Week 1

Question 1

Pharmacokinetics -

Answer 1

What the body does to the drug

Question 2

Absorption:

Answer 2

The movement of a drug from its site of administration into the blood

Question 3

Distribution:

Answer 3

The movement of drugs throughout the body

Question 4

Metabolism:

Answer 4

Transformation of a drug by enzymes into metabolites

Question 5

Excretion:

Answer 5

Drug removal from the body

Question 6

Pharmacodynamics -

Answer 6

What the drug does to the body; Study of the relationship between the drug and a target cell or receptor to produce a therapeutic effect in a patient

Question 7

Pharmacogenomics -

Answer 7

Study of the genetic attributes of an individual that lead to variable responses to drugs

Question 8

Pharmacoeconomics -

Answer 8

Description and analysis of the cost of drug therapy to healthcare systems and society

Question 9

Drug:

Answer 9

any chemical that produces a measurable biological response

Question 10

Pharmacology:

Answer 10

the study of drugs and their actions

Question 11

Pharmacotherapeutics:

Answer 11

the use of drugs to diagnose, prevent, or treat disease or to prevent pregnancy

Question 12

Prodrugs:

Answer 12

Inactive compounds that rely on metabolism to become active

Question 13

Bioavailability:

Answer 13

percentage of administered dose that enters the bloodstream

Question 14

Efficacy:

Answer 14

index of the maximal response a drug can produce regardless of dose

Question 15

Potency:

Answer 15

index of how much drug must be administered to elicit a desired response

Question 16

ED50 =

Answer 16

amount of drug that produces the desired effect in 50% of the people taking it

Question 17

LD50 =

Answer 17

amount of drug that produces toxicity in 50% of the people taking it

Question 18

Therapeutic index:

Answer 18

Ratio of LD50 to ED50; Drugs with narrow therapeutic index have a very narrow range between the dose that is effective and the dose that is toxic

Question 19

Genes:

Answer 19

a stretch of DNA which encodes for proteins and determines genetic characteristics.

Question 20

Genotype:

Answer 20

an individual’s genetic makeup derived from mixing of genes from that individual’s parents

Question 21

Phenotype:

Answer 21

physical characteristics of an individual based on expression of the genotype

Question 22

Common Supplements

Answer 22

o Calcium o Echinacea o Fish Oil o Ginseng o Glucosamine and/or Chondroitin Sulphate o Garlic o Vitamin D o St. John’s Wort o Saw Palmetto o Ginkgo o Green Tea

Question 23

Describe how ABSORPTION affects drug movement throughout the body.

Answer 23

i) Rate of absorption determines how soon effects will begin: ii) Route (e.g. IV, IM, PO, topical, rectal, inhaled, etc..) iii) Characteristic of pharmaceutical preparation (e.g. immediate versus extended release) iv) Most oral absorption occurs in the small intestine v) Amount of absorption determines intensity of effect: (1) Plasma drug levels (2) Bioavailability: percentage of administered dose that enters the bloodstream (a) 100% for parenteral administration (b) Ranges for oral administration (c) Low bioavailability = higher dose needed

Question 24

Describe how DISTRIBUTION affects drug movement throughout the body.

Answer 24

i) Factors affecting distribution (1) Blood flow (2) Lipid/water solubility (3) pH (a) pH changes the charge of drugs depending on the pKa (4) Protein binding (a) Albumin (b) Can increase circulation, decrease metabolism and excretion (c) Needs to be unbound to have effect ii) Passage of drugs across membranes (1) Drugs may need to pass through membranes to get to site of action (a) Three ways: Channels and pores, Transport systems (P-glycoprotein), Direct penetration of the membrane (2) Medications that do NOT pass through the plasma membranes easily: (a) Polar molecules (b) Ions (c) Large molecules iii) Medications that DO pass through the plasma membranes easily: (1) Neutral molecules (2) Lipophilic (3) Small iv) Barriers to know about (1) Blood Brain Barrier (a) Capillary endothelial cells are surrounded by a sheath of glial tissue (b) Impermeable to water soluble drugs and ionized drugs (2) Placental Barrier (a) Lipid membrane that allows passage of drugs by simple diffusion (b) Smaller molecules cross most easily v) Transport systems (1) E.g. p-glycoprotein (P-gp) (a) Membrane bound transport system which moves drugs from across membranes (i) Member of ATP binding proteins (b) Affects level of substrate available for absorption/elimination (i) If an P-gp inhibitor is given, P-gp substrate levels will rise (c) Examples of P-gp substrates: carvedilol, diltiazem, digoxin (d) Examples of P-gp inhibitors: verapamil, quinidine, cyclosporine, ketoconazole (2) Protein Binding (a) Drugs can form reversible bonds with various proteins in the blood (i) Albumin 1. Most abundant and important 2. Large molecule that always remains in the bloodstream 3. Impacts drug distribution – if drug is bound to protein, it cannot leave the blood to get to its site of action (protein is too large) a. E.g. phenytoin

Question 25

Describe how METABOLISM affects drug movement throughout the body.

Answer 25

i) Transformed into a molecule that is: (1) More easily excreted (a) Usually becomes more water soluble (less lipid soluble) (2) Increased or decreased therapeutic action (3) Increased or decreased toxicity ii) Phase I and Phase II Metabolism (1) Phase I metabolism: Oxidation, reduction, and hydrolysis (a) Cytochrome P450 (CYP 450) system (2) Phase II metabolism: Conjugation reactions (a) E.g. glucuronidation, sulfation iii) Prodrugs (1) Inactive compounds that rely on metabolism to become active (2) Example: codeine is not active as codeine, but is metabolized to morphine by CYP2D6 iv) First pass metabolism (1) When oral drugs are absorbed by the GI tract they are carried directly to the liver (a) Some drugs can be completely inactivated on first pass if liver is able to metabolize (2) For this reason some medications cannot be given orally (a) E.g. nitroglycerin v) Hepatic Dose Adjustments (1) For medications metabolized in the liver, may need to adjust the dose in patients with liver dysfunction. (2) Stages of liver disease: Child’s Pugh Score (a) Given points for ascites, encephalopathy, bilirubin, albumin, and prothrombin time (b) Higher points value = worsening liver function

Question 26

Describe how EXCRETION affects drug movement throughout the body.

Answer 26

i) Most commonly occurs in the kidneys ii) Steps in renal excretion: (a) Glomerular filtration to passive and active tubular reabsorption to active tubular secretion iii) Renal function (1) Methods of assessing renal function: (a) Estimated glomerular filtration rate (eGFR) (b) Creatinine clearance (CrCl) iv) Renal dosing (1) If patient’s kidneys are not working properly, may need to adjust dose based on renal function to prevent toxicity.

Question 27

Identify the importance of the CYP450 system in drug metabolism and how drug interactions and genetics can affect the metabolism of medications.

Answer 27

a) Cytochrome P450 (CYP450) enzymes i) Primarily found in the liver ii) Account for 70-80% of the enzymes involved in drug metabolism iii) Examples: (1) CYP3A4 – 50% of drug metabolism (2) CYP2D6 – 25% of drug metabolism (a) Selective serotonin reuptake inhibitors (SSRIs), Tricyclic antidepressants (TCAs), Beta blockers, codeine (3) CYP2C9 (a) Warfarin, antiepileptic drugs (phenytoin), glipizide

Question 28

Recognize how changes in pharmacokinetics in PEDIATRIC patients may affect medication therapy.

Answer 28

i) Children are NOT just small adults ii) Absorption (1) Normal pH around age 2 (2) Normal motility around 6-8 months iii) Distribution (1) Decreased protein binding (2) Adult values between 7 – 12 years (3) More lipid soluble meds may cross BBB iv) Metabolism (1) Increased metabolic rate and clearance for first 2 years (2) Decreased metabolic rate and clearance until puberty v) Elimination (1) Kidney matures around 6 – 12 months

Question 29

Recognize how changes in pharmacokinetics in GERIATRIC patients may affect medication therapy.

Answer 29

i) absorption (1) May have decreased acid secretion, increased gastric pH, decreased first pass effect leading to increased bioavailability (2) Medications (a) Proton pump inhibitors (b) H2 receptor antagonists (3) Drug interactions (a) Drug-drug (e.g. sucralfate) (b) Drug-food (e.g. tetracyclines with milk) (c) Drug-disease state (e.g. s/p bariatric surgery) ii) distribution (1) Decrease in lean body mass (a) Impact drug volume of distribution (i) Fat soluble medications: duration of action frequently prolonged (e.g. benzodiazepines) (ii) Water soluble drugs: e.g. acyclovir dosed based on ideal or adjusted body weight (2) Decreased blood flow and tissue perfusion (3) Decrease in serum albumin and protein binding iii) Metabolism (1) Changes in hepatic function with aging (a) Decreased hepatic blood flow (especially in heart failure, etc..) (b) Decreased ability to recover from injury (alcohol, hepatitis, etc..) (c) Decreased CYP450 activity with decreasing hepatic function iv) Elimination/Excretion (1) Decreased renal function associated with aging (a) Age-related decrease in creatinine clearance (b) Estimates for renal function based on various equations (i) E.g. eGFR, Cockcroft-Gault (c) Drugs doses and recommendations based on renal function to avoid toxicity

Question 30

Recognize how changes in pharmacokinetics in PREGNANT patients may affect medication therapy.

Answer 30

i) Most drugs taken by pregnant women will cross the placenta and expose the developing embryo and fetus to pharmacologic and teratogenic effects ii) Critical factors include: (1) Properties of the drug (2) Rate and amount that crosses placenta (3) Duration of exposure (4) Distribution characteristics in fetal tissues (5) Stage of placental and fetal development iii) Pregnancy Categories (1) Pregnancy categories are being taken away – in future will just have a description of risks/studies

Question 31

Define Half-life

Answer 31

time required for the amount of drug in the body to decrease by 50%

Question 32

What is half-life dependent on?

Answer 32

(1) Clearance (2) Volume of distribution (3) Steady state

Question 33

How many days does it take to reach a steady state?

Answer 33

Takes ~5 half-lives to reach steady state and to get rid of drug from system

Question 34

Define Volume of Distribution (Vd)

Answer 34

Proportion of drug in body to the serum concentration; The volume that the drug would occupy if it were present throughout the whole body at the serum concentration i) Vd= (Amount of drug)/(Serum concentration) ii) High volume of distribution = higher concentrations in tissue iii) Low volume of distribution = higher concentrations in the vascular component

Question 35

Define Therapeutic Index

Answer 35

Ratio of LD50 (amount of drug that produces toxicity in 50% of the people taking it) to ED50 (amount of drug that produces the desired effect in 50% of the people taking it) i) Drugs with narrow therapeutic index have a very narrow range between the dose that is effective and the dose that is toxic (1) E.g. phenytoin, warfarin

Question 36

Drug action at receptors: Agonists

Answer 36

increase the action of the receptor (1) Reversible or irreversible

Question 37

Drug action at receptors: Antagonists/inhibitors

Answer 37

decrease the action of the receptor (1) Competitive or noncompetitive (allosteric)

Question 38

Drug action at receptors: Partial agonist

Answer 38

competes with the normal ligand for the receptor, and causes a smaller action/response at the receptor

Question 39

Drug Targets/Receptors: Ion Channel Receptors

Answer 39

i) Ion channel receptors (1) Binding changes ion movement (2) E.g. acetylcholine, GABA

Question 40

Drug Targets/Receptors: G protein coupled receptors

Answer 40

ii) G protein coupled receptors (1) E.g. Hormones and slow transmitters e.g. dopamine

Question 41

Drug Targets/Receptors: Transmembrane Receptors/Enzyme linked receptor

Answer 41

iii) Transmembrane Receptors/Enzyme linked receptor (1) Extracellular binding with intracellular enzyme (a) E.g. insulin receptors, platelet-derived growth factor

Question 42

Drug Targets/Receptors: Intracellular receptors

Answer 42

iv) Intracellular receptors (1) Located in cytosol (2) Migrates to nucleus after binding to signaling molecule to then move to nucleus and control transcription (a) E.g. thyroid hormone and steroids

Question 43

Agonists vs antagonists

Answer 43

Agonist: enhances cellular activity; Antagonist: blocks cellular activity

Question 44

Competitive vs. Non-competitive antagonist

Answer 44

(1) Competitive Inhibitor – binds to same site as substrate (2) Noncompetitive inhibitor – binds to a different site

Question 45

Types of Adverse Drug Reaction: Pharmacological and Idiosyncratic

Answer 45

i) Pharmacological (intrinsic): predictable based on drug’s mechanism of action and is typically dose-related (1) E.g. hypotension from a blood pressure medication; diarrhea from metformin (2) 85-90% of adverse drug reactions ii) Idiosyncratic: unpredictable; mediated by immune system, receptor abnormalities, drug-drug interactions, abnormalities in drug metabolism, pharmaceutical variations, etc. (1) E.g. anaphylaxis, drug rash (2) 10-15% of adverse drug reactions

Question 46

Identify appropriate resources for identifying and researching dietary supplements.

Answer 46

a) National Institutes of Health – Office of Dietary Supplements (https://ods.od.nih.gov/) i) Dietary Supplement Fact Sheets b) National Center for Complementary and Integrative Health (https://nccih.nih.gov/) c) Natural Medicines Database (https://naturalmedicines.therapeuticresearch.com/) i) Monographs ii) Drug Interaction checker

Question 47

Recognize the importance of drug interactions in patients taking dietary supplements with CYP450 enyzmes

Answer 47

i) Some supplements can inhibit or induce the CYP450 system, same as prescription medications (1) Example: CYP1A2, 2C9, and 3A4 are responsible for the metabolism of progestins and estrogens in oral contraceptives; St. John’s Wort is an inducer of these CYP450 enzymes= reduces the effectiveness of oral contraceptives by increasing inactive metabolites

Question 48

Recognize the importance of drug interactions in patients taking dietary supplements with absorption

Answer 48

i) Some supplements, especially divalent cations (e.g. Ca2+, Mg2+), can slow absorption of certain medications (1) Example: calcium can bind to tetracyclines in the gut, so doxycycline should be taken 2 hours before or 4 hours after calcium supplements

Question 49

Identify how dietary supplements are regulated and quality measures that may be taken by the manufacturers of dietary supplements: Federal Food, Drug, and Cosmetic Act

Answer 49

a) The Federal Food, Drug, and Cosmetic Act defines a dietary ingredient as: i) “A vitamin; mineral; herb or other botanical; amino acid; dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of the preceding substances.”

Question 50

Identify how dietary supplements are regulated and quality measures that may be taken by the manufacturers of dietary supplements: Regulations

Answer 50

b) Regulations i) Dietary supplements do not require premarket review or approval by the FDA. ii) Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), manufacturers and distributors of dietary supplements are prohibited from marketing products that are adulterated or misbranded. (1) The manufacturers are responsible for evaluating the safety and labeling of their products before marketing iii) The FDA can remove products from the market, but must first establish that such products are either: (1) Adulterated (the product is unsafe) (a) E.g. contain a potentially unsafe ingredient (2) Misbranded (the labeling is false or misleading) (a) E.g. the label claims that the supplement can cure a disease

Question 51

Identify how dietary supplements are regulated and quality measures that may be taken by the manufacturers of dietary supplements: Good Manufacturing Practices

Answer 51

c) Good Manufacturing Practices i) The FDA has established good manufacturing practices (GMPs) for dietary supplements to help ensure their identity, purity, strength, and composition. ii) These GMPs are designed to prevent: (1) The inclusion of the wrong ingredient (2) The addition of too much or too little of an ingredient (3) The possibility of contamination (4) The improper packaging and labeling of a product.

Question 52

Identify how dietary supplements are regulated and quality measures that may be taken by the manufacturers of dietary supplements: Independent Testing Laboratories

Answer 52

d) Independent testing laboratories i) Several independent organizations offer quality testing and allow products that pass these tests to display their seals of approval. (1) Provide assurance that the product was properly manufactured, contains the ingredients listed on the label, and does not contain harmful levels of contaminants. (2) Does not guarantee that a product is safe or effective. ii) Organizations that offer this quality testing include (1) U.S. Pharmacopeia (USP), Consumerlab.com, NSF International

Question 53

Identify how dietary supplements are regulated and quality measures that may be taken by the manufacturers of dietary supplements: Dietary Supplement Label

Answer 53

e) Dietary Supplement label i) The FDA requires that dietary supplement labeling include: (1) Name of the product stating that it is a “dietary supplement“ (2) Name and place of business of the manufacturer (3) List of ingredients (4) Net contents

Question 54

What is the Naranjo ADR Probability Scale?

Answer 54

helps determine the likelihood that a adverse reaction is related to a drug

Question 55

Two ways for ADR reporting.

Answer 55

i) FDA Adverse Event Reporting System (FAERS): computerized database of adverse events, medication error reports, and product quality complaints resulting in adverse events (1) Post marketing surveillance system ii) MedWatch (1) How healthcare professionals, consumers, and manufacturers submit reports of adverse drug events (2) https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program

Question 56

Adverse Drug Reactions: Drug-Drug Interactions

Answer 56

i) If drugs have similar side effects/toxicity, their adverse effects may be compounded if taken together (1) E.g. taking aspirin and warfarin together increases risk of bleeding ii) Some drugs can change the metabolism of other drugs (1) Some drugs can induce enzymes – increase metabolism (2) Some drugs can inhibit enzymes – decrease metabolism

Question 57

Adverse Drug Reactions: CYP450 Enzymes

Answer 57

i) Can be inhibited or induced by drugs (1) May change the levels of the drugs that are normally found in the body

Question 58

Recognize how pharmacogenomics can impact medication therapy and how variants can occur in human genotypes: Goals

Answer 58

i) Understanding how genetic variation contributes to variability in drug pharmacokinetics, pharmacodynamics, and toxicity ii) Enhance drug therapy to maximize efficacy based on individual’s genomic variants iii) Identify optimal doses based on individual’s genomic variants iv) Avoid ADRs

Question 59

Recognize how pharmacogenomics can impact medication therapy and how variants can occur in human genotypes: Genetic variants- allele, genetic polymorphism, variants of specific genes, phenotypes

Answer 59

b) Genetic variants i) Allele – one of two or more alternative forms of a gene that arise by mutation ii) Genetic polymorphism: if an allele is common in a population, that gene is considered to be polymorphic iii) Variants of specific genes are numerically and sequentially named (1) Normal/nonmutated copy: “wild-type” (2) Example: (a) Wild-type: CYP2D6 (b) Mutant copy: CYP2D6*1 iv) Phenotypes: (1) May contribute to pharmacokinetics and pharmacodynamics (2) Variations in drug metabolizing enzymes (e.g. CYP450 enzymes) and drug transporters (e.g. P-gp) affect drug disposition (3) Can have different phenotypes of CYP enzymes: (a) Poor metabolizers (b) Intermediate metabolizers (c) Extensive metabolizers (d) Ultra-rapid metabolizers

Question 60

Recognize how pharmacogenomics can impact medication therapy and how variants can occur in human genotypes: Warfarin Example

Answer 60

c) Warfarin example i) CYP2C9 metabolizes >90% of active warfarin (1) Variant alleles associated with increased sensitivity to Warfarin (CYP2C9*2,*3 - most common variants) ii) Studies have demonstrated how to adjust warfarin dose based on SNP type iii) August 2007, FDA label now provides info regarding altered metabolism in CYP2C9 genetic variants (1) Pharmacogenetic dosing based on testing may help determine initial dose and titration although still a long way off (2) Package insert has recommendations for dosing for specific alleles: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/009218s118lbl.pdf

Question 61

Recognize how pharmacogenomics can impact medication therapy and how variants can occur in human genotypes: Drugs with FDA label for genetic testing

Answer 61

Drugs with FDA label for genetic testing i) 120 drugs identify genetic variability in labeling ii) FDA Table of Pharmacogenomic Biomarkers in Drug Labeling iii) https://www.fda.gov/drugs/scienceresearch/ucm572698.htm iv) Infectious disease (voriconazole) v) Cardiology and hematology (warfarin) vi) Neurology (carbamezapine) vii) Psychiatry (atomoxitine) viii) Oncology (azathioprine)

Question 62

Describe the varying types of costs and the outcomes that can be impacted by medications: Brand vs. Generic

Answer 62

i) Most pharmacy benefit groups select a drug with the lowest acquisition cost regardless of generic or brand-name status (1) Most insurances have formularies that include “tiers” of coverage, with cheaper medications at lower tiers and more expensive at higher tiers, in general (2) Generic medications are often cheaper (but not always) ii) The FDA Orange Book specifies which mediations are rated as therapeutic equivalents (1) Pharmacists may dispense a generic equivalent for a brand name unless the prescriber specified “Dispense as Written” on the prescription

Question 63

Describe the varying types of costs and the outcomes that can be impacted by medications: Types of cost- direct, in-direct, intangible

Answer 63

i) Direct costs – directly attributed to the treatment or disease (1) Medical (e.g. price of medications, health care provider time, diagnostic tests) (2) Nonmedical (e.g. transportation) ii) Indirect costs – derived from morbidity and mortality (1) E.g. loss of income iii) Intangible costs – nonfinancial outcomes (1) E.g. pain, suffering, grief

Question 64

Describe the varying types of costs and the outcomes that can be impacted by medications: Consequences of drugs

Answer 64

i) Economic outcomes: costs/benefits ii) Clinical outcomes: medical events iii) Humanistic outcomes: quality of life iv) Can be positive or negative

Question 65

Describe the varying types of costs and the outcomes that can be impacted by medications: Cost of Illness

Answer 65

d) Cost of Illness i) Does NOT include intangible costs – difficult to quantify ii) Example: per the American Diabetes Associate (2013), the cost of diabetes in the US is $327 billion (2017), a 26% increase from previous estimate of $245 billion (in 2012 dollars)

Question 66

Describe the varying types of costs and the outcomes that can be impacted by medications: Cost-Minimization

Answer 66

e) Cost-Minimization (CMA) i) Assumes that evidence supporting efficacy of each alternative already exists and strictly looks at which would be least costly to administer ii) E.g. generic lamotrigine vs. brand name Lamictal

Question 67

Describe the varying types of costs and the outcomes that can be impacted by medications: Cost-Effectiveness

Answer 67

f) Cost-Effectiveness i) Compares two or more treatments that are NOT therapeutically equivalent ii) Example: lisinopril versus olmesartan

Question 68

Describe the varying types of costs and the outcomes that can be impacted by medications: Cost-Benefit

Answer 68

g) Cost- Benefit (CBA) i) Looks at two separate interventions or programs and determines which produces a greater benefit for the money; often for budgeting purposes ii) Example: determining if an existing anticoagulation program is worth keeping or whether that money would be better spent on a new hypertension clinic or diabetes education program

Question 69

Describe the varying types of costs and the outcomes that can be impacted by medications: Cost-Utility

Answer 69

h) Cost- Utility i) Can be very subjective, so best use if when quality of life is considered the most important factor ii) Example: cancer treatment options

Question 70

What does it mean for a drug to have low bioavailability? a. A high percentage of administered dose enters the blood stream b. A low percentage of administered dose enters the blood stream c. The drug was administered incorrectly d. The drug will have a short half-life

Answer 70

B

Question 71

What types of medications do NOT pass-through membranes easily? a. Non-ionic (neutral) molecules b. Lipophilic molecules c. Polar molecules d. Small molecules

Answer 71

C

Question 72

What are prodrugs? a. A drug before it is approved by the FDA. b. People who support the use of medications. c. Compounds that are excreted quickly. d. Drugs that rely on metabolism to become active.

Answer 72

D

Question 73

Which of the following is a change in ADME associated with the elderly? a. Increased acid secretion b. Decrease in lean body mass c. Increased hepatic blood flow d. Increased renal function

Answer 73

B

Question 74

Approximately how many half-lives does it take for a medication to reach steady state? a. 7 b. 6 c. 5 d. 4

Answer 74

C

Question 75

Competitive inhibitors bind to the same site as the substrate. a. True b. False

Answer 75

A

Question 76

What is the ratio of the LD50 to the ED50 called? a. Efficacy b. Potency c. Toxic Dose d. Therapeutic Index

Answer 76

D

Question 77

Simvastatin is metabolized to its inactive metabolite in part by CYP3A4. Diltiazem is an inhibitor of CYP3A4. Which of the following is most likely to happen if simvastatin and diltiazem are taken together? a. Increased concentration of simvastatin b. Increased concentration of diltiazem c. Decreased concentration of simvastatin d. Decreased concentration of diltiazem

Answer 77

A

Question 78

CYP2C9 is involved in the metabolism of warfarin. If a SNP leads to a mutation in the gene for CYP2C9 which results in the patient being a poor metabolizer, how will the patient respond to warfarin? a. Increased response b. Decreased response c. No change in response d. Either B or C

Answer 78

A

Question 79

Which of the following costs is correctly matched to its type of cost? a. Cost of valsartan – direct nonmedical cost b. Cost of driving to get lab tests done – direct medical cost c. Cost of losing job due to illness – direct nonmedical cost d. Cost of pain from amputation – intangible cost

Answer 79

D

Question 80

Describe the pregnancy categories.

Question 81

Cockcroft and Gault Formula