Genito, Electro, And Nutrit. Flashcards
- A 77-year-old white man presents with a 2-month
history of nocturia, dribbling, and decreased urine
stream. His International Prostate Symptom Score
(IPSS) is 6 of 35, his prostate is slightly enlarged, and
his prostate-specific antigen concentration is within
normal limits. He has not tried to treat his symptoms.
He takes amlodipine 5 mg daily for hypertension
(HTN) and oral diphenhydramine 50 mg at bedtime
for insomnia. Which therapy plan is most appropriate
for this patient?
A. Initiate dutasteride 0.5 mg/day.
B. Initiate tamsulosin 0.8 mg/day.
C. Change amlodipine to terazosin.
D. Discontinue diphenhydramine.
- This patient has mild symptoms that are associated with BPH. Because his symptom score is 6, watchful waiting would be an appropriate treatment option at this time, making Answers A and B incorrect. However, he is taking a first-generation antihistamine (diphenhydramine) known to contribute to or exacerbate his BPH symptoms, so discontinuing this drug might help reduce his symptoms, making Answer D correct. Changing his antihypertensive regimen to an α1-antagonist is not recommended
by current HTN guidelines or the Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack study
because of inferior cardiovascular effects compared with
other antihypertensive agents, making Answer C incorrect.
Correct Answer: D
- An older adult man comes to the pharmacy for a medication therapy management visit. You begin discussing benign prostatic hyperplasia (BPH) with him, and he has many questions because his symptoms have not resolved with his current medication regimen. Which education point is best to include in your disease and drug discussion with him?
A. α1-Antagonists (e.g., tamsulosin) are effective at
reducing BPH symptoms, providing benefit by
reducing the size of the prostate.
B. The 5-α-reductase inhibitors (e.g., finasteride)
should reduce BPH symptoms within 1–2 weeks.
C. Increasing fluid intake and adding fiber to the diet
will reduce the severity of BPH symptoms.
D. BPH typically requires drug therapy to reduce
symptoms, but when the symptoms become
severe, surgery may be the only treatment option.
- Disease and drug therapy counseling for BPH is helpful for patients. Benign prostatic hyperplasia often requires surgery if the disease progresses beyond the benefits of drug therapy (Answer D is correct). Dietary changes (e.g., avoiding caffeine and alcohol, avoiding fluids at bedtime) might reduce symptoms. Adding fiber is not a change known to affect symptoms, and increasing fluid intake may actually worsen symptoms (Answer C is incorrect). The 5-ARIs are the only drug therapy capable of reducing prostate size; this category of medications can take 3–6 months to provide symptom relief (Answer B is incorrect). The α1-antagonists work very quickly to provide BPH symptom relief, but they have no effect on the size of the prostate (Answer A is incorrect).
Correct Answer: D
- A 72-year-old woman with Medicare Part D presents
to the ambulatory care clinic requesting help with her
urgency incontinence medications. She tried darifenacin, but it caused too much dry mouth. Her physician gave her a prescription for fesoterodine, but it is not covered by her insurance. You review her plan’s formulary options for urinary incontinence. The plan covers oxybutynin transdermal patch and solifenacin at tier 2 and oxybutynin immediate release (IR) at tier 1. Her current medications include amlodipine 5 mg/day, lisinopril 10 mg/day, ranitidine 150 mg twice daily, and atorvastatin 20 mg/day. The patient wants to save money, if possible, because she is on a limited income. Which best fits her needs?
A. Pay cash for fesoterodine.
B. Discontinue fesoterodine and initiate the over-the-counter (OTC) oxybutynin patch.
C. Discontinue fesoterodine and initiate oxybutynin
IR.
D. Discontinue fesoterodine and initiate solifenacin
- The cash price for fesoterodine is quite expensive, with an average wholesale price of $297 (Answer A is incorrect). In addition, fesoterodine still has a high rate of anticholinergic adverse effects, such as dry mouth. Oxybutynin IR is tier 1, but it has the most peripheral anticholinergic adverse effects of all agents (Answer C is incorrect). The patient did not tolerate darifenacin (an M3-selective agent), so she would not be expected to tolerate solifenacin, which has the same mechanism (Answer D is incorrect). The oxybutynin patch has the lowest incidence of dry mouth of the formulary agents. This formulation avoids first-pass metabolism of the drug to the active metabolite N-DEO and, as such, has a reduced adverse effect profile compared
with oxybutynin IR tablets (Answer B is correct).
Correct Answer: B
- A 50-year-old woman presents to the family medicine clinic requesting help with her urinary incontinence symptoms and worsening depression. She states that she has had incontinence problems since she had her three children. She loses a small amount of urine mainly when she coughs and laughs or does high-impact exercise. Although she has tolerated these symptoms in the past, they are more bothersome to her now because she is trying to exercise more often. Her depression has been controlled for the past 2 years, but she is now experiencing worsening symptoms. Her
current medications include simvastatin, fluoxetine, a
multivitamin, calcium, vitamin D, and estrogen vaginal cream. Which recommendation is best at this time?
A. Initiate pseudoephedrine.
B. Change from estrogen vaginal cream to oral estrogen therapy.
C. Change from fluoxetine to duloxetine.
D. Initiate oxybutynin gel.
- This patient likely has stress incontinence, possibly caused by bladder neck instability or urethral sphincter weakness from childbirth and/or changes associated with menopause. None of the treatment options are currently FDA approved for the treatment of stress incontinence. Pseudoephedrine is not recommended for stress incontinence treatment because the risk of adverse effects with alpha and beta agonism outweigh the potential benefit (Answer A is incorrect). Changing the patient’s topical hormone therapy to oral therapy could have no effect, or it could worsen her
urinary symptoms (Answer B is incorrect). Oral estrogen is also not recommended for use in older women because of risk outweighing benefit. Fluoxetine does provide benefit for stress incontinence; however, fluoxetine is no longer controlling the patient’s depression. Duloxetine, an SNRI, is an alternative antidepressant that could improve her stress incontinence by improving urethral tone, most
likely caused by the reuptake inhibition of norepinephrine. Several clinical trials have shown clinical benefits of duloxetine (Answer C is correct). Initiating oxybutynin gel would be an option if the patient had symptoms or a diagnosis of OAB (Answer D is incorrect).
Correct Answer: C
- You are tasked with reviewing a new agent (“Wood-E”) for erectile dysfunction (ED) for your pharmacy and
therapeutics committee. You include in your presentation a table of the odds ratios (ORs) pertaining to adverse events.
Incidence Rate of Adverse Events (Call this AE) and OR (n=500 in Each Group):
AE, Placebo, n (%) Wood-E, n (%) OR 95% CI)
Headache 25 (5.0) 40 (8.0) 1.25 (1.12–1.98)
Acute respiratory
infections:
12 (2.4) 16 (3.2) 1.11 (0.85–1.26)
Flushing: 11 (2.2) 20 (4.0) 1.31 (1.01–2.86)
CI = confidence interval; OR = odds ratio
Which statement best describes the data in the table
about adverse events?
A. All three adverse events are statistically significantly more likely to occur in the “Wood-E”
group.
B. Headache is significantly less likely to occur in
the “Wood-E” group.
C. Acute respiratory infections are significantly
more likely to occur in the “Wood-E” group.
D. Flushing is significantly more likely to occur in
the “Wood-E” group.
- All three adverse events occurred more often in the
“Wood-E” group; however, only two of the adverse events that occurred significantly more often were headache and flushing (Answers A and B are incorrect; Answer D is correct). This is based on the OR of 1.31 with a CI not including 1.0 (i.e., 1.01–2.86) for flushing, and the OR of 1.25 with a CI not including 1.0 (i.e., 1.12–1.98). Acute respiratory infections had CIs including 1.0, thus suggesting the results did not meet the statistical requirements to state that they occurred significantly more often in the “Wood-E” group (Answer C is incorrect). For more information, it might be helpful to review the Biostatistics chapter.
Correct Answer: D
- You are a clinical pharmacist in a resistant HTN clinic
working under a collaborative practice agreement. A
78-year-old male patient in your care is currently prescribed the following antihypertensives: labetalol 400 mg twice daily, valsartan 320 mg daily, chlorthalidone 25 mg daily, amlodipine 10 mg daily, and spironolactone 25 mg daily. The patient’s blood pressure today is 132/84 mm Hg. As part of your HTN protocol, you order laboratory tests and identify that this patient is in acute renal failure and has a potassium concentration of 7.7 mEq/L. The patient noted the onset of some muscle weakness the previous day. Which is the most appropriate action at this time?
A. Discontinue valsartan; recheck potassium concentration in 1 week.
B. Increase chlorthalidone to 50 mg daily; recheck
potassium concentration in 1 week.
C. Discontinue spironolactone; recheck potassium
concentration in 1 week.
D. Send the patient to the emergency department for
further evaluation.
- This patient has an elevated serum potassium concentration in addition to symptoms of hyperkalemia. Valsartan and spironolactone, in addition to acute renal failure, are likely contributing to this elevated concentration. Because he has symptoms and severe hyperkalemia currently, he should be sent to the emergency department (Answer D is correct). Discontinuing valsartan or spironolactone will likely be done after the patient’s visit to the emergency
department (Answers A and C are incorrect). Increasing
chlorthalidone could have some effect on further lowering his potassium concentration, but it would not acutely treat his elevated concentration (Answer B is incorrect).
Correct Answer: D
- While training first-year medical residents in a family
medicine clinic, you discuss the case of a 92-year-old
man with a history of difficult-to-treat depression.
Although this patient has previously attempted suicide,
his depression has finally been treated successfully by
psychiatry with venlafaxine extended release (ER) 75
mg daily plus mirtazapine 7.5 mg daily, after several
medication changes. His other medications include
hydrochlorothiazide 12.5 mg, lisinopril 20 mg, and
pravastatin 40 mg daily to treat his HTN and hyperlipemia. His blood pressure and lipid values are well controlled. His laboratory tests show a serum sodium concentration of 133 mEq/L (a decrease from 135 mEq/L in the past month), but he is asymptomatic.
Which therapy plan is most appropriate at this time?
A. Change hydrochlorothiazide to amlodipine.
B. Discontinue mirtazapine.
C. Change venlafaxine to duloxetine.
D. Continue current medications, increase dietary
sodium, and reduce free water intake.
- This patient has mild hyponatremia, and his sodium concentration is not much lower than the normal range. The drugs that could be contributing to his condition include hydrochlorothiazide, venlafaxine, and mirtazapine. Because his venlafaxine plus mirtazapine dose appears to have been changed and/or adjusted recently, these two agents are the most likely culprits. Because of his difficult psychiatric issues, it would not be wise for the primary care provider to manipulate his antidepressants (Answers B and C are incorrect). In addition, his blood pressure is well controlled. Because his sodium concentration is mildly low, it
is reasonable to continue with his current medications and try to increase his sodium concentration through nonpharmacologic means (Answer D is correct) rather than change his medications (Answer A is incorrect).
Correct Answer: D
- An 83-year-old woman comes to the pharmacy for
a medication therapy management visit. You begin
discussing vitamin D with her, and she has many questions because she recently learned that her vitamin D concentration is 10 ng/mL. She does not currently take vitamin D. Which counseling point is best to include in your discussion with her about vitamin D?
A. Individuals with obesity are less likely to develop
vitamin D deficiency.
B. Supplementing with vitamin D will likely reduce
the risk of falling in this older adult.
C. Only prescription vitamin D (ergocalciferol)
should be used to correct and maintain vitamin D
values.
D. Vitamin D toxicity is common because vitamin D
is a fat-soluble vitamin that can build up in the
body
- Although vitamin D is a fat-soluble vitamin, toxicity is very rare (Answer D is incorrect). Individuals with obesity have
lower vitamin D serum values and are more likely to have
vitamin D deficiency. This is most likely because vitamin
D is fat soluble and prefers storage in the fat to storage
in the serum (Answer A is incorrect). Either prescription
vitamin D (ergocalciferol) or cholecalciferol is a reasonable option to supply and maintain vitamin D (Answer C is incorrect). There is strong evidence to show that vitamin D doses of 700–1000 international units daily or higher and values higher than 24 ng/mL reduce fall risk in older adults (Answer B is correct).
Correct Answer: B
When the male patient presents what mild symptoms ipss score of less than equal to 7, and no bother some symptoms reported what is the preferred treatment
None
Watchful waiting
Which drugs exacerbate symptoms of BPH
Alpha adrenergics such as sudafed
Anticholinergic such as antihistamines, TCA,
Benztropine
Inhaled anticholinergics
diuretics
caffeine
alcohol
For patients with BPH IPSS> 8, treat with a
Uroselective alpha antagonists for 6 to 12 weeks
If sx don’t significant improve with alpha blocker, what to switch to
PDE 5 specifically tadalafil
Or
Add on 5 alpha reductase inhibitor (dutasteride, finasteride)
Uroselective Alpha 1 antagonists (aka blocker) is preferred first line therapy for bph
Name drugs
Tamsulosin , sildosin, alfuzosin (all uroselective)
Doxazosin, Terazosin (non selective)
List two 5-ARI
Dutasteride and finasteride
Most effective in pts with prostate> 40g
Tadalafil is approved as monotherapy for
BPH
BPH/ED
