
Patient requires low dose chlorperazine to handle Zolmitriptan nausea
A patron enters your pharmacy curious about their new lasamiditan prescription. Which of the following could be possible counseling points?
Make sure you have a replacement driver while taking this medication.
You may experience a serious condition called Serotonin Syndrome that may involve agitation and restlessness.
You'll be able to repeat a dose after 2 hours if your symptoms have not resolved.
You may do well to reduce your alcohol intake and OTC melatonin until you know how this medication affects you.
Which of the migraine treatments are Schedule V?
Ubrogepant (Ubrelvy)
Lasmiditan
Rimegepant (Nurtec)
Dihydroergotamine
Which of the following are true regarding lasmiditan?
No need to renally adjust or avoid.
Avoid in severe hepatic dysfunction
Avoid caffeine use and CNS stimulants
May have interactions with CNS depressants and P-GP substrates like oxycodone and doxylamine
Which of the following medications are repeatable for migraine treatment?
Naratriptan after 2 hours
Rimegepant po after 3 hours
Lasmiditan po
Ubrogepant SQ
Which of the -gepants could potentially be used at adjusted doses for severe renal or hepatic failure?
Ubrogepant
Rimegepant
A patient is precribed Rimegepant. Which of the following are 3A4 inhibitors that could pose a problem?
Clarithromycin and Ketoconazole
Various antivirals
Amiodarone and Verapamil
Cimetidine
A patient is experiencing 1-8 migraines per month and has failed both a triptan and dihydroergotamine. What do you recommend?
Retry DHE
Botox 31 inj every month
Ubrogepant
Valium
You have a patient experiencing 9-18 migraines per month and has severe HTN preventing them from using -triptans and DHE. What do you recommend?
IV DHE and triple their antihypertensive doses
Ask if they're lying
Tylenol and Aspirin
Rimegepant
What is an option for non-oral route migraines?
Ketorolac IM or IN
Give them oral sumatriptan anyway
Apply fentanyl patch directly to the shaved scalp
Transdermal Voltaren gel
How long should a valid trial of an antimigraine medication last?
Therapeutic dose for 8 weeks
6-12 months after a partial response
3-6 months after a CGRP targeting MAb
Which of the following are compelling indications for beta blocker migraine treatment?
Hypertension
Anxiety
Chronic insomnia
COPD
Topiramate has which of the following considerations for migraine therapy:
Tapered up and then down at d/c
Alright for pregnancy
C/I sumatriptan
Resolves kidney stones
A patient with migraines, depression, and peripheral neuropathy is looking for a new migraine med. What is a reasonable choice?
Botox
Amitriptyline or Venlafaxine
Propranolol or Inderal
Erenumab
A woman comes in complaining of head pain after using a butalbital product for the past 5 days. What do you diagnose her with?
Serotonin Syndrome
Medication Overuse Tension HA
Stroke
Cluster headache
What is the preferred prevention medication for frequent tension headaches?
Sumatriptan
Gabapentin
Local baclofen injections
Amitriptyline
A young man enters your ED complaining of intense debilitating pain behind an eye. What do you diagnose and treat them with?
Cluster headache - Oxygen
Tension headache - immediate botox
Cluster headache - STAT lithium
Migraine - valium
Your ED is on oxygen shortage and you have a patient with cluster headache. How do you treat them?
Galcanezumab
Erenumab
Sodium phosphate IV
SQ Sumatriptan
What best describes chronic pain?
Likely to be IV treatment
Start with high dose opiates
Possible causes depression and anxiety
Ketorolac can be used for a week max
What's an acceptable first line for acute pain?
Low dose methadone
Trolamine salicylate lotion applied to stitches
Ketorolac co-administered with pantoprazole
Tylenol for inflammation causing pain
In which of the following situations would Celecoxib be preferable over Ketorolac?
Patient is at slightly increased risk of GI bleed
Recently post-operative patients
Renal failure requiring CRRT
Chart shows recent digoxin toxicity
Onset of po opioids?
5-15 min
~30 min
8-24 hrs
Couple of days
Onset of parenteral opioids?
5-15 min
~30 min
2-4 hrs
5-15 hrs
Major considerations of morphine do not include:
Hepatic metabolism alters dosing in some patients
Expensive
Dose stacking and histamine release could complicate some patients
Toxic CNS metabolite accumulates in renal dysfunction
Which of the following situations could be a poor reason to choose codeine?
Primarily presenting with pain
Hepatic dysfunction disallows metabolism to morphine
GI bleed exacerbation
Sedated patient needing dexmedetomidine
Which opioid analgesic is preferred but not DOC in renal or hepatic dysfunction?
Oxymorphone
Fentanyl
Oxycodone
Codeine
What opioid analgesic should be first line for those with renal and/or hepatic dysfunction but has never received an opioid before?
Oxycodone
Fentanyl
Morphine
Codeine
What is the multidimensional pain assessment?
Wong-Baker Scale
Brief Pain Inventory
Codeine
Visual analogue
What may be a good idea for escalating analgesic therapy?
Adding methadone to Tylenol for unresolved moderate pain
Prescribing hydrocodone-APAP for a patient experiencing debilitating back pain
Prescribing fentanyl patches to a patient taking 60 MME once a month
Giving methadone to a patient with a new fracture currently on oxycodone
What is the incorrectly matched consideration for acute pain:
Methadone - delayed respiratory depression
Methadone - increased duration as therapy length increases
Tramadol - increased seizure threshold
Codeine - poor pain effect
What opioid agonist-antagonist can have complicated dosage forms depending on indication?
Butorphanol
Buprenorphine
Morphine
Enoxaparin
When may Tylenol be preferred over an NSAID?
AKI or dehydration
Inflammation dominant pain
Opioid tolerant
Previous use of buprenorphine
In which of the following patients may Codeine be the best option?
Patient experiencing nerve irritation causing frequent coughing/hiccuping and 6/10 pain
Patient in step-down unit recovering from previous open heart surgery
Trauma consult following motor vehicle collision
Migraine patient experiencing 9-18 migraines per month
Select all of the following that could be good options for anesthesia:
Remifentanil
Fentanyl
Alfentanil
Meperidine
What is the reason for avoiding meperidine in the elderly, renal dysfunction, and long term therapy?
Accumulation of a CNS toxin
Blood dyscrasias
Severe peripheral neuropathy
Exacerbation of rigors
What opioid is good for abuse management but causes QTc prolongation?
Fentanyl
Buprenorphine
Methadone
Alfentanil
Definition of opioid naive?
>60 MME/d up to a week
<60 MME/d up to a week
Satifactory pain relief on one opioid
Taking a hydrocodone combo product or codeine
A patient returns to your pain clinic after mild improvement but desires more pain relief according to the plan discussed with another PCP. What do you recommend?
Increasing dose by 1.5-2x
Repeat dose when appropriate
Use same dose prn
A patient returns to your pain clinic after mild improvement but desires more pain relief according to the plan discussed with another PCP. What do you recommend?
Increasing dose by 1.5-2x
Repeat dose when appropriate
Use same dose prn
A patient returns to your pain clinic after an appropriate opioid trial not giving relief. What do you recommend?
Increasing dose by 1.5-2x
Repeat dose when appropriate
Use same dose prn
(Select multiple) What is cross tolerance and when should it be considered for switching opioids?
Severe pain medications targeting different opioid receptors
Dose reduction 10-15%
The concern of a patient being underdosed on a new opioid
Dose reduction 25-50%
95% of opioid users experience constipation. Which of the following options would be best for a new patient?
PEG or docusate
Meperidine
Senna or bisacodyl
MgOH or sorbitol
In which of the following situations would morphine be preferred?
Advanced COPD air hunger
Renal dysfunction
Child-Pugh C
Artificial ventilation
When calculating a new around the clock severe pain regimen, how much of the total daily dose should be used for low dose IR prn?
10-15%
25-50%
150-200%
None, you should use ER
In opioid PCAs, how much of the basal rate is used for demand doses?
15-20%
25-30%
50%
200%
What is the major consideration for gabapentinoid-opioid synergy?
Increased seizure risk
Reduced need for renal adjustment
Increased CNS/respiratory depression
Decreased reduction of pain score
Best candidate for topical capsaicin?
Severe but conscious total body burn patient admitted to the ICU
Elderly outpatient recovering from a non-open fracture
Young teen developing rapid MS with an ocular focus
Mid-20s male presenting to the ED with a cluster headache and remarkably high substance P
Which product requires a drug-free period?
Fentanyl patches
Trolamine salicylate cream
Capsaicin cream
Lidocaine patches
What pain adjunct is noted as being great for cancer and bone pain?
Corticosteroids
Gabapentin
Lidocaine patches
Topiramate
How frequently should a chronic pain plan be reviewed?
Initially within 1-4 wks
At least every 3 months
Every other year
Only when the patient calls you
To which of the following should naloxone be offered?
>50 MME/d
Concurrent benzodiazepine
Patients being given fentanyl for analgesia
Previous overdose or substance use disorder
How long could a patient be given acute care opioids (disregarding exceptions) in the state of SC?
7 days
31 days
3 months
How long the insurance approves
Which of the following are possible indications for opioid urine drug monitoring?
Expected patient pharmacokinetic issues
Tracking adherence
Reliable detection of synthetic opioids
Tracking prn opioid dosing over the past 15 days
What is an early sign of respiratory depression in methadone users?
Increased seizure frequency
Increased use of prn opioids
Sedation
Agitation and restlessness
Which of the following are xanthine oxidase inhibitors?
Probenecid
febuxostat
Pegloticase
Allopurinol
Which of the following are uricosurics?
Allopurinol
Febuxostat
Pegloticase
Probenecid
When should an acute gout flare patient receive NSAIDs and steroids for attack management?
If the NSAID is topical
If using intra-articular steroids
If the attack is severe
Never
A patient experiencing a moderate gout attack enters your ED. What do you recommend?
Colchicine 1.2 mg now and 0.6 mg in an hour
Naproxen tablets
Anakinra
Febuxostat
You get a call for an ID patient with a severe gout attack. The patient is on fluconazole and has potentially severe kidney disease. What do you recommend?
Colchicine 1.2 mg now and 0.6 mg in an hour
Voltaren gel
Indomethacin + methylprednisolone dual therapy
Indomethacin IV
(Multiple right answers) You're having a diabetes foot exam with an active infection. The patient begins to have a gout attack. What do you recommend?
Colchicine 1.2 mg now and 0.6 mg in an hour
Indomethacin tablets
Naproxen tablets
Dexamethasone
Which of the following are true regarding gout prophylaxis?
Colchicine 0.6 mg with/without low dose NSAIDs
Lasts for 3 months minimum
Colchicine initiated 12 hours after previous dose during acute attack
Could include allopurinol + pegloticase
Following up with a previous gout patient after their third annual attack and a uric acid of 6.1. They're on colchicine+NSAID prophylaxis and have no comorbidities. What do you recommend?
Nothing, they're on prophylaxis
Add on methylprednisolone low dose
Allopurinol 100 mg qd
Pegloticase
A consult with cardiology is asking for a recommendation on a heart valve replacement patient needing ULT. They're currently on warfarin. What do you recommend?
Colchicine 1.2 mg now and 0.6 mg in an hour
Allopurinol but monitor INR closely
Probenecid initiated at half dose and titrated up
They are not a candidate for ULT due to heart valve replacement
Which of the following is a risk indicator for hypersensitivity to allopurinol?
HLA-B*58:01
G6PD
Concomitant warfarin
CYP2D6 poor metabolizer
A physician asks you to review a medication choice. Previous MI patient needing ULT fails allopurinol due to hypersensitivity. The physician chose febuxostat. What do you say?
This patient is a good candidate for febuxostat
Febuxostat can't be initiated due to cardiovascular death risk
Febuxostat requires a dose decrease of half for MI patients
Get out of this hospital
(Multiple answers) When would Probenecid be a good option for ULT?
Renal-competent patient not fully controlled on allopurinol or febuxosstat
Frequently dehydrated patient
A patient able to manage pain on non-salicylate NSAIDS
A patient with hemolytic anemia and G6PD deficiency
A patient in your clinic has failed both XO and both uricosuric ULTs. Which of the following will likely be prescribed?
Allopurinol
Pegloticase
Sulfinpyrazone
Colchicine
Which of the following can be used while on pegloticase?
None
Allopurinol
Febuxostat
Probenecid
Sulfinpyrazone
(Multiple answers) Which of the following are considerations for pegloticase?
Black Box for severe infusion reactions
Black Box for severe hypersensitivity
Black Box for G6PD deficiency
Gout flares common early in treatment
A patient comes to you asking about treatment for their remarkably mild fibromyalgia. What do you say?
Milnacipran
Aerobic exercise
Pregabalin
Tramadol
What's the mainstay and general 1st line of fibromyalgia treatment?
Amitriptyline
Sulindac
Milnacipran
Cyclobenzaprine
A friend of yours asks for advice regarding their new Rx of amitriptyline for fibromyalgia. What do you tell them?
You'll be started at a low dose taken at bed time
It may take 2 weeks of taking the med for improvement
Stand up slowly (orthostatic hypotension)
You may have some swelling in your feet
A patient is not experiencing fibromyalgia relief after a valid trial of amitriptyline. What do you recommend?
Duloxetine 30 mg
Milnacipran 200 mg
Gabapentin 100 mg
Pregabalin 75 mg BID
Your client has failed both amitriptyline and duloxetine due to excessive orthostatic hypotension and bleed risk. What do you recommend?
Milnacipran
Pregabalin 75 mg BID
Gabepentin 300 mg BID
Tramadol 5 mg QOD
Which of the following drugs would be a cause of gout?
Aspirin
Losartan
Diuretics
Fenofibrate
In which type of migraine is it acceptable to continue COC?
Migraine with aura
Migraine without aura
Both
Neither
