Foundations 1 Flashcards by Payton Dennis

Primary NT involved in somatic nervous system

Acetylcholine (Ach)

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What receptor does Ach bind to in skeletal muscles to affect muscle movement?

Nicotinic receptors

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What NT does the parasympathetic nervous system release, what receptor does it bind to, and what response does the binding cause?

ACh

Muscarinic receptors (GI tract, bladder, and eyes)

SLUDD

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SLUDD

Salivation, lacrimation, urination, defecation, and digestion

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What are the main NTs released by the sympathetic nervous system, what receptors do these bind to, and what response occurs due to this binding?

Epinephrine and norepinephrine

Adrenergic receptors

Increased BP, HR, and bronchodilation

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Where are alpha 1 receptors located?

Smooth muscles (e.g., blood vessels)

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Where are beta 1 receptors located?

Heart

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Where are beta 2 receptors located?

Lungs and GI tract

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Antagonists binds to SAME ACTIVE SITE of receptor as the endogenous substrate —> prevents substrate from binding —> reaction

Competitive inhibition

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Antagonist binds to receptor at a site other than the active site (ALLOSTERIC SITE) —> shape of active site changes —> prevents endogenous substrate from binding

Non-competitive inhibition

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MUSCARINIC RECEPTOR

Endogenous substrate:
Agonist action:
Drug agonists:
Antagonist action:
Drug antagonists:

Endogenous substrate: ACh

Agonist action: Increases SLUDD

Drug agonists: Pilocarpine, bethanechol

Antagonist action: Decreases SLUDD

Drug antagonists: Atropine, oxybutynin

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NICOTINIC RECEPTOR

Endogenous substrate:
Agonist action:
Drug agonists:
Antagonist action:
Drug antagonists:

Endogenous substrate: ACh

Agonist action: Increased BP, HR

Drug agonists: Nicotine

Antagonist action: Neuromuscular blockade

Drug antagonists: Neuromuscular blockers (rocuronium)

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ALPHA-1 (mainly peripheral)

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Epi, NE

Agonist action: Smooth muscle vasoconstriction, increased BP

Drug agonists: Phenylephrine, dopamine (dose-dependent)

Antagonist action: Smooth muscle relaxation, decreased BP

Drug antagonists: Alpha 1 blockers (doxazosin, carvedilol, phentolamine)

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ALPHA 2 (mainly brain; central)

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Epi, NE

Agonist action: Decreased release of Epi and NE, decreased BP and HR

Drug agonists: Clonidine, brimonidine (ophthalmic for glaucoma)

Antagonist action: Increased BP, HR

Drug antagonists: Ergot alkaloids, yohimbine

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BETA 1 (mainly heart)

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Epi, NE

Agonist action: Increased myocardial contractility, CO, HR

Drug agonists: Dobutamine, isoproterenol, dopamine (dose-dependent)

Antagonist action: Decreased CO, HR

Drug antagonists: Beta blockers

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BETA 2 (mainly lungs)

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Epi

Agonist action: Bronchodilation

Drug agonists: Albuterol, terbutaline, isoproterenol

Antagonist action: Bronchoconstriction

Drug antagonists: Non-selective beta blockers (propranolol, carvedilol)

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DOPAMINE

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Dopamine

Agonist action: Renal, cardiac, and CNS effects

Drug agonists: Levodopa, pramipexole

Antagonist action: Renal, cardiac, and CNS effects

Drug antagonists: 1st generation antipsychotics (haloperidol) and metoclopramide

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SEROTONIN

Endogenous substrate:

Agonist action:

Drug agonists:

Antagonist action:

Drug antagonists:

Endogenous substrate: Serotonin

Agonist action: Platelet, GI, and psychiatric effects

Drug agonists: Triptans (sumatriptan)

Antagonist action: Platelet, GI, and psychiatric effects

Drug antagonists: Ondansetron, 2nd generation antipsychotics (quetiapine)

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ACETYLCHOLINESTERASE

Endogenous effects:

Drug examples:

Drug action:

Endogenous effects: Breaks down ACh

Drug examples: Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine)

Drug action: Blocks acetylcholinesterase —> increases ACh levels; used to treat Alzheimer’s disease

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Angiotensin-converting enzyme (ACE)

Endogenous effects:

Drug examples:

Drug action:

Common uses:

Endogenous effects: Converts angiotensin I to angiotensin II (potent vasoconstrictor)

Drug examples: ACE inhibitors

Drug action: Inhibit production of angiotensin II —> decreases vasoconstriction and aldosterone secretion

Common uses: Used to treat HTN, HF, and kidney

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Catechol-O-methyltransferase

Endogenous effects:

Drug examples:

Drug action:

Common uses:

Endogenous effects: Breaks down levodopa

Drug examples: COMT inhibitor (ent a sponge)

Drug action: Blocks COMT enzyme to prevent peripheral breakdown of levodopa —> increases duration of action of levodopa

Common uses: Parkinson’s disease

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Cyclooxygenase (COX)

Endogenous effects:

Drug examples:

Drug action:

Common uses:

Endogenous effects: Converts arachidonic acid to prostaglandins (cause inflammation) and thromboxane A2 (causes platelet aggregation)

Drug examples: NSAIDS

Drug action: Block COX to decrease prostaglandins and thromboxane A2

Common uses: Treat pain/inflammation and decrease platelet activation/aggregation (aspirin)

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Monoamine oxidase (MAO)

Endogenous effects:

Drug examples:

Drug action:

Common uses:

Endogenous effects: Breaks down catecholamines (DA, NE, Epi, 5-HT)

Drug examples: MAO inhibitors (phenelzine, tranylcypromine, isocarboxazid, selegiline, rasagiline, methylene blue, linezolid)

Drug action: Block MAO —> increases catecholamine levels

Common uses: Depression

**Increasing catecholamines too much can cause toxicity (hypertensive crisis, serotonin syndrome)

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Phosphodiesterase (PDE)

Endogenous effects:

Drug examples:

Drug action:

Common uses:

Endogenous effects: Breaks down cGMP (smooth muscle relaxant)

Drug examples: PDE-5 inhibitors (sildenafil, tadalafil)

Drug action: Competitively bind to same active site as cGMP on the PDE-5 enzyme —> prevents breakdown of cGMP and prolong smooth muscle relaxation

Common uses: Erectile dysfunction

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VITAMIN K EPOXIDE REDUCTASE Endogenous effects: Drug examples: Drug action: Common uses:

Endogenous effects: Converts vitamin K to active form required for production of select clotting factors Drug examples: Warfarin Drug action: Blocks vitamin K epoxide reductase enzyme —> decreases production of clotting factors II, VII, IX, and X Common uses: Treat/prevent blood clots

XANTHINE OXIDASE Endogenous effects: Drug examples: Drug action: Common uses:

Endogenous effects: Breaks down hypoxanthine and xanthine into uric acid Drug examples: Xanthine oxidase inhibitor (allopurinol) Drug action: Blocks xanthine oxidase —> decreases uric acid production Common uses: Prevent gout attacks

Occurs when a drug binds to polyvalent cations (Mg++, Ca++, Fe++) in another compound (antacids or iron supplements) Causes reduced absorption

Chelation

Name 4 drugs/drug classes that have to separated from polyvalent cations (antacids, multivitamins, sucralfate, bile acid resins, aluminum, Ca, Fe, Mg, zinc, phosphate binders)

Quinolones, tetracyclines, levothyroxine, oral bisphosphonates

What CYP450 metabolizes codeine? What happens if someone is a UM? PM?

CYP2D6; risk of toxicity; poor analgesia

What CYP450 converts clopidogrel into its active metabolite? What drugs inhibit this enzyme and should be avoided due to decreased antiplatelet effects?

Omeprazole and esomeprazole

Polymorphic phase II enzyme

N-acetyltransferase (NAT)

Acronym for common CYP3A4 inhibitors

G-PAC-MAN Grapefruit Protease inhibitors Azole antifungals Cyclosporine, cobicistat Macrolides (not azithromycin) Amiodarone and dronedarone Non-DHP CCBs

CYP enzyme ___________ increase the concentration of substrate drugs and decrease the concentration of active form of prodrugs. CYP enzyme _______ do the exact opposite.

Inhibitors; inducers

Acronym for common CYP3A4 inducers

PS PORCS Phenytoin Smoking Phenobarbital Oxcarbazepine Rifampin, rifabutin, and rifapentine Carbamazepine St. John’s wort

located in many tissue membranes and protect against foreign substances by moving them out of critical areas some are located in cell membrane of Gi tract and pump drugs and their metabolites out of the body by pumping them into the gut, where they can be excreted in the stool

permeability glycoprotein pumps (P-gp)

P-gp _________ increases the absorption of drugs that are P-gp substrates (less drug is pumped into the gut). P-gp ______ do the opposite.

Inhibitors; inducers

Mechanism that increases duration of action of drugs by transporting an already metabolized drug through the bile and back to the gut --> drug gets reabsorbed in small intestine --> goes through portal vein and back to liver

enterohepatic recycling

What should you do when a patient has been taking warfarin and gets newly prescribed for amiodarone?

Decrease warfarin dose 30-50%

A patient that is taking digoxin is getting prescribed amiodarone for treatment of their afib. What should you do and why?

Decrease digoxin dose by 50% because amiodarone causes decreased excretion of digoxin. There is also an increased risk of bradycardia.

What should you be concerned for when a patient is taking digoxin and a loop diuretic?

Increased risk of digoxin toxicity

Simvastatin and lovastatin are contraindicated with strong CYP___ _________.

3A4 inhibitors

Azole antifungals, bactrim, amiodarone, metronidazole

CYP2C9 inhibitors

CYP2C9 inducers

rifampin, St. John's wort

What should you monitor when a patient is taking warfarin AND a CYP2C9 inhibitor/inducer?

INR

What drugs specifically include instructions that say you can NOT drink grapefruit juice with?

Amiodarone, simvastatin, lovastatin, nifedipine, tacrolimus

What drug class should be avoided with an CYP3A4 inhibitor due to increased ADRs (sedation) and can be fatal?

opioids

A patient that is taking Valproate is being newly prescribed lamotrigine. What should you be concerned for and how can you help decrease that risk?

Valproate decreases lamotrigine metabolism, which increases the risk of serious skin reactions. Initiate lamotrigine using the starter kit that begins with lower doses and titrate carefully every 2 weeks.

What should be done when switching between drugs with MAO inhibition or serotonergic properties?

2 week washout period

When switching between MAO inhibitors and fluoxetine, how long should wait to do so?

5 weeks

CYP2D6 inhibitors

Amiodarone, fluoxetine, paroxetine, fluvoxamine

Common CYP2D6 substrates

Codeine, meperidine, tramadol, tamoxifen

Do not exceed citalopram __ mg daily or ___ mg dialy in elderly (> 60 y/o)

40; 20

Do not exceed escitalopram __ mg daily or __ mg daily in elderly.

20; 10

What SSRI is considered safest in patients with cardiovascular disease?

Sertraline

A patient is being prescribed cisplatin. What should also be prescribed to protect the patient's kidneys?

Amifostine (Ethyol)

Provides rapid results at the site of patient care

Point-of-care (POC) testing

Involves obtaining a drug level or other relevant labs to monitor efficacy and safety

Therapeutic drug monitoring

When this type of lab test is ordered, the types of neutrophils are analyzed.

CBC with differential

What lab values does a basic metabolic panel (BMP) analyze?

Electrolytes, glucose, renal function, and acid/base (HCO3) status

Leukocytosis

increased WBCs

Thrombocytosis

increased platelets

leukopenia

decreased WBCs

thrombocytopenia

decreased platelets

myelosuppression

decreased WBCs, RBCs, and platelets

total calcium

8.5-10.5 mg/dL

What lab value should be calculated if albumin is low?

corrected calcium

Vitamin D and thiazide diuretics can _______ calcium.

increase

What drugs can decrease calcium? (4)

Long-term heparin, loop diuretics, bisphosphonates, cinacalcet

magnesium

1.3-2.1 mEq/L

What drugs can decrease magnesium? (3)

PPIs, diuretics, amphotericin B

phosphate

2.3-4.7 mg/dL

Chronic kidney disease can _______ phosphate.

increase

potassium

3.5-5 mEq/L

What drugs can increase potassium? (10)

ACE inhibitors, ARBs, aldosterone receptor antagonists (ARAs), aliskiren, canagliflozin, cyclosporine, tacrolimus, potassium supplements, bactrim, drospirenone

Beta-2 agonists, diuretics, and insulin can ______ potassium.

decrease

sodium

135-145 mEq/L

Hypertonic saline and tolvaptan can ______ sodium.

increase

What drugs can decrease sodium? (4)

Carbamazepine, oxcarbazepine, SSRIs, and diuretics

HCO3 (venous and arterial)

Venous: 24-30 mEq/L Arterial: 22-26 mEq/L

Topiramate can _____ bicarbonate.

decrease

blood urea nitrogen (BUN)

7-20 mg/dL

What disease states can increase BUN? (2)

renal impairment and dehydration

SCr

0.6-1.3 mg/dL

What drugs increase SCr due to impairing renal function? (11)

Aminoglycosides, amphotericin B, cisplatin, colistimethate, cyclosporine, loop diuretics, polymyxin, NSAIDs, radiocontrast dye, tacrolimus, vancomycin

anion gap

5-12 mEq/L

An elevated anion gap can suggest what disease state?

metabolic acidosis

WBCs

4000-11000 cells/mm3

Systemic steroids can ______ WBCs.

increase

What drugs can decrease WBCs? (4)

clozapine, chemotherapy, carbamazepine, immunosuppressants

Neutrophils

45-73%

Neutrophils are also called what 2 things?

polymorphonuclear cells (PMNs) or segmented neutrophils (segs)

immature neutrophils that are released from the bone marrow to fight infection

bands

What is the term used to describe elevated bands?

left shift

bands

3-5%

eosinophils

0-5%

What disease states can increase eosinophils? (3)

asthma, inflammation, parasitic infections

basophils

0-1%

What disease state can increase basophils? (1)

hypersensitivity reactions

lymphocytes

20-40%

What disease states can increase lymphocytes? (2)

viral infections, lymphoma

What disease states/drugs can decrease lymphocytes? (3)

bone marrow suppression, HIV, systemic steroids

RBCs (males and females)

Males: 4.5-5.5 x 10^6 cells/uL Females: 4.1-4.9 x 10^6 cells/uL

What drugs can increase RBCs? (1)

erythropoietin-stimulating agents (ESAs)

What things can decrease RBCs? (4)

chemotherapy, deficiency anemias, hemolytic anemia, sickle cell anemia

Hgb (males and females) (g/dL)

Males: 13.5-18 Females: 12-16

What drugs can increase hgb and hct? (1)

ESAs

Mean corpuscular volume (MCV) (fL)

80-100

MCV is increased in macrocytic anemia due to what deficiency?

B12 or folate

MCV is decreased in microcytic anemia due to what deficiency?

iron

Folic acid (folate) (mcg/L)

5-25

What drugs can decrease folate? (5)

phenytoin/fosphenytoin, phenobarbital, primidone, methotrexate, bactrim

vitamin B12 (pg/mL)

> 200

What drugs can decrease vitamin B12? (2)

PPIs, metformin

reticulocyte count

0.5-2.5%

Reticulocyte count can _____ due to untreated anemia and bone marrow suppression.

decrease

What test is used in the diagnosis of hemolytic anemia?

Coombs test

What drugs can cause hemolytic anemia? (15)

penicillins, cephalosporins, dapsone, isoniazid, levodopa, methyldopa, methylene blue, nitrofurantoin, pegloticase, primaquine, quinidine, quinine, rasburicase, rifampin, and sulfonamides

What should you do if a Coombs test is positive and a drug-induced cause is suspected?

discontinue the suspected drug

You should obtain a peak anti-Xa level ______ after the administration of LMWH.

4 hours

You should obtain a peak anti-Xa level ______ after the IV infusion of unfractionated heparin.

6 hours

Monitoring for LMWH is recommended in __________.

pregnancy

A 50 y/o male presents to the ED with chest pain. The triage nurse reports to the Dr that the pt is diaphoretic, nervous, and is clenching his his against his shirt over the chest region. What section of the chart note is the correct place to record the nurse's report? a. Subjective b. Objective c. Assessment d. Plan e. Chief complaint

b Info obtained or observed by the clinician is recorded in the objective section of the note.

KG is an elderly female with osteoporosis, HTN, and glaucoma. She picks up her BP pills and glaucoma drops at the pharmacy near her home. This pt has a Medicare Plan, which covers her inpatient and outpatient med costs. The pharmacy bills the costs for the HTN and glaucoma meds to the following Medicare program: a. Part A b. Part B c. Part C d. Part D e. Part E

d Part D covers outpatient drug costs.

A 77 y/o female with HTN, high cholesterol, and HF was admitted to the ED with chest pain. The pt was initially given aspirin, NTG, and oxygen. The physical exam in the ED was positive for epigastric pain and tachycardia. She was sent for a CT scan of the abdomen. The notes on the preliminary read included "no acute intra-abdominal process and small bilateral PE." The abbreviation "PE" was meant to indicate pulmonary effusion. The inpatient team initiated IV heparin for a pulmonary embolus. The pt later died d/t internal bleeding. What is the cause of the medical error? a. Lack of an advanced directive b. The use of medical abbreviations in a patient's chart c. The use of inappropriate diagnostic tools d. The use of a med known to have a high risk of bleeding e. The miss of a critical value that had been identified earlier

TA is a 48 y/o female pt who's hospitalized with chest pain and SOB. She takes multiple drugs, including Cozaar, Coumadin, Coreg, Lasix, and Micro-K. An INR is drawn and reported as 4.5 (critical is >/= 4 at this institution). Which of the following is the best definition of a critical value? a. A value that can be life-threatening if corrective action isn't taken directly b. A value that can cause the pt to suffer physical or psychological harm c. A value that has to be acted on within 6 hours d. A value that has to be acted within 8 hours

A pharmacist is counseling a pt on a new antihypertensive med. After he finishes the counseling, he says "any questions?" What is a better way to conclude the counseling session that would likely make the pt feel more comfortable asking questions? a. "Do you understand your HTN regimen?" b. "Read over the info stapled to your Rx bag. It will answer your questions." c. "What questions can I answer about your new med?" d. "Call us here in the pharmacy if you have any questions." e. "It seems like you understand this. I think you will do well on this med."

Convert 88F to Celsius. Round final answer to the nearest TENTH.

31.1 C = (F - 32) / 1.8

Which drugs can increase the QT interval? a. Levofloxacin b. Methadone c. Lotrel d. Miralax e. Amitriptyline

a, b, e

A 74 y/o woman had been taking metoprolol succinate 100 mg daily, warfarin 4 mg daily, and amitriptyline 50 mg QHS for several years. Shortly after the death of her spouse, she experienced some depression and was prescribed citalopram 40 mg daily. The pt is most at risk for: a. Nephrotoxicity b. Orthostasis c. Torsade de Pointes d. Hyperkalemia e. Seizures

c Citalopram can prolong the QT interval (the max dose is 20 mg in patients age > 60 years), which can lead to Torsades de Pointes

Which of the following is an inducer of CYP3A4? a. Ketoconazole b. Erythromycin c. Clarithromycin d. Phenobarbital e. Amiodarone

d CYP3A4 substrate - ketoconazole CYP3A4 inhibitor - erythromycin, clarithromycin, amiodarone

Which of the following are P-gp substrates? a. Apixaban b. Tacrolimus c. Colchicine d. St. John's wort e. Phenytoin

a, b, c P-gp substrates - tacrolimus, cyclosporine, colchicine, dabigatran, apixaban, rivaroxaban, digoxin, diltiazem, verapamil P-gp inducers - St. John's wort, phenytoin

A 65 y/o woman brings a new Rx for a monoamine oxidase inhibitor to the pharmacy. Which of the following foods should she be counseled to avoid? a. Sauerkraut b. Grapefruit c. American cheese d. Potatoes e. Walnuts

a Monoamine oxidase metabolizes tyramine. If tyramine is consumed while taking a MAO inhibitor, the tyramine levels will increase. Tyramine increases NE, which can lead to a hypertensive crisis.

Which of the following drugs increase the risk of a pt having a fall that could result in injury? a. Cyclobenzaprine b. Remeron c. Armodafinil d. Bactrim e. Restoril

a, b, e Muscle relaxants, mirtazapine, and BZDs are CNS depressants. CNS side effects are caused by drugs that enter the CNS (lipophilic) and result in sedation (somnolence), dizziness, confusion (decreased cognitive function, and altered consciousness.

A pt is at risk for afib; she has had afib in the past. The medical team has asked the pharmacist to check for drugs on her profile that can increase her risk of arrhythmia. The pharmacist should include which of the following meds? a. Omalizumab b. Levetiracetam c. Ziprasidone d. Fluticasone e. Sildenafil

c Ziprasidone can cause additive QT prolongation and must be used with caution in patients with any arrhythmia risk.

A pt with afib has been using warfarin for 9 months, and his INR is stable between 2.3-2.7. What is most likely to occur if he starts taking ginkgo biloba? a. The INR will decrease and the bleeding risk will decrease. b. The INR will stay at about the same and the bleeding risk will increase. c. The INR will increase and the bleeding risk will increase. d. The INR will increase and the bleeding risk will decrease. e. The INR will decrease and the bleeding risk will increase.

A pt with afib has been using warfarin for 9 months, and his INR is stable around 2.3. The pt has been diagnosed with depression and asked for a Rx that won't interact with his other meds. Which of the following drugs won't increase the bleeding risk in this pt? a. Wellbutrin b. Effexor c. Pristiq d. Lexapro e. Cymbalta

a SSRIs and SNRIs increase bleeding risk. The INR doesn't increase, but the bleeding risk increases.

A pt has an estimated CrCl of 25 mL/min. Her potassium level is 4.8 mEq/L. Which of the following drugs will increase her risk of hyperkalemia and should be used with caution? a. Micafungin b. Enalapril c. Paroxetine d. Hydrochlorothiazide e. Metolazone

Which of the following are CYP450 enzyme inducers? a. Trileptal b. Dilantin c. Tegretol d. St. John's wort e. Neoral

a, b, c, d

A pt with a DVT has been using warfarin for 4 months, and his INR is stable ~ 2.5. Which of the following interactions is correct? a. If amiodarone is added, the INR will decrease. b. If Bactrim is added, the INR will decrease. c. If phenobarbital is added, the INR will increase. d. If rifampin is added, the INR will decrease. e. If phenytoin is added, the INR will increase.

d CYP2C9 inducers (which decrease the INR) include phenobarbital, phenytoin, primidone, rifampin (large decrease in INR) and St. John's wort.

Theophylline is a substrate of CYP1A2. A pt on long-term theophylline, who has been well-controlled with infrequent use of her rescue inhaler, has developed a UTI that's difficult to treat. The Dr prescribed a 7-day course of ciprofloxacin. Which of the following is most likely to occur? a. Worsening asthma control b. No effect c. Increased seizure risk from ciprofloxacin d. Possible theophylline toxicity e. Untreated UTI; poor tx outcome

d Ciprofloxacin is a moderately strong inhibitor of CYP1A2 and a weaker inhibitor of other isoenzymes. This will increase theophylline levels.

BH takes an estrogen and progestin combo oral contraceptive (COC). She recently received a Rx for phenytoin. Which of the following best describes the interaction between these meds? a. Phenytoin is an inhibitor of the metabolism of estrogen; it will increase the levels of the COC. b. Phenytoin is an inducer of the metabolism of estrogen; it will decrease the levels of the COC. c. Phenytoin is an inhibitor of the metabolism of estrogen; it will decrease the levels of the COC. d. COCs are prodrugs; the addition of phenytoin will have no effect. e. Phenytoin is an inducer of the metabolism of estrogen; it will increase the levels of the COC.

b Phenytoin is a potent inducer. Inducers result in higher levels of CYP enzymes, which decrease levels of substrate drugs (e.g., estrogen).

MT is taking Aggrenox, torsemide, Crestor, Toprol XL, Lotensin, Cardizem, Klor-Con, Nitrostat PRN, fish oil, and DHEA. Based on his med list, MT is most at risk for: a. QT prolongation b. Bradycardia c. CNS depression d. Ototoxicity e. Anticholinergic toxicity

b The combined use of a BB (Toprol XL) and a non-DHP CCB (Cardizem) increases the risk of additive bradycardia.

Which of the following is an inhibitor of CYP3A4? a. Warfarin b. Pacerone c. Rifampin d. Meperidine e. Norvasc

b Pacerone = amiodarone CYP3A4 inducer - rifampin CYP3A4 substrate - amlodipine, amiodarone (only one out of these options that's an inhibitor)

Which of the following statements best describes warfarin metabolism? a. Warfarin is racemic; the S-isomer is more potent and is (primarily) a substrate of CYP2C9. b. Warfarin is renally cleared. c. Warfarin is a potent enzyme inducer and has interactions with many other drugs. d. Warfarin is racemic; the R-isomer is more potent and is (primarily) a substrate of CYP2D6. e. Warfarin is subject only to pharmacodynamic interactions.

a -CYP450 drug interactions with warfarin are the most common cause of an INR increase or decrease -S-isomer is 3-5x more potent than the R-isomer -The S-isomer is a CYP2C9 substrate, and inducers/inhibitors of this enzyme have the most effect on the INR -The R-isomer is a CYP1A2 substrate

Select the correct statements concerning the drug interaction between valproic acid and lamotrigine. a. VPA inhibits lamotrigine metabolism b. This interaction increases the risk for a severe lamotrigine-induced rash c. This interaction increases the risk for severe VPA-induced pancreatitis d. When using these 2 meds at the same time, the appropriate Lamictal Starter Kit should be used e. This interaction increases the risk for severe VPA-induced hepatotoxicity

a, b, d

Drug A is a CYP2C9 substrate and a potent 3A4 inhibitor. Drug B is a 2D6 and 1A2 substrate as well as a potent 2C19 inhibitor. Drug C is a 3A4 substrate and potent 2D6 inhibitor. If all three drugs were given together, what would the levels of each drug be expected to do? a. Drug A levels would stay the same, Drug B levels would increase, and Drug C levels would increase. b. Drug A levels would increase, Drug B levels would decrease, and Drug C levels would increase. c. Drug A levels would decrease, Drug B levels would decrease, and Drug C levels would increase. d. Drug A levels would increase, Drug B levels would stay the same, and Drug C levels would decrease. e. Drug A, B, and C levels would all increase.

Which of the following drugs can cause hearing loss? a. Torsemide b. Vancomycin c. Tobramycin d. Cisplatin e. Adalimumab

a, b, c, d Loop diuretics, vancomycin, aminoglycosides, cisplatin, and salicylates are drugs that can cause ototoxicity.

A pt with afib has been using warfarin for 4 months, and his INR is stable ~ 2.3. Select the interaction that can occur with the addition of these other meds: a. Clopidogrel - INR will increase and bleeding risk will be elevated b. Naproxen - INR may or may not increase and bleeding risk will be elevated c. Ibuprofen - INR may or may not increase and bleeding risk will be reduced d. Citalopram - INR will decrease and bleeding risk will be reduced e. Acetaminophen - INR may or may not increase but bleeding risk will be lowered

b -The most common pharmacodynamic interaction with warfarin is with NSAIDs, including aspirin and ibuprofen (but not the selective agents such as celecoxib; however, pts on warfarin should likely not be using celecoxib d/t CVD risk), and with other antiplatelets. -These interactions increase bleeding risk, but the INR may or may not be affected.

Phosphodiesterase inhibitors (e.g., tadalafil) can't be used safely with nitrates. What is most likely to happen if a pharmacist misses this interaction? a. QT prolongation b. Hypertensive crisis c. Cerebrovascular accident d. Acute drop in BP e. Serotonin syndrome

d PDE-5 inhibitors are contraindicated in combo with nitrates d/t the risk of hypotension.

Clopidogrel is a prodrug metabolized by CYP2C19. What effect will a CYP2C19 inhibitor have? a. Increased antiplatelet effect immediately b. Decreased antiplatelet effect immediately c. No effect d. Increased antiplatelet effect in 4 weeks d. Decreased antiplatelet effect in 4 weeks

b Enzyme inhibition is fast; effects are seen within a few days.

CL is being placed on the waiting list for a kidney transplant. She has a CrCl of 22 mL/min and experiences frequent bouts of hyperkalemia. Which meds elevate potassium and would put her at risk for arrhythmia? a. Altoprev b. Torsemide c. Eplerenone d. Aldactone e. Yasmin

c, d, e

Drug A is a substrate of enzyme X. Drug A is also an inducer of enzyme Y. Drug B is a substrate of enzyme Y. Drug B is also an inhibitor of enzyme X. When these drugs are both administered, what will happen to the concentrations of Drug A and Drug B? a. Levels of both Drug A and Drug B will increase b. Levels of Drug A will increase and levels of Drug B will decrease c. Levels of Drug A will decrease and levels of Drug B will increase d. Levels of Drug A will increase and levels of Drug B will stay the same e. There's not enough info given

Drug A is an active substrate of enzyme X. Drug B is an inhibitor of enzyme X. A pt has been using Drug A with good results. The pt has now started therapy with Drug B. The concentration of Drug A will: a. Increase b. Decrease c. Stay the same d. Not enough info is provided to draw a conclusion e. Increase or decrease

What can occur if a CYP3A4 inhibitor is given to a pt on oxycodone? a. Liver toxicity b. Myopathy c. Respiratory depression d. Sedation e. Uncontrolled pain

c, d

A pt who is a CYP2D6 rapid metabolizer is using codeine for pain. What effect will the 2D6 polymorphism have on the concentration of morphine? a. The morphine concentration will decrease b. The morphine concentration will stay the same c. The morphine concentration will increase d. The morphine concentration will become subtherapeutic e. None, codeine isn't metabolized by the 2D6 enzyme

c The conversion of codeine to morphine is increased in rapid metabolizers of 2D6

Which of the following drugs can cause hearing loss? a. Magnesium salicylate b. Vancomycin c. Gentamicin d. Ethacrynic acid e. Hydrochlorothiazide

a, b, c, d

Which of the following statins has the lowest risk of drug interactions? a. Atorvastatin b. Pravastatin c. Lovastatin d. Simvastatin e. Fluvastatin

b -Atorvastatin, lovastatin, simvastatin, and fluvastatin are all metabolized by CYP450 enzymes. When taken with an inhibitor, the risk of myopathy is increased. In severe cases, rhabdomyolysis can occur, which may lead to acute renal failure. -To avoid this interaction, recommend a statin not metabolized by CYP450 enzymes (e.g., pravastatin and rosuvastatin).

A pharmacy resident is completing a formulary review and is looking for a resource to compare oral contraceptive products. Which of the following resources provides drug class comparisons? a. Pharmacist's Letter b. DailyMed c. MedlinePlus d. Facts and Comparisons e. Epocrates

a, d, e Pharmacist's Letter is an online service that provides a monthly newsletter and other useful summary documents, including drug class comparison charts.

A pharmacist needs to price a drug in her store. Which drug reference will list the average wholesale price (AWP) and the suggested retail price? a. The Red Book b. The drug's package insert c. Index Nominum d. Goodman and Gilman's e. Merck Index

JF, a 55 y/o female, asks the pharmacist to recommend a natural product to treat her "low mood." Which resource would best help the pharmacist with providing a recommendation to JF? a. The Natural Medicines Database b. Remington: The Science and Practice of Pharmacy c. The NIOSH list d. The Red Book (AAP) e. King Guide

A pharmacy student is preparing for a journal club and wants to search for clinical trials that have evaluated the risk of amputations with SGLT2 inhibitors. Which resource should she use? a. Mayo Clinic b. PubMed c. MedWatch d. LactMed e. Merck Manual

A nurse practitioner would like to know what adverse reactions are possible following the administration of the DTaP vaccine. Which reference can be used to acquire this info? a. Trissel's Pharmaceutics Database b. Hale's c. TOXLINE d. The Pink Book e. USP 800

d The CDC's Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book) provides the most comprehensive info on routinely used vaccines and the diseases they prevent.

A pt who takes Lamictal is hospitalized with SJS that has progressed to toxic epidermal necrolysis (TEN). The pt's physician wants to know what other possible adverse reactions from using this drug can increase the risk of mortality or hospitalization. What is the preferred resource to find this info? a. ASHP's Handbook on Injectable Drugs b. The American Association of Poison Control Centers c. The ISMP Medication Errors Reporting Program d. The Lamictal package insert e. Morbidity and Mortality Weekly Report

d The package insert will provide the most accurate info regarding boxed warnings, contraindications, warnings and precautions, and adverse reactions that can lead to an increased risk of mortality or morbidity.

A pharmacist wants to refresh her knowledge on the diagnosis and management of common neurological diseases. Which of the following would be a useful resource for the pharmacist to use? a. Koda-Kimble's Applied Therapeutics b. UpToDate c. The Merck Manual d. DiPiro's Pharmacotherapy: A Pathophysiologic Approach e. Martindale: The Complete Drug Reference

a, b, c, d

Which reference name is matched correctly with its purpose? a. Yellow Book - therapeutic equivalence b. Orange Book - principles of immunization c. Green Book - drug pricing d. Red Book - travelers' health info e. Pink Sheet - regulatory and business developments

e -Yellow Book - travelers' health info -Orange Book - therapeutic equivalence -Green Book - info on approved animal drug products -Red Book - drug pricing

A pharmacist has opened his own community pharmacy and wishes to find a compounding formula for metronidazole benzoate PO suspension. He may be able to find guidance in which of the following resources? a. The FDA's Center for Evaluation and Research b. DiPiro's Pharmacotherapy: A Pathophysiologic Approach c. The United States Pharmacopeia National Formulary d. Allen's The Art, Science, and Technology of Pharmaceutical Compounding e. The Infectious Diseases Society of America

c, d Other compounding and pharmaceutics resources: -ASHP Guidelines on Compounding Sterile Preparations -Handbook of Pharmaceutical Excipients -Safety Data Sheets (SDS) -Merck Index: An Encyclopedia of Chemicals, Drugs, and Biologicals -Remington: The Science and Practice of Pharmacy -Trissel's Stability of Compounded Formulations

Select the correct chapter of USP Compounding Compendium that includes standards for non-sterile compounding. a. 785 b. 795 c. 797 d. 800 e. 825

b -797 - sterile preparations -800 - hazardous drugs -The other 2 don't exist

BL is a 57 y/o male who arrives at the hospital with his meds in a weekly pill dispenser. He's unable to remember all of the drug names. The nurse call the pharmacy for assistance. The pharmacist can identify the medications using which of the following resources? a. LactMed b. Merck Index c. Clinical Pharmacology d. FDAble e. Micromedex f. Lexicomp g. Drugs.com

c, e, f, g Other drug identification resources: -Epocrates -Facts and Comparisons -mobilePDR

A pt with pancreatic cancer has had a poor response to traditional therapies. The medical team wants to research if there are any investigational treatments for this condition. Which resource would be most useful for the medical team? a. ashp.org b. hivinfo.nih.gov c. kdigo.org d. clinicaltrials.gov e. cdc.gov

A pharmacist is preparing a presentation on the "Top Drug Interactions in Pharmacy" for a regional conference. Which resource would be useful in developing the presentation content? a. Hansten and Horn's b. MedWatch c. USP-NF d. Harriet Lane Handbook e. Lexi-Tox

A 25 y/o male comes to the pharmacy to ask for a recommendation to self-treat nasal congestion caused by seasonal allergies. Which resource can the pharmacist use to find the recommended tx for his symptoms? a. The Handbook of Nonprescription Drugs b. NeoFax c. Remington: The Science and Practice of Pharmacy d. The NCCN website e. Trissel's Pharmaceutics Database

A pharmacist would like to know if there's a biosimilar product for Neupogen. What reference could the pharmacist use to find this info? a. Plumb's b. DSM-5 c. The Purple Book d. FDAble e. Remington's

c The Purple Book lists biological products, including any biosimilar and interchangeable biological products licensed by the FDA.

A new hospital pharmacist is being trained to evaluate and verify orders for the pediatric medicine units. Which drug info resource/s will be most useful to the pharmacist? a. The Harriet Lane Handbook b. Lexicomp c. AHFS Drug Information d. The Pink Sheet e. The American Academy of Pediatrics (AAP)

a, b, c, e

A pharmacist wants to find info on a new boxed warning he heard about for febuxostat. Where is the best place to locate this info? a. The Material Data Safety Sheet b. The NIOSH list c. The FDA website d. TOXLINE e. PubMed

A medical resident stops by the pharmacy satellite to inquire if he can use a copy of the "Briggs" reference guide. He needs to answer a question for his attending physician before morning rounds. The medical resident is researching which type of info? a. Drug use in pregnancy b. Tx of cardiac conditions c. Drug use in the elderly d. Tx of psychiatric conditions e. Management of overdoses

An 85 y/o female is admitted to the hospital after experienced a fall-related hip fracture. The pharmacist is asked to assess whether any of her home meds could have contributed to her fall risk. Which of the following resources would be most useful to the pharmacist? a. The WHO b. The Beers Criteria c. Hansten and Horn's d. The Green Book e. The Harriet Lane Handbook

A medical resident is prescribing olopatadine for a pt with allergic conjunctivitis. He recently heard that some of the branded formulations for this drug were switched to OTC, and he asks the pharmacist for assistance. Where can the pharmacist find info on the OTC status of olopatadine? a. Clinical Pharmacology b. ASHP's Guidelines on Compounding Sterile Preparations c. Index Nominum d. The Green Book e. Koda-Kimble's Applied Therapeutics

a DailyMed and the FDA website are other possible resources to find this info.

A pharmacy student is researching for off-label uses of propranolol. This info is best located in which of the following resources? a. Drugs@FDA b. Clinical Pharmacology c. Drugs.com d. King Guide e. Lexicomp

b, c, e Other off-label uses resources: -AHFS/AHFS CDI -Epocrates -Facts and Comparisons -Micromedex

A pharmacy intern is participating in team-based rounds for a pt with hospital-acquired pneumonia. She wishes to review the recommended empiric antibiotic tx. Which of the following resources could she use? a. IDSA website b. ADA website c. MedlinePlus d. ACC/AHA website e. The Sanford Guide

a, e

Which organization issues a guideline for the tx of asthma? a. ADA b. GINA c. GOLD d. KDIGO e. ACIP

Which resource would provide the best review of a drug's chemical structure and related therapeutic effects? a. Goodman and Gilman's b. The Red Book c. The Handbook of Nonprescription Drugs d. Morbidity and Mortality Weekly Report e. WebMD

a Goodman and Gilman's The Pharmacological Basis of Therapeutics provides detailed info regarding drug/drug class chemical structure and MOA.

Select the correct chapter of USP Compounding Compendium that includes standards for sterile compounding. a. 785 b. 795 c. 797 d. 800 e. 825

EK is beginning amiodarone therapy. She's easily stressed and worried about having "racing heart and dizziness" or what her Dr said was an "arrhythmia." She uses furosemide and has had hypokalemia in the past. She's been told that her potassium and magnesium need to be within normal limits to keep her heart at a normal rhythm and that she should try to relax. The Dr has decided that she wants to check magnesium and potassium and orders a BMP. Select the correct statement. a. The Dr should also order the potassium level; this isn't included in the BMP. b. The Dr should also order the magnesium level; this isn't included in the BMP. c. A CBC would include all of the labs the Dr is interested in checking. d. The BMP will also allow the Dr to check the pt's thyroid status. e. The Dr should also order the sodium level; this isn't included in the BMP.

b The BMP includes glucose, sodium, potassium, bicarbonate, chloride, BUN, and creatinine.

A 44 y/o Asian female with a hx of non-Hodgkin's lymphoma received several cycles of chemo. The pt was in remission for 11 years until recently when she experienced a relapse. She was admitted for inpatient chemo. The pt received the CODOX-M/VAC regimen (cyclophosphamide, doxorubicin, MTX, etoposide, and cytarabine). During the hospitalization, she developed Streptococcus viridans sepsis and is being treated with levofloxacin 500 mg IV daily. The pt is found to have decreased serum folate levels. The clinical pharmacist participating in medical rounds is asked if any of the pt's meds could have contributed to the low folate levels. Select the best response: "The most likely drug contributing to the decrease in folate is..." a. Levofloxacin b. Cytarabine c. Cyclophosphamide d. Methotrexate e. Doxorubicin

d Drugs that cause decreased folate levels: -Phenytoin/fosphenytoin -Phenobarbital -Primidone -Methotrexate -Bactrim

Which of the following meds are known to contribute to drug-induced hemolysis and would require d/c in a pt who developed hemolysis after use of the drug? a. Methyldopa b. Quinidine c. Rasburicase d. Naloxone e. Linezolid

a, b, c -The Coombs test is used in the diagnosis of hemolytic anemia. If the Coombs test is positive and a drug-induced cause is suspected, d/c the offending drug. -Drugs that can cause hemolytic anemia: Penicillins and cephalosporins (prolonged use/high concentrations), dapsone, isoniazid, levodopa, methyldopa, methylene blue, nitrofurantoin, pegloticase, primaquine, quinidine, quinine, rasburicase, rifampin, and sulfonylurea

A pt presents with confusion and rapid breathing. A lap report reveals a low serum bicarbonate level and metabolic acidosis. Which of the following meds would most likely cause this abnormality? a. Phenytoin b. Carbamazepine c. Topiramate d. Levetiracetam e. Valproic acid

c -Topiramate and zonisamide are 2 antiepileptic drugs that can cause low serum bicarbonate and metabolic acidosis. -Salicylate overdose can also cause low bicarbonate.

Which med can cause B12 deficiency when used long-term? a. Dapsone b. Nitrofurantoin c. Levodopa d. Omeprazole e. Bactrim

d PPIs and metformin can cause B12 deficiency if used long-term

MB is being seen today by his PCP. Na = 132 (135-145) SCr = 0.5 (0.6-1.3) Glucose = 98 (100-125) Ca = 8.2 (8.5-10.5) WBC = 11.3 (4-11) Plt = 145 (150-450) AST = 52 (10-40) ALT = 46 (10-40) T bili = 2.3 (0.1-1.2) Albumin = 1.4 (3.5-5) INR = 1.8 Amylase = 28 (60-180) Without knowing MB's meds or PMH, what is the most likely diagnosis based on his labs? a. Hypocalcemia b. Pancreatitis c. Acute kidney injury d. Chronic liver disease e. Anemia

d -The elevated INR, hypoalbuminemia, and thrombocytopenia point toward a reduced synthetic function of the liver. -Bilirubin is metabolized through the liver and levels are often elevated in patients with liver disease. -In advanced or chronic liver disease, most of the hepatocytes are damaged or destroyed and AST/ALT will return to normal. -The pt doesn't have hypocalcemia after correcting for his hypoalbuminemia.

A pt presents with a butterfly-shaped rash on her face and achy joints. The Dr is concerned for drug-induced lupus. The pt's chronic meds include potassium chloride, furosemide, metoprolol succinate, hydralazine/isosorbide dinitrate, candesartan, and eplerenone. Which of the daily meds is most likely contributing to this presentation? a. Furosemide b. Metoprolol succinate c. Hydralazine/isosorbide dinitrate d. Candesartan e. Eplerenone

c DILE can be caused by: -anti-TNF agents -Hydralazine -Isoniazid -Methimazole -Methyldopa -Minocycline -Procainamide -Propylthiouracil -Quinidine -Terbinafine

A lab report indicates an elevated CRP. Which of the following causes is most likely? a. Acute renal failure b. Afib c. Systemic lupus erythematosus d. Prostate cancer e. Acute gouty crystallization

c -CRP is an indicator of inflammation of many conditions -It's used to monitor numerous inflammatory conditions like SLE and rheumatoid arthritis but also to detect acute inflammation in patients with infection

Select the name of the lab test used to distinguish between a microcyctic and macrocytic anemia: a. RDW b. MCH c. MCV d. MCHC e. TIBC

c -High MCV = macrocytic anemia d/t B12 or folate deficiency -Low MCV = microcytic anemia d/t iron deficiency

Which of the following drugs shouldn't be dispensed to a pt with known G6PD deficiency? a. Tranexamic acid b. Tigecycline c. Pegloticase d. Dapsone e. Methylene blue

c, d, e Drugs that shouldn't be used in patients with known G6PD deficiency: -Dapsone -Methylene blue -Nitrofurantoin -Pegloticase -Primaquine -Rasburicase -Sulfonamides

A drug that's highly protein bound (95% or higher bound to albumin) will have a large change in free drug concentration when the protein level changes. If a pt was using warfarin, and the albumin decreased from 2.5 g/dL to 1.5 g/dL, what would be expected to happen to the warfarin and the INR result? a. The free warfarin would increase, and the INR would stay the same. b. The free warfarin level would decrease, which would cause the INR to decrease. c. The free warfarin level would decrease, which would cause the INR to increase. d. The free warfarin level would increase, which would cause the INR to increase. e. The free warfarin level would increase, which would cause the INR to decrease.

d -Many drugs and compounds are highly protein bound, including warfarin, phenytoin, valproate, calcium, and others. -Free levels of highly protein bound drugs increase when albumin decreases.

A pt has G6PD deficiency. What can occur as a result of this disease if the pt receives primaquine for malaria prophylaxis? a. The pt will be at higher risk of contracting malaria. b. The pt will be at higher risk of developing primaquine-induced neurotoxicity. c. The pt will be at risk for excessive destruction of red blood cells. d. The pt will have increased renal excretion of electrolytes. e. The pt will develop leukopenia.

c Patients with G6PD deficiency and their health care providers should know the drugs that put them at risk for hemolysis and shouldn't be used.

What lab values are most indicative of a decline in renal function? a. BUN, creatinine, LDH b. BUN, creatinine, ALT c. BUN, creatinine, albumin d. BUN, creatinine, phosphate e. BUN, creatinine, total cholesterol

d Phosphate is renally cleared and increase with renal impairment.

TG, a 72 y/o male, is hospitalized with a pulmonary embolism. He's receiving UFH initiated at a rate of 1000 units/hr. The control value at this hospital is 22-38 seconds. Select the correct monitoring parameters for patients receiving heparin. a. aPTT b. Serum creatinine c. Platelets d. Hgb/Hct and signs of bleeding e. Serum phosphate

a, c, d

What is normal INR for a patient who isn't taking warfarin?

< 1.2

A pt's med list: Zocor 40 mg daily, levothyroxine 125 mcg daily, Norvasc 10 mg daily, Flovent HFA 88 mcg (2 puffs) BID, multivitamin Which of the pt's lab abnormalities is a well-known adverse effect of one of her meds? a. Hypocalcemia: Ca = 8.2 (8.5-10.5) b. Hypoalbuminemia: Albumin = 2.8 (3.5-5) c. Hypernatremia: Na = 146 (135-145) d. Anemia: Hgb = 10.8 (12-16 female) and Hct = 32.1 (36-46 female) e. Increased LFTs: AST = 142 (10-40) and ALT = 130 (10-40)

e Increased LFTs are a known AE of statin therapy. Statins should be stopped if LFTs are > 3x ULN.

A pt is taking levothyroxine 125 mcg daily and is seeing her PCP for a routine follow-up. Labs are taken and her TSH = 0.15 (0.3-3) and her FT4 = 4.2 (0.9-2.3). Which of the following is the correct assessment of the pt's thyroid function? a. She's currently hypothyroid. Increase levothyroxine dose. b. She's currently hypothyroid. Decrease levothyroxine dose. c. She's currently hyperthyroid. Increase levothyroxine dose. d. She's currently hyperthyroid. Decrease levothyroxine dose. e. Must obtain T3 and total T4 to adequately assess.

d Low TSH and increased FT4 indicate hyperthyroidism.

The pharmacist on rounds has a pt with an acid-base imbalance. The pharmacist has calculated the pt's anion gap. This calculation is performed to identify if the pt has an anion gap or non-anion gap: a. Induced renal toxicity b. Induced hepatotoxicity c. Metabolic alkalosis d. Metabolic acidosis e. Lactic acidosis

d Anion gap is calculated with the sodium, chloride, and bicarb from the BMP.

A pt's albumin level is 2. Which of the following would need to have the level adjusted d/t this albumin level? a. Digoxin b. Calcium c. Phenytoin d. Lisinopril e. Valproate

b, c, e If the free level is ordered, or the ionized calcium, no adjustment is required. The lower the albumin level, the higher the actual drug concentration will be when it's adjusted.

JS is being seen today in the ER. Abnormal Labs: -K = 5.2 (3.5-5) -Glucose = 142 (100-125) -WBC = 14.3 (4-11) -Neut = 88 (45-73) -Bands = 7 (3-5) -CRP = 53 (0-0.5) Without knowing JS's meds or PMH, what is the most likely diagnosis based on his labs? a. Lactic acidosis b. Cholecystitis c. Viral infection d. Parasitic infection e. Bacterial infection

e The leukocytosis with increased neutrophils, bands, and CRP point toward a bacterial infection.

Calcium levels may decrease with chronic use of these drugs: a. Bumetanide b. Aliskiren-HCTZ c. Alendronate d. Cinacalcet e. HCTZ-triamterene

a, c, d -Long-term use of heparin, loop diuretics, bisphosphonates, cinacalcet, systemic steroids, calcitonin, foscarnet, and topiramate can decrease calcium levels. -Thiazide diuretics decrease renal excretion of calcium and increase serum calcium.

The time that's generally preferred to take drug levels (for most drugs) is called: a. The equilibrium level b. The peak c. The trough d. The therapeutic index e. Steady state

e Steady state occurs when the amount of drug entering the body is equal to the amount of drug leaving the body (through metabolism, excretion).

Which of the following meds is incorrectly matched with its usual therapeutic range? a. Digoxin for HF: 0.5-0.9 ng/mL b. VPA: 50-100 mcg/mL c. Vancomycin for cellulitis: 10-15 mcg/mL d. Phenytoin: 4-12 mcg/mL e. Gentamicin trough for traditional dosing: < 2 mcg/mL

d The usual therapeutic range for phenytoin is 10-20 mcg/mL. Be sure to assess serum albumin for patients on phenytoin, as the phenytoin level may require correction.

Which of the following drugs can contribute to low serum sodium levels? a. Tolvaptan b. Torsemide c. Escitalopram d. Carbamazepine e. Oxcarbazepine

b, c, d, e -Tolvaptan is used in the tx of specific types of hyponatremia and cal lead to elevated serum sodium levels.

The following patch is used for topical pain relief and can be cut into pieces by the pt to be applied "where it hurts": a. Lidoderm b. Neupro c. EMSAM d. Duragesic e. Catapres-TTS

a Lidoderm is the only pain patch that's designed to be cut and applied over the painful regions.

Which of the following patches is changed every 3 days? a. Xulane b. Transderm-Scop c. Vivelle-Dot d. Catapres-TTS e. Daytrana

b -Transderm-Scop is applied behind the ear. If the procedure or travel is complete, the patch doesn't need to stay on for the full 3 days. Wash hands well after handling the patch. Keep fingers out of eyes. -Duragesic is also changed every 3 days. If it wears off after 48 hours, change to every 48 hours. -Xulane - weekly for 3 weeks, off for 1 week -Vivelle-Dot - twice weekly -Catapres-TTS - weekly -Daytrana - daily (QAM, 2 hours prior to school)

A 67 y/o man was prescribed Lidoderm for persistent pain after his shingles lesions resolved. Which of the following counseling points for Lidoderm is incorrect? a. Up to 3 patches can be applied per day b. The patches can be cut to fit the painful area c. The patches can be worn for up to 2 days, but should be replaced if the effect wears off sooner d. Apply the patch to clean dry skin e. Avoid exposure to external heat sources (e.g., heating pad, hot tub)

c Lidoderm patches should be applied once daily and removed after 12 hours. They can be reapplied 12 hours after removal.

What is the primary purpose of using a glycerin suppository in a child or adult? a. To prevent constipation b. To treat constipation c. To prevent ileus d. To treat ileus e. To avoid the use of oral agents

b A suppository (glycerin, bisacodyl) is used to treat constipation, not to prevent constipation.

SK is a 32 y/o female with depression. She presents to the pharmacy on 6/17 for a refill of her bupropion. Upon reviewing her chart, the pharmacist sees the following refill hx: 4/30: Buproprion SR 150 mg 1 tab PO BID; Quantity 60 4/30: Lo Loestrin Fe 1 tab PO daily; Quantity 84 3/15: Bupropion SR 150 mg 1 tab PO BID; Quantity 60 2/5: Bupropion SR 150 mg 1 tab PO BID; Quantity 60 2/5: Lo Loestrin Fe 1 tab PO daily; Quantity 84 Based on SK's refill hx, which statement regarding her adherence is true? a. SK is adherent to both her Lo Loestrin Fe and bupropion b. SK is adherent to her Lo Loestrin Fe but non-adherent to her bupropion c. SK is adherent to her bupropion but non-adherent to her Lo Loestrin Fe d. SK is non-adherent to both her Lo Loestrin Fe and bupropion e. There's not enough info available to determine SK's adherence

Phenylalanine must be avoided in patients with PKU. Which of the following formulations may contain phenylalanine? a. Granules b. Patches c. Injectables d. Chewable formulations e. ODTs or sublingual formulations

a, d, e Phenylalanine is a sweetener. It's dangerous for those with phenylketonuria (PKU), a genetic defect in which the enzyme that degrades phenylalanine is absent.

Which route of delivery is preferred for local tx of distal ulcerative colitis with mesalamine? a. Transdermal b. Oral c. Intravenous d. Sublingual e. Rectal

e Mesalamine is the DOC for distal ulcerative colitis. Using a suppository will allow for local tx and avoid systemic side effects.

Which patch formulation is dispensed with its own adhesive cover to hold the patch in place? a. Fentanyl b. Androderm c. Butrans d. Clonidine e. Transderm-Scop

d Fentanyl (Duragesic) and buprenorphine (Butrans) can only be covered by Tegaderm or Bioclusive (permitted adhesive film dressings). Most patches can't be covered with tape.

Which of the following is a long-acting opioid capsule that can be opened and the contents sprinkled on food? a. MS Contin b. Ritalin LA c. Depakote Sprinkles d. Micro-K e. Kadian

e Kadian is an ER formulation of morphine.

All of the following meds can be administered as a self-injectable SC injection EXCEPT: a. Invega Sustenna b. Imitrex c. Enbrel d. Humira e. Forteo

a Invega Sustenna is an IM injection.

Select the transdermal patch that can be applied to the butt. a. Transderm-Scop b. Butrans c. Xulane d. Exelon e. Daytrana

c -Xulane and the oxybutynin patch can be applied to the butt -Transderm-Scop - behind the ear -Butrans - sides of the body, level to the chest (upper arms) -Exelon - chest, back, upper arm -Daytrana - hip

Methylphenidate comes in an OROS formulation called Concerta. This formulation provides the following benefits to children with ADHD: a. No need for noontime dosing b. Immediate release to enable adequate drug levels early in the day c. Lower risk of loss of appetite relative to the patch formulation d. Extended release to provide smoother drug delivery over the course of the day e. Lower risk of liver damage relative to atomoxetine

a, b, d The OROS formulation provides both an IR and ER in one delivery system.

Which of the following patches is changed daily? a. Xulane b. Duragesic c. Vivelle-Dot d. Transderm-Scop e. Daytrana

e Daytrana is changed daily, alternating between left and right hip.

Application instructions for the hormone patches (estrogen, progestin, and testosterone) include the following correct counseling points: a. Don't let children or animals near used patches; dispose of safely. b. Don't apply > 1 patch at a time. Don't apply to broken or irritated skin. c. Estrogen patches can be used if the woman has had breast cancer, but PO formulations can't be used with this hx. d. Don't apply to breasts or genitals. e. Can be applied to the lower abdomen.

a, b, d, e If a female has had cancer in any part of the reproductive tract, including breast, estrogen is contraindicated in any formulation.

Many patches work systemically. A few treat a topical condition. Which of the following patches are applied topically to treat pain? a. Flector b. Androderm c. Lidoderm d. Exelon e. Catapres-TTS

a, c

Which of the following opioids comes in several SL formulations designed to provide faster onset of action (relative to oral gut absorption) for cancer patients requiring breakthrough pain medication? a. Oxycodone b. Morphine c. Fentanyl d. Buprenorphine/Naloxone e. Hydromorphone

c Buprenorphine/Naloxone (Bunavil) is a buccal film used primarily for maintenance tx of opioid dependence (addiction).

Which of the following drugs is available in an ODT formulation? a. Memantine b. Dextroamphetamine/amphetamine c. Mirtazapine d. Esomeprazole e. Morphine

c This type of question should be solved by thinking about which drug would have benefit for use in small children, someone with dysphagia, pain with swallowing, non-adherence, or nausea. Mirtazapine (Remeron) is an antidepressant often used in residents of SNFs and in patients receiving cancer tx.

Patients with CF typically require pancreatic enzyme products, such as Creon capsules, to help with absorption of food. Which of the following statements concerning this type of product is correct? a. The capsule contents can be sprinkled on food, then the pellets chewed. b. The capsule contents should be mixed with foods with a high pH only. c. Capsule contents that are mixed with food or liquid can be stored for up to 24 hours. d. The capsule contents should only be mixed with specific foods listed in the instructions. e. It's best to mix capsule contents with hot liquids so they dissolve more quickly.

A middle-aged man has paranoid schizophrenia. He's been in intensive therapy and states he's willing to use his antipsychotic. However, he has a hx of forgetting to take his daily doses. Which meds are available in a long-acting injection that may be useful to improve adherence? a. Aripiprazole b. Quetiapine c. Haloperidol d. Lurasidone e. Risperidone

a, c, e Haldol Decanoate - every 4 weeks Abilify Maintena - every 4 weeks Invega Sustenna (paliperidone) - every 4 weeks Risperdal Consta - every 2 weeks

Which of the following patches is changed twice weekly? a. Xulane b. Exelon c. Vivelle-Dot d. Lidoderm e. Daytrana

c -Exelon - daily -Xulane - weekly -Lidoderm - 1-3 patches PRN, on for 12 hours, off for 12 hours -Daytrana - daily

A 35 y/o woman has migraines with dizziness, nausea, and occasional vomiting. The migraines come on quickly and cause debilitating pain. Choose the drug and formulation that would be preferable: a. Frovatriptan compressed tablet b. Maxalt-MLT c. Imitrex STATdose d. Duragesic injection e. Calcitonin nasal spray

c The ODT formulation (Maxalt-MLT) would help decrease nausea. However, d/t the pt's vomiting and immediate onset, the injection (Imitrex STATdose) would be a preferable option.

What is the reason that some patches need to be removed prior to an MRI procedure (e.g., Androderm or clonidine)? a. The patch could break the expensive MRI machine. b. The patch could become sub-therapeutic. c. The MRI will inactivate the patch. d. The MRI will cause the metal in the patch to burn the skin. e. The heat from the MRI can release the drug from the patch, causing OD.

A 32 y/o man was prescribed Flector (diclofenac) patch for a high ankle sprain he sustained while playing basketball. How frequently should the patch be applied? a. Twice daily b. Once daily c. Twice weekly d. Weekly e. As needed

Which of the following should accompany a micafungin dose when it's delivered to the nursing unit for pt administration? a. 0.22 micron filter b. 0.5 micron filter c. Light-protective covering d. Non-PVC infusion set e. Y-site tubing

Which of the following is an example of a physical incompatibility that can occur with a drug? a. Drug degradation d/t hydrolysis b. Drug toxicity d/t oxidation c. Drug decomposition d. Drug that can't be placed into PVC container e. Drug incompatible with saline

d, e -Chemical incompatibility: Causes drug degradation or toxicity d/t a hydrolysis, oxidation, or decomposition reaction -Physical incompatibility: Occur between a drug and the container, the diluent (e.g., dextrose or saline), or another drug

Which of the following IV meds require filtration? a. Precedex b. Ativan c. Lasix d. Amiodarone e. Moxifloxacin f. Vancomycin

b, d Remember: That's my GAL, PLAT -Golimumab (Simponi), Amiodarone, Lorazepam, Phenytoin, Lipids (1.2 micron), Ampho B (lipid forms), Taxanes (except docetaxel) -Phenytoin and lorazepam require filters when administered by continuous IV; a filter isn't required for IV push -Ampho B requires a 5 micron filter

Which of the following meds is incompatible with PVC bags? a. Precedex b. Ativan c. Lasix d. Amiodarone e. Moxifloxacin f. Vancomycin

b, d Remember: Leach Absorbs To Take In Nutrients -Lorazepam, Amiodarone, Tacrolimus, Taxanes, Insulin, Nitroglycerin

Which of the following meds should not be refrigerated? a. Precedex b. Ativan c. Lasix d. Amiodarone e. Moxifloxacin

a, c, e Remember: Dear Sweet Pharmacist, Freezing Makes Me Edgy! -Dexmedetomidine (Precedex), SMX/TMP, Phenytoin (crystallizes), Furosemide (crystallizes), Metronidazole, Moxifloxacin (Avelox), Enoxaparin (Lovenox) -Diluted Precedex and furosemide can be kept cold

When compounding IV meds from ampules, what's used to prevent particles from getting into the IV bag? a. Filter needles b. Tuberculin syringes c. Y-sites d. Multidose vials e. In-line filters

Which statement is INCORRECT regarding IV access? a. Peripheral IV lines are typically used for short-term access needs b. Peripheral lines are associated with phlebitis (irritation of the vein) c. Peripheral lines are preferred for higher osmolality solutions d. Central lines are preferred for infusions of vesicant solutions or vasopressors e. Central lines are preferred for highly concentrated drugs

c Central lines can accommodate higher osmolality solutions than peripheral IV access

The majority of drugs that require filters use what size filter? a. 0.10 micron b. 0.15 micron c. 0.22 micron d. 1.2 micron e. 5 micron

c Lipids require a larger pore size (1.2 micron)

Which of the following meds should be protected from light? a. Bactrim b. D5NS c. Enoxaparin d. Nitroprusside e. Phenytoin

d Remember: Protect Every Necessary Med from Daylight -Phytonadione (vit K; Mephyton), Epoprostenol (Flolan), Nitroprusside (Nitropress), Micafungin (Mycamine), Doxycycline

Which of the following meds shouldn't be refrigerated? a. Bactrim b. Hydralazine c. Enoxaparin d. Nitroprusside e. Regular insulin f. Phenytoin

a, c, f Remember: Dear Sweet Pharmacist, Freezing Makes Me Edgy! -Dexmedetomidine (Precedex), SMX/TMP, Phenytoin (crystallizes), Furosemide (crystallizes), Metronidazole, Moxifloxacin (Avelox), Enoxaparin (Lovenox)

Which of the following meds require filtration? a. Bactrim b. Hydralazine c. Phenytoin d. Nitroprusside e. Insulin regular

c Remember: That's my GAL, PLAT -Golimumab (Simponi), Amiodarone, Lorazepam, Phenytoin, Lipids (1.2 micron), Ampho B (lipid forms), Taxanes (except docetaxel) -Phenytoin and lorazepam require filters when administered by continuous IV; a filter isn't required for IV push -Ampho B requires a 5 micron filter

You are preparing a phenytoin piggyback. Which diluent should be used? a. 0.9% NS b. D5W c. D5W1/2NS d. Lactated Ringer's e. Albumin

a Remember: A DIAbetic Can't Eat Pie -Ampicillin, Daptomycin (Cubicin), Infliximab (Remicade), Ampicillin/Sulbactam (Unasyn), Caspofungin (Cancidas), Ertapenem (Invanz), Phenytoin (Dilantin)

Which of the following IV meds must be diluted in dextrose? a. Bactrim b. Hydralazine c. Phenytoin d. Remicade e. Insulin regular

a Remember: Obese Baker Avoids Salt -Oxaliplatin, Bactrim, Ampho B (all), Synercid (Quinupristin/Dalfopristin)

A pt is receiving ceftriaxone through her IV line. Which of the following products is incompatible if administrated with ceftriaxone? a. Calcium chloride b. Sodium chloride c. Potassium acetate d. Magnesium chloride e. Sodium acetate

a Ceftriaxone cannot be mixed with any calcium-containing product, or it will precipitate.

A hospital pharmacist is compiling a chart of compounding instructions for IV meds in the cleanroom. Which of the following meds should be indicated as "Do Not Shake?" a. Insulin b. Immune globulins c. Phenytoin d. Infliximab e. Alteplase

a, b, d, e Hormones and proteins are compounds that can be damaged by agitation. This should be considered when compounding and delivering meds (some meds shouldn't be sent via the pneumatic tube system)

TS presents to the ER with chest pain and SOB. His BP is 195/115 mmHg, HR is 102 BPM, and he's found to be having an acute MI. A NTG drip has been ordered. Premixed IV NTG has been on shortage, so the nurse removes a compounded bag from the refrigerator to start the infusion. Which of the following is true? a. The bag should be discarded because NTG shouldn't be refrigerated. b. NTG requires use of an in-line filter to prevent possible precipitates from reaching the pt. c. The pharmacy should have supplied a brown bag as NTG must be protected from light during the infusion. d. The drug should be compounded in a glass bottle or other non-PVC container. e. NTG must be diluted with dextrose solutions only to prevent a precipitate from forming.

A nurse calls the pharmacy to see if she can infuse diltiazem via Y-site into the same line with heparin. What is a reputable resource for this compatibility info? a. Critical Care Handbook b. The ICU Book c. The Drug Information Handbook d. Harrison's Principles of Internal Med e. Handbook on Injectable Drugs

The somatic nervous system controls voluntary muscle movement by releasing which NT? a. Acetylcholine b. NE c. Dopamine d. Epinephrine e. Vasopressin

Which of the following are side effects of IV epinephrine? a. Increased HR b. Pupil constriction c. Increased BP d. Bronchodilation e. Lacrimation

a, b, c, d Epinephrine stimulates alpha-1, beta-1, and beta-2. Fight or flight

Which of the following statements describes the expected effect of a drug that's a selective beta-2 agonist? a. Decreased HR b. Neuromuscular blockade c. Relaxation of bronchial smooth muscle d. Increased salivation, lacrimation, and urination e. Inhibition of monoamine oxidase

Which enzyme does allopurinol work on? a. Xanthine oxidase b. Angiotensin-converting enzyme c. Monoamine oxidase d. Acetylcholinesterase e. Cyclooxygenase

Irinotecan is a chemo drug known to cause many AEs through an increase in acetylcholine. Which of the following are expected AEs of increased acetylcholine? a. Urination b. Constipation c. Increased peristalsis d. Increased secretion of tears e. Salivation

a, c, d, e

TZ presents to the community pharmacy with a prescription for selegiline. The pharmacist notes that TZ has a diagnosis of depression and Parkinson Disease and is currently taking tranylcypromine (Parnate). What must the pharmacist do? a. Counsel the pt to increase consumption of tyramine-containing foods b. Call the prescriber to discuss the major DDI c. Call the prescriber to obtain a prescription for an albuterol inhaler to manage bronchoconstriction d. Counsel the pt to d/c tranylcypromine and start selegiline tomorrow e. Fill the new prescription and provide standard counseling

b -Both are MAO inhibitors -A 14-day washout period is generally recommended between MAO inhibitors -Using multiple MAO inhibitors together increases the risk of serotonin syndrome and/or hypertensive crisis

Which drug-receptor interaction would most likely result in smooth muscle vasodilation? a. Nicotinic receptor agonist b. Beta-1 receptor antagonist c. Beta-2 receptor antagonist d. Alpha-1 receptor antagonist e. Serotonin receptor agonist

d Alpha-1 receptors are primarily found in the peripheral smooth muscle Antagonism causes smooth muscle vasodilation and a decease in BP