genitourinary, electrolytes, nutritional deficiency, supplementation in older adult Flashcards
1
Q
- 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.
A
- Answer: D
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.
2
Q
- 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.
A
- Answer: D
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).
3
Q
- 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 - 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 overthe-
counter (OTC) oxybutynin patch.
C. Discontinue fesoterodine and initiate oxybutynin
IR.
D. Discontinue fesoterodine and initiate solifenacin.
A
- Answer: B
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).
4
Q
- 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 highimpact
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.
A
- Answer: C
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).
5
Q
- 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.
ACCP/ASHP 2022 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
1226
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.
A
- Answer: D
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.
6
Q
- 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.
A
- Answer: D
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 ACCP/ASHP 2022 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
1268
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).
7
Q
- 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.
A
- Answer: D
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).
8
Q
- 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.
A
- Answer: B
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).
9
Q
- A 78-year-old man presents with new-onset mild BPH symptoms (IPSS 5) that he states are not bothersome. He
also presents with mildly elevated blood pressure and is currently receiving no treatment for this condition. His
only medications are pravastatin, vitamin D, and alendronate. Which medication is most appropriate for treating
this patient currently? (Domain 1)
A. Hydrochlorothiazide.
B. Amlodipine.
C. Doxazosin.
D. Terazosin.
A
- Answer: B
This patient has only mild BPH symptoms, which do not
appear to be affecting him. He currently has no medication-
related problems. At present, “watchful waiting” is the
most appropriate treatment option for his BPH. However,
this patient still requires treatment of his uncontrolled
HTN. Both doxazosin and terazosin are tempting options
because this would treat both BPH and HTN with only one
drug. However, α-blockers are not recommended as monotherapy
for HTN treatment because the Antihypertensive
and Lipid-Lowering Treatment to Prevent Hearth Attack
trial showed worse outcomes with α-blockers than with
other HTN treatments (Answers C and D are incorrect).
Hydrochlorothiazide is an option, but it could worsen
symptoms because it is a diuretic, although a weak one
(Answer A is incorrect). Amlodipine is unlikely to worsen
BPH and is an appropriate first-line monotherapy treatment
of HTN (Answer B is correct).
10
Q
- A 74-year-old man presents with slow stream, intermittency, and straining, together with an infrequent sense of
urgency. His IPSS is currently 23, and his symptoms are significantly affecting his quality of life. His prostate is
large (greater than 40 g) on physical examination, and his PSA concentration is 1.5 ng/mL. His blood pressure is
well controlled (132/78 mm Hg; amlodipine 5 mg daily plus lisinopril 10 mg daily). Which medication would be
best to recommend currently? (Domain 1)
A. Alfuzosin 10 mg daily.
B. Dutasteride 0.5 mg daily.
C. Oxybutynin 2.5 mg twice daily.
D. Alfuzosin 10 mg daily plus dutasteride 0.5 mg daily.
A
- Answer: D
This patient has severe symptoms of BPH that are significantly
affecting his quality of life. He also has a large
prostate (greater than 40 g). An α-blocker is important
to provide quick relief of this patient’s symptoms and is
expected to provide symptomatic benefit within days to
1–2 weeks. According to the Medical Therapy of Prostatic
Symptoms and Combination of Avodart and Tamsulosin
trials, this patient would also benefit from concomitant
5-ARI therapy, especially because of his large prostate
(Answer A and B are incorrect). Combination therapy
would be expected to slow the clinical progression of BPH
and would likely reduce the risk of acute urinary retention
and BPH-related surgery compared with mono-therapy
with either alfuzosin or dutasteride (Answer D is correct).
Oxybutynin is not appropriate because the patient clearly
has obstructive symptoms of BPH with an enlarged prostate
(Answer C is incorrect). If the patient has irritative
symptoms (e.g., signs of urgency), oxybutynin could be
an appropriate choice, assuming the patient has a normal
postvoid residual.
11
Q
- An 84-year-old woman presents to the ambulatory clinic with significant symptoms of urinary incontinence,
urgency, frequency, and nocturia. She is accompanied by her daughter, with whom she just moved in 1 week ago.
Her daughter has noticed that her mother cannot control her urination. She states that the patient can get to the
restroom fairly quickly, but that she has typically lost urine before even realizing she has to go to the restroom.
The patient has a medical history of moderate to severe dementia, atrial fibrillation, HTN, insomnia, and osteoporosis.
She takes the following medications: donepezil 5 mg daily, warfarin 2 mg daily, digoxin 0.125 mg every
other day, metoprolol 50 mg twice daily, amlodipine 5 mg daily, trazodone 50 mg at bedtime, and alendronate 70
mg once weekly. The patient has not tried any agents to treat her urinary incontinence. The PVR test, urinalysis,
and all physical examination results are normal. Which recommendation is most appropriate for this patient for
her urinary incontinence symptoms? (Domain 1)
A. Discontinue trazodone, and initiate diphenhydramine.
B. Discontinue donepezil, and initiate memantine.
C. Initiate darifenacin.
D. Initiate oxybutynin gel.
A
- Answer: B
Medications should always be evaluated with new-onset
urinary incontinence because they are often a cause of
incontinence. Urge incontinence can be caused by treatment
with cholinesterase inhibitors such as donepezil
because of stimulation of detrusor contraction. Thus, donepezil should be discontinued to determine whether
it was playing a role in the patient’s symptoms, especially
because these are significant. Memantine can be substituted
as monotherapy for this patient’s moderate to severe
dementia (Answer B is correct). Because the patient has
significant incontinence issues, the benefit of discontinuing
donepezil appears to outweigh the risk. Trazodone is not an
anticholinergic, and it would not affect continence in this
patient. Changing to diphenhydramine for insomnia would
not be recommended and would likely increase incontinence
symptoms (Answer A is incorrect). Darifenacin and
oxybutynin gel would be reasonable options (in that order)
to treat the patient’s urge incontinence if the patient has
symptoms after the donepezil dose is reduced, although
these could affect memory in this patient with dementia
(Answer C and D are incorrect).
12
Q
- A 78-year-old woman with a diagnosis of OAB has urinary urgency, frequency, and episodes of incontinence.
This is significantly affecting her quality of life. She is otherwise healthy. She was initially prescribed oxybutynin
ER 5 mg daily (titrated to 10 mg daily), which provided significant benefit, but she could not tolerate it because of
peripheral anticholinergic adverse effects (dry mouth and constipation). She had similar benefits with tolterodine
LA and darifenacin but also self-discontinued them because of similar adverse effects. Which recommendation
is most appropriate for this patient for her urinary incontinence symptoms? (Domain 1)
A. Manage only with lifestyle changes.
B. Initiate mirabegron.
C. Initiate solifenacin.
D. Initiate trospium.
A
- Answer: B
The patient has difficulty tolerating the anticholinergic
adverse effects of the antimuscarinic agents. She has tried
several oral options, including two nonspecific antimuscarinics
(tolterodine and oxybutynin) and an M3-specific
agent, darifenacin. The patient should receive pharmacologic
treatment when appropriate agents are available
because she is having significant symptoms (Answer A is
incorrect). Trospium is positively charged, so it is less likely
to cross the blood-brain barrier, but it would still likely
cause peripheral anticholinergic adverse effects (Answer
D is incorrect). Solifenacin is also an M3-specific agent
that would be expected to have adverse effects similar to
those of darifenacin (Answer C is incorrect). Mirabegron
has the novel mechanism of β3-agonism, so it does not have
anticholinergic adverse effects. This specific mechanism
of action makes mirabegron a reasonable option for this
patient at this time (Answer B is correct).
13
Q
- A 68-year-old man with a history of ED, obesity, HTN, dyslipidemia, BPH, and insomnia presents to his primary
care provider requesting treatment of his ED. The primary care provider performs a physical examination and
measures his blood pressure as 152/87 mm Hg. The patient states that he has not exercised in years. He is retired
and has not been sexually active for more than 1 year. Given the patient’s cardiovascular risk, which is the most
appropriate plan for treating his ED currently? (Domain 1)
A. Initiate sildenafil.
B. Initiate alprostadil suppository.
C. Initiate testosterone replacement therapy.
D. Defer ED treatment for further cardiovascular testing (e.g., exercise stress testing).
A
- Answer: D
The patient has several cardiovascular risk factors (age,
obesity, HTN, and dyslipidemia). Because he has not exercised
in years and has not had sexual activity in more than
1 year, it is unknown whether he is physically fit to engage
in sexual activity without adverse cardiovascular consequences.
Thus, ED management should be deferred until
he can have specialized cardiovascular testing to assess
for exercise capacity and development of symptoms, ischemia,
or arrhythmias (Answer D is correct). Treating the
patient with sildenafil or alprostadil currently could place
him at risk of a cardiovascular event during sexual activity
because he may not be physically fit to be sexually active
(Answers A and B are incorrect). Testosterone replacement
therapy would be indicated only if this patient had hypogonadism
(Answer C is incorrect).
14
Q
- You are a clinical pharmacist in an internal medicine clinic working under a collaborative HTN practice agreement.
A 68-year-old woman is prescribed the following antihypertensives: carvedilol 25 mg twice daily, lisinopril
40 mg daily, chlorthalidone 25 mg daily, and felodipine 10 mg daily. As part of your HTN protocol, you order
laboratory tests and identify that this patient has a potassium concentration of 3.0 mEq/L. All other laboratory
values are within the normal range. The patient reports no symptoms with the hypokalemia. The patient has a
blood pressure of 154/88 mm Hg, which has been consistent on her current blood pressure regimen. She has been
filling her prescriptions and states that she is taking everything as prescribed. Which is the most appropriate
therapy plan for this patient? (Domain 1)
A. Decrease chlorthalidone to 12.5 mg daily.
B. Initiate spironolactone 25 mg daily.
C. Initiate potassium chloride 20 mEq daily.
D. Initiate amiloride 5 mg daily.
A
- Answer: B
This patient has hypokalemia and takes four appropriate
medications for HTN, yet her blood pressure is still above
goal. Decreasing chlorthalidone will not provide further
blood pressure benefit, but it may raise potassium concentration
(Answer A is incorrect). Potassium supplements
will not provide further blood pressure benefit, but they
will raise potassium concentration (Answer C is incorrect).
Amiloride has nominal, if any, blood pressure effect,
although it will raise potassium concentration (Answer
D is incorrect). Spironolactone will raise potassium concentration
and will lower blood pressure further, so it is
preferred (Answer B is correct).
15
Q
- An 86-year-old woman presents to your ambulatory care clinic for a routine follow-up of her chronic conditions.
Her current medications include furosemide 20 mg daily, carvedilol 12.5 mg twice daily, atorvastatin 40 mg
daily, lisinopril 5 mg daily, alendronate 70 mg weekly, and vitamin D3 2000 units daily. Mirtazapine 15 mg was
initiated 2 months ago for depression. Her Chem-7 results are as follows: glucose 96 mg/dL, blood urea nitrogen
15 mg/dL, SCr 1.2 mg/dL (baseline 0.9 mg/dL), sodium 125 mEq/L, potassium 4.2 mEq/L, chloride 110 mEq/L,
carbon dioxide 22 mmol/L, and calcium 9.5 mg/dL. No symptoms have been noted. Which is most appropriate
for managing this patient’s condition? (Domain 1)
A. Change furosemide to hydrochlorothiazide.
B. Change mirtazapine to citalopram.
C. Change mirtazapine to bupropion.
D. Continue medications as currently prescribed.
A
- Answer: C
This patient has a low sodium concentration. Mirtazapine
was recently initiated and is known to cause hyponatremia
(Answer D is incorrect). Otherwise, she does not appear to
have other symptoms. Antidepressants that affect serotonin
(selective serotonin reuptake inhibitors, SNRIs, mirtazapine,
TCAs) can cause hyponatremia in older adults (Answer
B is incorrect). Bupropion does not affect serotonin and
therefore should not cause hyponatremia (Answer C is correct).
Furosemide and other loop diuretics are not likely to
contribute to hyponatremia, whereas hydrochlorothiazide
is a common drug-induced cause (Answer A is incorrect).
Because her sodium concentration is so low, an intervention
is required. At this time, changing mirtazapine to
bupropion for depression is the preferred approach.
