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24 Cards in this Set
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1. BG is shopping in your pharmacy. She has a cold and wants to buy some cough and cold products. She knows that some OTC medications are not recommended in people with high blood pressure, but needs your help with which one to avoid. Use of which of the following agents that she has chosen would be most likely to raise her blood pressure?
a. cetirizine (Zyrtec) b. diphenhydramine (Benadryl) c. dextromethorphan (Robitussin) d. pseudoephedrine (Sudafed) |
d. pseudoephedrine (Sudafed)
INCORRECT – A, B, and C are all cough and cold products that are not associated with causing an elevation in BP. CORRECT – D – decongestants are sympathomimetics and can cause BP elevations, including significant elevations in some people. See objectives 4, 7, & 9 |
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Which of the following would be the MOST appropriate time to obtain a blood sample for the purposes of monitoring the serum digoxin concentration?
a. Immediately after the third dose of a new or revised digoxin dosing regimen b. Approximately 1-2 hours after the dose in a patient at steady state c. At the time of the expected peak concentration in a patient at steady state d. Immediately prior to the next dose in a patient at steady state |
d. Immediately prior to the next dose in a patient at steady state
Answer D. In a patient at steady state, a blood sample for measurement of the serum digoxin concentration should be obtained at least 6-8 hours after the dose and preferably, 12-24 hours after the dose (slide 12). See objective #1 |
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3. KK is a 45 year old man who presents to his local emergency room with sub-sternal chest pain and is subsequently found to have an STEMI. Therapy with tenecteplase (TNKase) is planned. Which of the following would be an ABSOLUTE contraindication to use of this agent in this patient?
a. blood pressure >180/110 mmHg b. history of a gastrointestinal bleed 3 weeks ago c. history of a cerebral hemorrhage 2 years ago d. history of heparin-induced thrombocytopenia |
Selection “c” is correct; please see objectives 2 and 5. Any cerebral hemorrhage represents an absolute contraindication to any thrombolytic agent regardless of how long ago it occurred. The remainder of the selections are relative contraindications. Please see slide #11 of ACS-II presentation.
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4. Which of the following strategies would be the most INCORRECT in a patient who reports gaining 7 pounds in the last 4 days despite taking their furosemide and other heart failure medications as directed?
a. Add metolazone to furosemide until baseline weight is achieved b. Increase the patient’s dose of furosemide until baseline weight is achieved c. Increase the patient’s dose of bisoprolol until baseline weight is achieved d. Switch the patient from furosemide to torsemide until baseline weight is achieved |
c. Increase the patient’s dose of bisoprolol until baseline weight is achieved
The addition of metolazone will enhance natriuresis and diuresis (“sequential nephron blockade”) and would be an acceptable intervention. Increasing the patient’s furosemide dose or switching furosemide to torsemide (a more bioavailable loop diuretic) would be expected to facilitate weight loss. Either of these strategies could be implemented. Increasing the patient’s beta blocker could be detrimental since the patient is currently not stable as evidenced by the recent 7 pound weight gain. See objectives 2, 4 |
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5. Which of the following statins is NOT predominately eliminated by CYP3A4-mediated metabolism?
a. Atorvastatin b. Fluvastatin c. Lovastatin d. Simvastatin e. All of these statins are extensively metabolized by CYP3A4 |
b. Fluvastatin
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6. LK is a 46 year old African American male who was recently diagnosed with hypertension. His average BP is 152/102 mmHg. He has no other significant past medical history. Based on the JNC 7 guidelines, and principles of hypertension pathophysiology, which of the following would be the most appropriate initial therapy for LK?
a. Lifestyle modifications for 6 months b. HCTZ c. HCTZ + verapamil d. HCTZ + lisinopril |
d. HCTZ + lisinopril
a. INCORRECT - While it is recommended that lifestyle modifications be implemented in all, it is not recommended to do this only, particularly in a patient with Stage 2 HTN, as this patient. b. INCORRECT – this patient has Stage 2 HTN and it is recommended to initiate therapy with 2 drugs, since 1 drug is unlikely to lead to adequate BP reduction c. INCORRECT – The best combinations (and the ones marketed commercially) all include drugs that address the “two sides” of the pathophysiology. This combination, a thiazide and CCB would only address one side. d. CORRECT – 2 drug therapy is recommended for Stage 2 HTN; a combination of a thiazide and ACE inhibitor is highly effective, independent of race. In combination therapy it is best to pair (and the commercially available combination products always pair) a thiazide or CCB with a BB, ACEI or ARB. You don’t see thiazide + CCB combos nor do you see BB + ACEI or ARB combos, because these are not effective combinations. See objective 2. |
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7. LL started antihypertensive therapy one month ago, and is in for a follow-up visit. The clinician is going to check LL’s laboratory values. In particular, the clinician wants to monitor for any changes in: glucose, uric acid, potassium and triglycerides. Which antihypertensive drug can cause abnormalities in all of these laboratory parameters, and thus is the drug LL is MOST LIKELY taking?
a. metoprolol b. chlorthalidone c. diltiazem d. candesartan |
b. chlorthalidone
a. INCORRECT – metoprolol can cause changes in all the laboratory parameters but is not associated with significant changes in potassium b. CORRECT – the thiazide diuretics can cause significant changes in all these laboratory parameters c. INCORRECT – diltiazem is not associated with changes in any of these laboratory parameters d. INCORRECT - candesartan is not associated with changes in any of these laboratory parameters except potassium See objective 6. |
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PB is a 51-year old woman with a history of type 2 diabetes, dyslipidemia, hypertension and paroxysmal atrial fibrillation. Echocardiogram reveals left ventricular ejection fraction of 60%, no evidence of thrombus, and no left ventricular hypertrophy.
Current Medications: Hydrochlorothiazide 25 mg po daily Metoprolol 50 mg po twice daily Aspirin 81 mg po daily Pravastatin 40 mg po daily Warfarin 2.5 mg po daily (initiated 6 months ago) Glyburide 5 mg po 2 times per day Notable lab values are serum creatinine of 2.0 mg/dL, potassium 4.5 mEq/L, INR 2.5. Her physician decides to admit her for electrical cardioversion due to increasing symptoms of fatigue and dizziness during episodes of atrial fibrillation. Once she is successfully cardioverted, which antiarrhythmic medication would be best to maintain normal sinus rhythm in this patient? a. Dofetilide b. Propafenone c. Amiodarone d. Procainamide |
b. Propafenone
This patient has no evidence of LV dysfunction. Therefore amiodarone (C) or dofetilide (A) are not indicated. Class 1A antiarrhythmics are not indicated when other options are available (D). Propafenone is an appropriate choice for this patient (D). See objective 3. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease, hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2¬ 25 meq/L, BUN 20 mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 µm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 µg/dl, Transferrin saturation 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs.
Three months after initiation of anti-hypertensive therapy, FJ’s serum creatinine has increased to 3.0 mg/dl. Based only on this new information which of the following is the most appropriate response to this observation? a. increase dose of anti-hypertensive agent b. decrease dose of anti-hypertensive agent c. discontinue present agent; begin therapy with an alternative agent d. make no change in antihypertensive therapy |
d. make no change in antihypertensive therapy
Selection “d” is correct; please see objectives 6 and 7. Such an increase in Cr is well within the 30 to 40% increase that can occur (see slide #37). Since there is no information about the patient’s serum K+ at this time(three months prior it was slightly elevated), there is insufficient information at present to justify any of the alternative strategies listed in selections a thru c. One of these changes might be appropriate if the patient’s blood pressure were known at this time. |
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Refer to Case 6
Which of the following are monitoring parameters for ACE inhibitors? a. Potassium b. Creatinine c. Heart rate d. A and B e. A, B, and C |
d. A and B
ACE inhibitors do not alter heart rate, but they can increase potassium and creatinine, both of which need to be monitored. |
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Which of the following best describes appropriate use of metoprolol tartrate (immediate release) vs. metoprolol succinate (controlled release) in this patient?
a. Metoprolol tartrate is preferred because it is available generic b. Metoprolol tartrate should not be used because carvedilol was shown to be superior c. Either agent may be used in the treatment of heart failure d. Neither metoprolol tartrate nor metoprolol succinate should be used because carvedilol is preferred |
b. Metoprolol tartrate should not be used because carvedilol was shown to be superior
MERIT-HF studied metoprolol succinate and found it to improve mortality in HF. Furthermore, the COMET study compared carvedilol and metoprolol tartrate and found carvedilol to be superior. Therefore, either carvedilol or metoprolol succinate are the preferred beta-blockers in heart failure. |
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4. QS is a 35 year-old white man with stage 1 primary hypertension. He is overweight, has impaired fasting glucose, and smokes, but is otherwise healthy. He is resistant to dietary and exercise interventions. What is the best drug choice for initial therapy for this patient?
a. triamterene/ hydrochlorothiazide b. atenolol c. valsartan d. trandolapril/ verapamil |
c. valsartan
a. Incorrect because the patient is likely to have high-renin hypertension, and the adverse metabolic effects may not be favorable given that he has impaired fasting glucose b. Incorrect because β-blockers are not the best choice for initial therapy of uncomplicated hypertension in the setting of obesity due to the potential for adverse metabolic effects. c. Correct because valsartan would be an appropriate initial drug choice for this patient, based on the fact that he is younger and white and may have a renin component, and also because ARBs have beneficial metabolic effects. d. Incorrect because 2 drug therapy is not necessarily indicated given that he has stage 1 hypertension. |
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5. Digoxin therapy for congestive heart failure will be started in a 62-year-old, 78-kg man with a stable serum creatinine concentration of 1.8 mg/dl. The patient is not obese (i.e., assume body weight is ideal). Calculate a maintenance dose regimen to achieve a target steady-state concentration at the LOWEST END of the reported therapeutic range for patients with heart failure. Select the regimen that is CLOSEST to the calculated value. Assume a tablet formulation that has a bioavailability of 75% will be used.
CLcr = [(140 – age) body weight] / (Scr 72)] Digoxin CL (L/hr) = 3.00 + (0.0546 CLcr ml/min) MD = [(Target Css CL ) / F] where = 24 hours and F = 0.75. a. 0.089 mg every day b. 0.107 mg every day c. 0.125 mg every day d. 0.142 mg every day e. 0.178 mg every day |
a. 0.089 mg every day
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HL is a 54 year old black male with chronic renal insufficiency (creatinine clearance = 28 ml/min) with proteinuria. He’s been hypertensive for years, but hasn’t been treated. His current blood pressure is 156/98 mmHg. Which of the following is the most appropriate recommendation regarding his hypertension therapy?
a. Initiate enalapril b. Initiate amlodipine + furosemide c. Initiate irbesartan + chlorthalidone d. Initiate ramipril + torsemide e. Initiate amlodipine + lisinopril |
d. Initiate ramipril + torsemide
This patient has a BP goal of < 130/80 (actually a lower BP would be better given proteinuria) and is highly unlikely to achieve this goal with monotherapy (a incorrect). All patients with renal disease should be on an ACE inhibitor or ARB (ACEI preferred) (thus B incorrect), and due to the fluid retention associated with renal disease, and diuretic is the most logical additional therapy. However, given this patient’s renal function, a thiazide would be ineffective (c incorrect). While a CCB with ACEI could be considered, most renal failure patients will require diuretic to control their HTN, so (d) preferred over (e). |
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RE has hypertension. Which of the following over-the-counter medications or products would you encourage her to avoid?
1) ketoprofen 2) loratadine 3) dextromethorphan 4) pseudoephedrine 5) ranitidine 6) ephedra weight loss products 7) omeprazole 8) chlorpheniramine a. 1, 4, 6 b. 1, 3, 6 c. 2, 4, 8 d. 1, 7, 8 e. 1, 4, 5 |
a. 1, 4, 6
OTC products to avoid include NSAIDS (ketoprofen), and sympathomimetics (e.g. decongestants (pseudoephrine) and ephedra-containing products). Antihistaimes (e.g. loratidine, chlorpheniramine), cough suppressants (dextromethorphan), H2-blockers (ranitidine) or proton pump inhibitors (omeprazole) are not problematic in hypertensive patients. |
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HJ is a 67 year-old Asian American male with a 3 year history of heart failure secondary to an acute myocardial infarction. He also has a 10 year history of Type 2 diabetes mellitus. At most clinic visits he is assessed as having Class III heart failure. He presents to clinic with complaints of increasing shortness of breath, and difficulty sleeping. He reports 3 pillow orthopnea (up from 2), and he is noted to have 2+ pedal edema, + jugular vein distention and 18 pound weight gain since his previous visit. Relevant labs include: Na – 134; K – 5.2; serum creatinine – 2.6; glucose – 154; total cholesterol -154; LDL – 87; HDL – 45; TG – 88; digoxin – 0.7 ng/ml; ejection fraction
– 21% Currents medications include: Enalapril 5 mg bid Toprol XL 50 mg daily Torsemide 10 mg daily Digoxin 0.125 mg daily K+ supplement – 20 mEq daily Pioglitazone 15 mg qd ASA 81 mg daily Atorvastatin 20 mg daily Acetaminophen 625 mg q6h prn VS: BP 142/88; HR: 75; RR: 15 T: afebrile Consideration is being given to starting this patient on spironolactone. Which of the following is the most appropriate response to this suggestion? a. Spironolactone (and eplerenone) should be avoided in this patient b. Given patient’s class III heart failure status and recent exacerbation, spironolactone is indicated and should be started c. Eplerenone should be recommended since spironolactone could be problematic in this patient d. This patient has no indication for spironolactone e. Spironolactone has only been studied in African Americans so its benefits in this patient are unclear, thus should probably be avoided. |
a. Spironolactone (and eplerenone) should be avoided in this patient
While this patient is a good candidate in general for an aldosterone antagonist, they should be avoided in him, due to his poor renal function and high K. It is not true that spironolactone has only been studied in African Americans, and if this patient had low K and good renal function, he might be a reasonable candidate for such therapy. |
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A 49 year-old man with anterior wall ST-segment elevated myocardial infarction is sent to the coronary catheterization lab for primary angioplasty. His course is uncomplicated and revascularization with stent placement is successful. He had no history of coronary disease before this event. His medical history is notable for childhood asthma, migraine headaches, and generalized anxiety disorder. His allergies include peanuts, penicillin, and aspirin. You are asked to write orders for his discharge medications by the cardiology fellow. Which of the following is the BEST regimen for this patient?
a. Metoprolol, fosinopril, aspirin, clopidogrel, and SL nitroglycerin b. Atenolol, ramipril, clopidogrel, and isosorbide dinitrate prn c. Atenolol, captopril, simvastatin, clopidogrel, and SL nitroglycerin d. Lisinopril, clopidogrel, aspirin, diltiazem, and SL nitroglycerin |
c. Atenolol, captopril, simvastatin, clopidogrel, and SL nitroglycerin
Correct answer is C. B is incorrect because isosorbide dinitrate is not a prn drug. D is incorrect because a beta-blocker (not diltiazem) should be given. C is a superior choice to A because a statin is part of the treatment plan. A and D are also incorrect since they include ASA, a medication to which the patient is allergic. |
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JW is a 46 year-old man with no past medical history and takes no medications. He presents to the clinic complaining of exertional chest pain that resolves with rest. It occurs about 3 times per week and has been present for a few months. He has no other complaints and no remarkable physical findings. HR 85 beats/min, BP 124/83 mmHg. His lipid panel reveals total-C 200 mg/dl, LDL 110 mg/dl, HDL 55 mg/dl, triglycerides 175 mg/dl. Stress electrocardiogram reveals 2 mm ST-depression. It is decided that he will be managed with atenolol 25 mg daily, nitroglycerin 0.4 mg prn, aspirin 325 mg daily, and atorvastatin 10 mg daily.
5. Which of the following is true regarding this patient’s regimen? a. fatigue may be a problematic side effect of atenolol b. verapamil is preferred for initial therapy c. atorvastatin is not necessary because his LDL-C is less than 130 mg/dl d. he should not take more than 3 nitroglycerin tablets for an acute chest pain episode e. clopidogrel should be used instead of aspirin |
a. fatigue may be a problematic side effect of atenolol
Please see 5th and 7th objectives. Fatigue is a very common cause of discontinuing beta-blockers. Beta-blockers are preferred for initial therapy; verapamil is useful as initial therapy if contraindications to beta-blocker therapy are present. Similarly, clopidogrel is recommended for those patients that are contraindicated to aspirin. Nitroglycerin use has no limit for acute chest pain episodes – it should be taken every 5 minutes until relief or medical attention. |
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Which drug exerts its LDL lowering effect by inhibiting intestinal absorption of dietary cholesterol?
a. atorvastatin b. gemfibrozil c. cholestyramine d. niacin e. ezetimibe |
e. ezetimibe
Answer E: Ezetimibe's MOA is reduce intestinal absorption of dietary cholesterol, while choices A-D do not affect cholesterol absorption. |
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Fluvoxamine is a potent inhibitor of which of the following cytochrome P450 (CYP) enzymes?
a. CYP1A2 b. CYP2C9 c. CYP2C19 d. CYP2D6 |
a. CYP1A2
CYP3A4 Answer A is correct as fluvoxamine is a very potent inhibitor of CYP1A2-mediated metabolism. |
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Which of the following statements concerning drug-drug interactions is TRUE?
a. The time of onset for interactions mediated by enzyme inhibition is delayed. b. The time of offset for interactions mediated by enzyme induction is immediate. c. St. John’s wort has the greatest effect on drugs that are metabolized by CYP1A2. d. The pharmacological effect of an active metabolite will be increased by induction of the enzyme(s) responsible for its formation. |
d. The pharmacological effect of an active metabolite will be increased by induction of the enzyme(s) responsible for its formation.
Answer D is correct because the effect of an active metabolite will be increased by induction of enzymes responsible for the metabolite’s formation. There will be a decrease in the effect of an active drug due to increased clearance and decreased blood concentrations. Answer A is not correct because the time of onset is typically immediate for inhibition interactions (although maximum inhibition may take time). Answer B is not correct because the time of offset is delayed for induction interactions (the effect is present but declines over time as the increased amount of enzyme goes back to normal). Answer C is not correct because St. John’s wort has the greatest effect on CYP3A-metabolized drugs |
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Which of the following drugs would be MOST susceptible to an interaction with grapefruit juice?
a. A drug with high bioavailability. b. A drug predominately metabolized by hepatic CYP1A2. c. A drug that undergoes intestinal metabolism predominately by CYP3A enzymes. d. A drug that is renally eliminated by an organic anion transporter. |
c. A drug that undergoes intestinal metabolism predominately by CYP3A enzymes.
Answer A is correct because GFJ has the biggest impact on drugs that are metabolized by CYP3A enzymes in the intestine. GFJ does not affect drugs that have a high bioavailability (answer A), drugs that are metabolized by enzymes other than CYP3A (answer B). GFJ also does not affect drug transporters outside of the intestine (answer D). |
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AZ is 54-year old woman with no significant past medical history who presents to an urgent care center complaining of palpitations and dizziness. She said the symptoms started while she was running in a shopping mall early morning yesterday. She also said this is the first time she has had symptoms like these. Today vitals show BP 112/68 mmHg, HR 145 beats/minute (irregular). Electrocardiogram (ECG) reveals atrial fibrillation. Which one of the following is the most appropriate for management of her atrial fibrillation?
a. Direct current cardioversion plus warfarin b. Metoprolol plus aspirin 325 mg with no scheduled cardioversion c. Digoxin plus aspirin 325 mg with no scheduled cardioversion d. Amiodarone plus warfarin after successful cardioversion |
b. Metoprolol plus aspirin 325 mg with no scheduled cardioversion
Key: B (Objective # 3). AA is not hemodynamically unstable. Therefore, there is no need to do DCC at this time (A is incorrect). This is the first episode of AA’s afib. Therefore, rhythm control is not recommended at this time (E is incorrect) and rate control plus stroke prevention therapy should be implemented. Since AA does not have any risk factor, aspirin is the drug of choice for preventing ischemic stroke for her (B is incorrect). Digoxin is considered as the second line because of slow onset (D is incorrect) and poor afib rate control with exercise/exertion. Therefore, C is correct. |
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RT is a 74 year old white female with systolic heart failure. The presumed
etiology of her heart failure is hypertension, and her medical history is otherwise insignificant. The physician judges her to have Class II heart failure Current medications: Enalapril (Vasotec) 10 mg bid Digoxin (Digitek, Lanoxin) 0.125 mg qd furosemide (Lasix) 20 mg qd KCl (potassium chloride) – 10 mEq qd. Vital Signs: BP – 94/52 mmHg P – 56/min R – 14/min Regarding the initiation of β-blocker therapy, which of the following would be most appropriate for this patient? a. Initiation of a β-blocker is inappropriate in this patient at this time b. Recommend using metoprolol (Lopressor, Toprol XL) over carvedilol (Coreg) because metoprolol doesn’t have alpha-blocking effects, which are a concern in this elderly patient. c. Recommend initiation of metoprolol because it has less blood pressure lowering effects than carvedilol d. Recommend decreasing the dose of enalapril, then initiating metoprolol. |
a. Initiation of a β-blocker is inappropriate in this patient at this time
While beta-blocker is strongly indicated in all heart failure patients, it is contraindicated in bradycardia and hypotension. The main issue of concern here is the bradycardia, secondarily the relatively low BP. It might be possible to get the BP up by reducing the enalapril dose and might be possible to get the HR up by stopping the digoxin. Since betab-blockers have mortality benefit and digoxin does not, this would be acceptable. Alternatively some would insert a pacemaker in bradycardic patients to be able to use a beta-blocker. |
