Gastrointestinal Disorders Flashcards
1
Q
- Nonpharmacologic interventions are aimed at
decreasing the incidence of acid reflux and enhancing
esophageal clearance in patients with gastroesophageal reflux disease (GERD). Which strategy would be
most effective?
A. Refraining from food consumption 1 hour before
going to bed.
B. Eating peppermint after meals.
C. Wearing tight-fitting clothes.
D. Discontinuing smoking.
A
- Answer: D
Lifestyle modifications are aimed at lessening the incidence
of acid reflux and enhancing esophageal acid clearance.
Modifications include dietary modifications, smoking
cessation, avoidance of tight-fitting clothes, avoidance of
medications that act on the lower esophageal sphincter,
elevation of the head of the bed while sleeping, weight
loss, and chewing gum to promote salivation. Answer A
is incorrect; avoiding food consumption within 1 hour of
bedtime is insufficient – the patient should avoid food consumption within 2–3 hours of going to bed. Answer B is
incorrect; eating peppermints after meals is not a recommended lifestyle modification; mint can loosen the lower
esophageal sphincter. Answer C is incorrect; the recommendation is NOT to wear tight-fitting clothes. Answer D
is correct; smoking cessation is a recommended lifestyle
modification. Avoidance of tobacco products and smoking is recommended for patients with GERD because it
may reduce esophageal acid exposure. Smoking decreases
saliva, and saliva can help neutralize acid that refluxes to
the mouth and throat. A cohort study showed that smoking
cessation improved GERD symptoms, and improvement
was shown by a validated questionnaire.
1
Q
- A 67-year-old woman with rheumatoid arthritis takes
naproxen 500 mg by mouth daily, metoprolol 25 mg
by mouth twice daily, aspirin, and alendronate 70 mcg
by mouth weekly. Which is the best recommendation
regarding gastroprotective therapy?
A. Lansoprazole 30 mg daily.
B. Esomeprazole 40 mg twice daily.
C. Misoprostol 200 mcg twice daily.
D. No gastroprotective therapy necessary.
A
- Answer: A
Preventive therapy should be selected according to a combined assessment of GI and CV risk. To calculate the GI
risk, risk factors should be assessed and tabulated (e.g.,
no risk factors: low risk; one or two risk factors: moderate risk; three or more risk factors or having a previous
ulcer complication or concomitant use of corticosteroids
or anticoagulants: high risk). This patient has two GI risk
factors (e.g., age older than 65 and aspirin therapy); she
thus has moderate GI risk. Cardiovascular risk is defined
as either low or high. This patient has low CV risk because
she does not have CV illness. Preventive therapy should
be selected for someone with moderate GI/low CV risk.
Therapy options include naproxen plus a PPI (or misoprostol). Answer A is correct; PPI is a recommended therapy.
Answer B is incorrect; standard-dose PPI is recommended
therapy, which is once daily, not twice daily. Answer D is
incorrect; from the GI and CV risk assessment, gastroprotective therapy is recommended. Answer C is incorrect;
although misoprostol is recommended for moderate GI/
low CV risk, the dose indicated is low, which may reduce
misoprostol adverse events. In addition, misoprostol is not
dosed often enough. The recommended dose is 800 mcg
four times daily
2
Q
- Which best describes the patient who would most
require counseling on the importance of using two
forms of contraception during hepatitis C virus (HCV)
treatment and for 6 months after completing treatment?
A. 29-year-old woman receiving elbasvir/grazoprevir
plus ribavirin.
B. 47-year-old woman receiving glecaprevir/
pibrentasvir.
C. 53-year-old woman receiving sofosbuvir/
velpatasvir.
D. 36-year-old woman receiving ledipasvir/
sofosbuvir.
A
- Answer: A
Answer A is correct. Ribavirin is category X and must not
be taken during pregnancy or within 6 months of the patient
or the patient’s partner becoming pregnant. Answers B–D
do not include ribavirin in the regimen, so teratogenicity is
not a concern.
3
Q
- A 52-year old woman with liver cirrhosis of unknown
cause presents to the emergency department today
with increased confusion, change in sleep patterns,
and decreased ability to function at work. Her head
computed tomography (CT) findings and vital signs
are normal. Liver function test results are consistent
with cirrhosis. Which therapy is best to recommend
for her hepatic encephalopathy (HE)?
A. Rifaximin.
B. Lactulose.
C. Flumazenil.
D. Protein restriction.
A
- Answer: B
Hepatic encephalopathy is a diagnosis of exclusion. On
diagnosis, treatment of HE should be initiated. Lactulose
is standard-of-care therapy according to the practice
guidelines; lactulose should be initiated at 45 mL/hour
until evacuation occurs and then tapered to achieve 2 or 3
stools daily. Answer A is incorrect; rifaximin is approved
pharmacotherapy for reducing the risk of OHE but is not
first-line therapy and is commonly reserved for patients
whose condition does not respond to, or patients who are
intolerant of, lactulose. Answer B is correct; lactulose is
first-line therapy according to the guidelines. Answer C
is incorrect; drugs affecting neurotransmission (e.g., flumazenil and bromocriptine) are not recommended by the
guidelines. Use of these agents should be reserved for those
with conditions unresponsive or refractory to other therapies. Answer D is incorrect; protein restriction is no longer
a standard therapy. Although protein restriction is sometimes used during acute episodes, long-term use should be
avoided
4
Q
- A 57-year-old white man with alcoholic liver disease
(Child-Turcotte-Pugh [CTP] class B) received initial
therapy with propranolol 10 mg by mouth twice daily
after a screening endoscopy 1 month ago revealed
grade 2, medium-sized varices. In the clinic today,
he appears to be tolerating the propranolol dose and
reports no signs of lightheadedness, fatigue, or shortness of breath. His vital signs from today and his visit
1 month ago are summarized in the following table.
Which drug is best for this patient?
Vital Signs 1 Mo Ago Today
Temperature, °F 98.8 98.7
Blood pressure, mm Hg 130/90 130/83
Respiratory rate, breaths/min 16 15
Heart rate, beats/min 89 81
A. Change propranolol to nadolol 20 mg by mouth
daily.
B. Add isosorbide mononitrate 10 mg by mouth twice
daily.
C. Continue current therapy and reevaluate in 4
weeks.
D. Increase propranolol to 20 mg by mouth twice
daily.
A
- Answer: D
Individuals with large varices and cirrhosis should receive
primary prophylaxis against variceal bleeding with nonselective β-blockers as first-line therapy. The guidelines
call for titrating the β-blocker to the maximal dose tolerated. A goal heart rate of 55–60 beats/minute is reasonable
if the patient’s blood pressure allows it. Answer A is
incorrect; according to the case, the patient seems to be
tolerating propranolol; thus, changing from one nonselective β-blocker to another is not the best option. Answer
B is incorrect; adding a long-acting nitrate would likely
reduce portal pressure, but studies have been inconclusive,
with some studies suggesting increased mortality. Thus,
this is not a recommended therapy for primary prophylaxis. Answer C is incorrect; 1 month of therapy without
meeting the targets shows that an intervention is necessary;
thus, making no changes is incorrect. Answer D is correct;
increasing the propranolol dose for someone who is tolerating the drug but not yet taking the maximal tolerated dose
is the best option. Continued follow-up and evaluation of
the need for additional dose adjustments according to heart
rate and blood pressure are necessary.
5
Q
- A patient who recently moved to the United States from
Indonesia with chronic hepatitis B virus (HBV) infection has taken lamivudine 100 mg by mouth daily for
18 months. His HBV DNA became undetectable after
2 months of therapy and remained so until 6 weeks
ago. Laboratory data from 6 weeks ago are as follows:
aspartate aminotransferase (AST) 197 IU/mL, alanine
Gastrointestinal Disorders
ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
952
aminotransferase (ALT) 227 IU/mL, total bilirubin 2.7
mg/dL (indirect 1.9 mg/dL, direct 0.8 mg/dL), serum
creatinine (SCr) 1.1 mg/dL, and HBV DNA 47,600
IU/mL. His HBV DNA value from 1 week ago was
51,200 IU/mL. Which is the best course of action?
A. Add entecavir.
B. Add adefovir.
C. Discontinue lamivudine and add entecavir.
D. Discontinue lamivudine and add tenofovir
A
- Answer: D
Patients develop virologic breakthrough while receiving NA therapy because of medication nonadherence or
the development of antiviral resistance. The guideline
recommendation for patients developing breakthrough is
counseling regarding medication adherence and confirmation of breakthrough by retesting HBV DNA in 1–3
months. This case provides no information regarding the
patient’s medication adherence but does provide two different HBV DNA concentrations that are 5 weeks apart and
detectable; thus, from the information given, the patient
has developed virologic breakthrough while adherent to
lamivudine therapy. To manage breakthrough, the guidelines recommend either changing the NA agent (preferred)
or adding another, different NA to the current therapy.
Specific management varies depending on the current NA
therapy (Table 15). Answers A and B are incorrect; adding
entecavir or adefovir to lamivudine is not recommended by
the guidelines. Changing to entecavir monotherapy is not
recommended by the guidelines, making Answer C incorrect. Answer D is correct because lamivudine resistance
can be managed by changing to tenofovir
6
Q
- Which best describes the correct population and
methodology recommended for serologic testing for
immunity after administration of the HBV vaccine?
A. Patients with chronic liver disease: Test for anti–
hepatitis B surface antibody (anti-HBs); test 1–2
months after the last dose of the vaccine series.
B. Patients with chronic liver disease: Test for anti–
hepatitis B early antigen (anti-HBe); test 3–4
months after the last dose of the vaccine series.
C. Health care workers: Test for anti-HBs; test 1–2
months after the last dose of the vaccine series.
D. Health care workers: Test for anti-HBe; test 3–4
months after the last dose of the vaccine series.
A
- Answer: C
Serologic testing for immunity is recommended only for
those whose subsequent clinical treatment relies on knowing their status (e.g., health care workers, public safety
workers) because of their high risk of continued exposure.
The guidelines recommend testing for anti-HBs concentrations 1–2 months after the last dose of the vaccine
series, making Answer C correct. Individuals with antiHBs concentrations of 10 IU/L or greater are considered
immune. Answer A is incorrect; although the serologic test
(anti-HBs) and the time point (1–2 months after completing the vaccine series) are correct, the patient population
with chronic liver disease is not. Answer B is incorrect;
the serologic marker (anti-HBe) and the time point (3–4
months after completing the vaccine series) are incorrect.
In addition, patients with chronic liver disease are not
included in the recommendations with respect to serologic
testing for immunity. Answer D is incorrect; health care
workers should be tested; however, testing for anti-HBe is
incorrect, as is the time point of 3–4 months.
7
Q
- You are contacted by one of the new gastrointestinal
(GI) medical fellows regarding the use of infliximab
for a patient with a history of Crohn disease (CD),
HBV, GERD, and arthritis. The patient takes mesalamine (Pentasa) 1 g by mouth four times daily,
azathioprine 100 mg by mouth once daily, esomeprazole 40 mg by mouth once daily, entecavir 0.5 mg
by mouth once daily, and acetaminophen 325 mg by
mouth twice daily. Which is the best first recommendation to provide the GI fellow regarding infliximab
therapy for this patient?
A. Premedicate with an antihistamine, acetaminophen, and corticosteroids before the first dose.
B. Obtain additional information regarding this
patient’s use of entecavir and HBV history before
prescribing therapy.
C. Assess cardiac function by obtaining an echocardiogram before administration.
D. Order a tuberculosis (TB) test to rule out TB; then
administer infliximab
A
- Answer: B
The GI fellow remembered correctly that infliximab
prescribing has special precautions. According to the prescribing information, therapy is contraindicated in patients
with active infection, latent TB (untreated), heart failure (New York Heart Association class III or IV), recent
malignancies, optic neuritis, or a preexisting demyelinating
disorder. In addition, because predisposition to infection
may occur with all the anti-TNFα agents, the risk-benefit
of use should be evaluated in those with chronic infections.
Before initiating therapy, patients should be screened for
TB, HBV, and HCV, and patients should be educated to
avoid live vaccines during therapy. Answer B is the best
recommendation because, according to this patient’s medication list, the patient takes entecavir, which suggests
the patient has a chronic infectious disease (e.g., HBV).
Additional information (e.g., the status of the patient’s
chronic infectious disease, whether the disease is active
[HBV RNA concentration]) must be obtained to determine
whether infliximab therapy is indicated for this patient,
making Answer B correct. Although premedicating with
an antihistamine, acetaminophen, and/or a corticosteroid
is recommended when administering infliximab, this is
not the best answer. First, it should be determined whether
therapy is even indicated for this patient; thus, Answer B
is better than Answer A. Infliximab therapy is associated
with exacerbating underlying heart failure and is contraindicated in a subpopulation of individuals with heart failure
(class III and IV). However, according to the information in the case, this patient does not have heart failure,
so an echocardiogram is not recommended (Answer C is
incorrect). Because of infliximab’s action on TNF, latent
infections such as TB can become reactivated during therapy. Therefore, a TB test before initiation is recommended;
however, this is not the best choice because it should first
be determined whether therapy is even indicated for this
patient; hence, Answer D is incorrect
