A patient normally takes furosemide 40 mg PO 1x daily but is now NPO. Bioavailability of furosemide is 50%. What is the equivalent IV furosemide dose?
2050% of 40mg is 20
A patient taking warfarin (blood thinner, CYP substrate) is started on fluconazole (CYP inhibitor). If the warfarin dose is not adjusted, what clinical effect is most likely to occur?
Warfarin levels will increase, causing more bleeding not clottingEnzymes not breaking down the warfarin
A patient is taking warfarin (blood thinner, CYP substrate) is started on fluconazole (CYP inhibitor). Will the warfarin half life increase or decrease?
The half life will increaseThere is a higher concentration of the drug in the body
JB is a 30-year-old female presenting to the ED for asthma exacerbation. In addition to oxygen, the patient is started on albuterol nebulizer. The provider determines that JB needs to be admitted. While waiting to be transported, the respiratory therapist asks to change the albuterol to levalbuterol.Which of the following is the most probable reason to choose levalbuterol over albuterol?A.Improved bronchodilationB.Less bitter tasteC.Less hypokalemiaD.Less tachycardia
Less tachycardia
A mother is picking up a new prescription of montelukast for her 10 year-old daughter. Which of the following counseling points should be provided to the mother at this time?A.Monitor for white lesions on the tongue or mouth (oral thrush)B.Monitor for changes in mood or behaviorC.Monitor for palpitations or fast heart rateD.Monitor for seizures
Monitor for changes in mood or behavior
CB is a 30-year-old female who comes in for her quarterly asthma follow-up visit and reports the following: Albuterol use = 0-3 times per month (no more than once a week)Nighttime awakenings = None in the past 3 monthsPeak flow readings = 90% of expected valuesDaily activity limitation = None, currently training for her first underwater diving tripWhich of the following BEST describes CB's asthma control and change that needs to be made to her asthma therapy?A.Uncontrolled; step downB.Uncontrolled; step upC.Well-controlled; step downD.Well-controlled; step up
Well-controlled; step down
CB returns to the clinic 6 months later and the provider determines that CB needs a step-up in her asthma therapy. Her current asthma regimen is as follows: Low dose ICS + PRN SABAWhich of the following is the BEST option for CB based on the NAEPP guidelines?A.Continue Qvar® and ProAir®, add biologicsB.Continue Qvar® and ProAir®, add daily low-dose Symbicort®C.Stop Qvar® and continue ProAir®D.Stop Qvar® and ProAir®, start daily and PRN low-dose Symbicort®
Stop Qvar® and ProAir®, start daily and PRN low-dose Symbicort®she's at step 2, need to go to step 3 so bring in LABA
An antibiotic has a volume of distribution (Vd) of 10 L/kg. Based on the Vd alone, would you predict this antibiotic to be more effective in treating bacteremia (bacteria in the blood) or tissue infections (such as in the skin or lungs)?
More effective for tissue infectionsThis is a very large volume of distribution given the human body's actual volume is close to 1 L/kg (e.g. an 80 kg patient has a volume of about 80 liters). For an 80 kg patient and a drug Vd of 10 L/kg, it would be "as if" a patient's volume is 800 liters (80 kg x 10 L/kg). Obviously a patient isn't 800 liters in volume -- in actuality, it means that very little of the drug stays in the blood and most of the drug distributes into other tissues of the body.
TW is admitted to the hospital with an acute myocardial infarction (heart attack) and is started on a variety of medications, including a heparin IV infusion (an anticoagulant). TW needs cardiovascular surgery, but the surgery cannot be done if he is anticoagulated. Assuming a heparin half-life of 90 minutes, how long should TW's heparin be stopped for before surgery can be safely done?
270 minutes Steady state occurs after at least 3 half-lives have elapsed. In this context, when heparin is stopped, it will take 3+ half-lives for the patient's new "steady state" of having no heparin (or at least very little heparin) in his blood. 90 minutes x 3 half-lives = 270 minutes.
A patient is admitted with a severe COPD exacerbation and a myocardial infarction (heart attack). Due to her myocardial infarction, she is indicated for a beta blocker. Which of the following beta blockers is most appropriate for this patient?CarvedilolLabetalolMetoprolol succinatePropranolol
Metoprolol succinateGiven this patient's COPD, the "best" B-blocker would be one that is selective to blocking B1 receptors (on the heart) and has minimal effect on blocking B2 receptors (on the lung). In this patient, her COPD could worsen if we block B2 receptors on the lung (causing bronchoconstriction, which can lead to bronchospasm and difficulty breathing). Of the B-blockers on this list, metoprolol is the only "cardioselective" (B1 selective) beta blocker.
What is the physiologic effect of a beta-2 agonist on lung tissue?
Bronchodilation
Which of the following organs is most responsible for "first pass" metabolism?
GI tract
NM is a 66-year-old male diagnosed with COVID-19. His prescriber would like to prescribe Paxlovid, an antiviral medication for COVID-19, but is alerted that Paxlovid interacts with NM's simvastatin (a cholesterol medication) -- Paxlovid is a CYP inhibitor and simvastatin is a CYP substrate. If this drug interaction is ignored and NM takes both simvastatin and Paxlovid, which of the following is most likely to happen?
Increased risk of simvastatin toxicitiesAs a CYP inhibitor, Paxlovid will decrease the amount of functional CYP enzymes in the liver that are responsible for metabolizing simvastatin. For example, if 500 enzymes are normally available to metabolize simvastatin, Paxlovid may inactivate half of these and only 250 enzymes may be available for simvastatin metabolism. If this drug interaction is ignored, simvastatin will not be metabolized as well as it normally would be -- simvastatin's half-life will increase, blood levels of simvastatin will increase, and the patient will be at a higher risk of simvastatin toxicities (e.g. muscle pain, hepatotoxicity, and rhabdomyolysis).
TT is a 50-year-old male admitted to the hospital with acute appendicitis and recently underwent an appendectomy. To treat an arrhythmia, TT required metoprolol tartate IV push 20 mg per day (given as 5 mg IV Q6hr). TT is now able to take oral medications. Assuming a metoprolol tartrate bioavailability of 40%, what is the most appropriate oral metoprolol tartrate dose for this patient?
Metoprolol tartrate 50 mg per day (25 mg PO Q12hr)A bioavailability of 40% means that when metoprolol tartrate is given orally, the resulting blood concentration is 40% of what the same IV dose would provide. An equivalent oral dose can be calculated as 20 mg/day divided by 0.4. A ratio using 100% bioavailability for IV can also be calculated (20 mg/day divided by 100% = X mg/day divided by 40%). Working backwards to confirm our answer, 50 mg/day (the correct answer) x 0.4 (bioavailability) = 20 mg/day
PJ is a 92-year-old male admitted to the hospital with community acquired pneumonia. During his hospital stay, PJ's heart rhythm changes into a rhythm called atrial fibrillation with rapid ventricular rate. The patient needs a medication to reduce his heart rate that will act as quickly as possible. Which of the following dosage forms is most appropriate for PJ's arrhythmia?
Immediate-release (IR) capsule
A patient has a deep vein thrombosis (DVT) in his leg and needs to be anticoagulated. Based on patient-specific factors, heparin 18 units/kg/hr IV is the most appropriate anticoagulant for treatment of this patient's DVT. Which of the following terms best describes how heparin will be given to this patient?
IV dripThis heparin dose is described as 18 units/kg per hour -- it is a continuous infusion, meaning the patient will receive the heparin dose through an IV line without any interruption. This method of administration is called an IV infusion or an IV "drip". IV bolus and IV push typically describe a medication given intermittently over seconds or minutes. IV piggy back typically describes a medication given intermittently over minutes or hours.
Doxazosin is an alpha-1 adrenergic receptor antagonist used in men with benign prostatic hypertrophy (BPH) who have difficulty urinating due to an enlarged prostate. Based on its alpha-1 receptor profile, what other physiologic effects most likely occur with doxazosin?
Decreases blood pressureNearly all tissues in the body are innervated with the sympathetic nervous system -- in class, we only focused on the cardiovascular and lung tissues. In this example, prostate tissue has alpha-1 adrenergic receptors that can cause smooth muscle constriction or relaxation. Doxazosin belongs to a drug class called "alpha blockers", which are designed to block (antagonize) alpha-1 receptors in the prostate; however, many of these drugs also block alpha-1 receptors in other tissues of the body. If doxazosin blocks alpha-1 receptors in the vasculature, it results in vascular smooth muscle relaxation, vasodilation, and a decrease in blood pressure. The heart and lungs uses beta receptors, not alpha receptors, so doxazosin should not have an effect on the heart or lung tissues.
Which of the following statements is true concerning the use of inhaled corticosteroids in children with mild persistent asthma?1) Inhaled corticosteroids are no more effective than montelukast.2) Inhaled corticosteroids are more effective than alternatives but are not recommended among children for safety reasons.3) Inhaled corticosteroids are the most effective controller but may come at risk of reduced growth rate in children if used chronically.4) Inhaled corticosteroids do not reduce severe exacerbations that can result in hospitalization and ED visits.
Inhaled corticosteroids are the most effective controller but may come at risk of reduced growth rate in children if used chronically.
Which of the following is the reason for the boxed warning in long-acting inhaled beta 2-agonist (LABA) FDA labeling?1) Their slow onset makes them ineffective in acute asthma exacerbations.2) They may cause prolongation of the QTc interval increasing the risk of cardiac arrhythmias.3) They may be associated with an increased risk of asthma deaths when prescribed without an inhaled corticosteroid.4) They may result in increased severe exacerbations when used in combination with inhaled corticosteroids.
They may be associated with an increased risk of asthma deaths when prescribed without an inhaled corticosteroid.
A mother is picking up a new prescription of montelukast for her 12 year-old daughter. Which of the following counseling points should be provided to the mother at this time?1) Monitor for white lesions on the tongue or mouth (called thrush)2) Monitor for palpitations or fast heart rate3) Monitor for seizures4) Monitor for changes in mood or behavior
Monitor for changes in mood or behavior
A 14-year-old basketball player is diagnosed with exercise-induced bronchospasm. The most efficacious therapy for him would be:1) Begin budesonide, an inhaled corticosteroid, once daily.2) Begin albuterol, taken minutes prior to exercise.3) Begin ipratropium bromide, taken 10-15 minutes prior to exercise.4) Begin Singulair, taken 2 hours prior to exercise.
Begin albuterol, taken minutes prior to exercise.
One of your adult patients with severe persistent asthma was prescribed fluticasone/salmeterol (Advair, with a "low-dose" ICS component) 3 months ago in addition to albuterol as needed. He states that the new therapy has made a significant difference in his well-being and that he has never felt better. On questioning him, he states that he continues to occasionally awaken at night, about one time per week. He also has symptoms about two to three times per week, but they always respond to albuterol. The physician monitoring this patient should:1) Continue with current therapy as the patient is improving.2) Increase the regimen to fluticasone/salmeterol (Advair, with a "moderate-dose" ICS) and continue albuterol as needed.3) Consider adding regular inhaled ipratropium bromide.4) Consider adding montelukast.
Increase the regimen to fluticasone/salmeterol (Advair, with a "moderate-dose" ICS) and continue albuterol as needed.
Which of the following medications should be inhaled slowly and deeply?1) Advair Diskus (fluticasone/salmeterol; dry powder inhaler)2) DuoNeb (albuterol/ipratropium; nebulizer)3) Singulair (montelukast; immediate-release tablet)4) Xopenex HFA (levalbuterol; metered dose inhaler)
Xopenex HFA (levalbuterol; metered dose inhaler)A slow inhalation is required for metered dose inhalers. Dry powder formulations, like the Advair Diskus, require a rapid, quick inspiratory effort. Nebulizer use does not require any specific inhaler technique.
A 30-year-old male with asthma presents to his primary care provider for routine follow-up. He currently takes low-dose Symbicort twice daily as a controller medication and as needed as a rescue inhaler. He has been on this regimen for three years. He has not needed to use an as-needed rescue inhaler in the past four months and has not woken up at nighttime with asthma symptoms in more than a year. He reports no activity interference and his PEF readings at home are consistently over 80% predicted. Which of the following is the most appropriate recommendation regarding his asthma regimen today?1) Continue the current regimen2) Discontinue Symbicort, start low-dose Flovent with Proair as needed3) Increase Symbicort dose from low-dose to medium dose, used twice daily and as needed4) Continue Symbicort twice daily and as needed and add Spiriva Respimat
Discontinue Symbicort, start low-dose Flovent with Proair as needed
A 22-year-old female, diagnosed with moderate persistent asthma, goes to her pharmacy to pick up her prescription for fluticasone/salmeterol (100 mcg/50 mcg) combination. The inhaler comes in a dry powder inhaler form called a Diskus, which she has never used before. Which of the following is the appropriate way for her to use this device?1) Dispense the dose of medication, place lips around the mouthpiece, exhale into the device, inhale steadily and deeply, hold breath for 10 seconds, and breathe out slowly.2) Shake the device, dispense the dose of medication, place lips around mouth piece, breathe in steadily and deeply, hold breath for 10 seconds, and breathe out slowly.3) Shake the device, dispense the dose of medication, place lips around mouth piece, exhale into the device, inhale steadily and deeply, hold breath for 10 seconds, and breathe out slowly.4) Dispense the dose of medication, place lips around mouthpiece, inhale forcefully and deeply, hold breath for 10 seconds, and breathe out slowly.
Dispense the dose of medication, place lips around mouthpiece, inhale forcefully and deeply, hold breath for 10 seconds, and breathe out slowly.A patient should NEVER exhale into a DPI device as it will moisten the dry powder, making it aggregate into large particles. Unlike an MDI, a DPI should not be shaken once activated because the powder could become displaced from within the device. Unlike an MDI, DPIs require a strong, forceful, quick inspiratory effort to pull the powder into the lungs. An MDI, on the other hand, needs a slower and deeper inspiration.
A 70-kg female arrives at the emergency department with an acute exacerbation of asthma. A peak flow measurement was obtained and the PEF showed 30% of the predicted value. Oxygen by nasal canula has been started. What additional medication(s) should the patient be getting in the ED?1) Albuterol by nebulization every 20 minutes2) Albuterol and ipratropium bromide by nebulization every 20 minutes3) Albuterol by nebulization every 20 minutes and IV magnesium sulfate4) Albuterol and ipratropium bromide by nebulization every 20 minutes and corticosteroids (e.g., prednisone, prednisolone, methylprednisolone)
Albuterol and ipratropium bromide by nebulization every 20 minutes and corticosteroids (e.g., prednisone, prednisolone, methylprednisolone)
A mother presents to a primary care office with her 12-year-old son for an asthma follow-up. The patient is currently using albuterol PRN for shortness of breath. The patient's mother reports her son is using albuterol daily, waking up overnight with shortness of breath once a month, and his peak flow meter readings have been 85% percent of expected values. Which of the following is the most appropriate recommendation at this time?1) Add montelukast PO daily2) Add low-dose fluticasone inhalation3) Add low-dose fluticasone-salmeterol inhalation4) Continue current therapy
Add low-dose fluticasone inhalationThis patient's asthma is not well controlled - he is using his SABA more often than twice per week. He is currently on step 1 (SABA as needed) and needs to be escalated to step 2. The preferred therapy in step 2 is either daily low-dose ICS with SABA as needed or low-dose ICS as needed with SABA as needed (concomitant use). Montelukast is a possible alternative to a low-dose ICS; however, it is less effective and there is no compelling reason to do so. A low-dose ICS-LABA combination (step 3) is not appropriate at this time until the patient has tried the ICS monotherapy and demonstrated the need for another step-up in the treatment algorithm.
Which of the following patients would be the BEST candidate for using a spacer with their Symbicort MDI?1) A patient with proper inhaler technique who wants to reduce tremor after inhalation2) A patient who forgets to use his inhaler most days of the week3) A 25 year-old patient who has not used Symbicort before4) A geriatric patient who has trouble pressing down the MDI canister and breathing at the same time
A geriatric patient who has trouble pressing down the MDI canister and breathing at the same time
Which of the following is can be used as a rescue inhaler for as-needed symptoms?1) Symbicort2) Advair Diskus3) Spiriva4) Pulmicort
Symbicort
A 13-year-old female is diagnosed with mild persistent asthma. Which of the following is the preferred initial therapy?1) As-needed inhaled albuterol only2) 5-mg chewable montelukast tablet every evening plus as-needed inhaled albuterol3) Formoterol metered dose inhaler twice times daily plus as-needed inhaled albuterol4) Fluticasone metered dose inhaler twice times daily plus as-needed inhaled albuterol
Fluticasone metered dose inhaler twice times daily plus as-needed inhaled albuterolAny patient (regardless of age), who has persistent asthma (i.e, not the "intermittent" stage), needs a "controller" medication in addition to a PRN rescue inhaler. ICSs are the cornerstone of therapy regardless of age. The first-line controller medication for persistent asthma is an ICS. Montelukast is always a non-preferred, alternative therapy. Formoterol (a LABA) should never ever, ever be used without an ICS for persistent asthma.
Which of the following is the preferred long-term controller medication for a 12-year-old female not controlled on just SABA as needed?1) Salmeterol twice daily2) Fluticasone propionate twice daily3) Spiriva once daily4) Singulair once daily
Fluticasone propionate twice dailySalmeterol (a LABA) should never be used as monotherapy in asthma. Montelukast (Singulair) could be considered, but only as a second-line or alternative therapy to an ICS. Tiotropium (Spiriva) is usually only added on after patients have been optimize on ICS-LABA treatment. For all patients (regardless of age), an ICS is the cornerstone of asthma therapy.
TJ is a 16-year-old female presenting to her primary care provider for routine follow-up of her asthma. Her current asthma regimen is low-dose fluticasone propionate inhaled BID with as-needed albuterol. She feels that her asthma is well controlled because she only needs to use her albuterol once every other day. She rarely has nighttime awakenings with symptoms and does not use a peak flow meter at home. Which of the following is the most appropriate recommendation regarding TJ's asthma regimen today?1) Replace fluticasone with salmeterol inhaled twice daily2) Replace fluticasone and albuterol with low-dose Symbicort inhaled twice daily and as needed3) Continue the same regimen but add Spiriva Respimat inhaled once daily4) Continue the same regimen
Replace fluticasone and albuterol with low-dose Symbicort inhaled twice daily and as needed
JC is a 50-year-old male recently diagnosed with COPD. The spirometry test completed at his physician's office at the time of diagnosis showed FEV1 of <30% of predicted and symptom assessment using the CATTM gave a score of 18. He has no history of COPD exacerbation.How would you classify JC's COPD?A.GOLD grade 3, group BB.GOLD grade 3, group CC.GOLD grade 4, group BD.GOLD grade 4, group C
GOLD grade 4, group B
Patients with COPD who are treated with inhaled corticosteroids have an increased risk of:A.BruisingB.Muscle atrophyC.Respiratory tract infectionsD.Weight gain
respiratory tract infections*specifically pneumonia
Which of the following conditions would make a patient with severe COPD a poor candidate for roflumilast?A.Cachectic, underweight patientB.History of peripheral neuropathyC.Recent bowel obstructionD.Recent GI bleeding
Cachectic, underweight patient
A patient treated with tiotropium (Spiriva® HandiHaler ®) should be instructed to:A.Inhale forcefully and deeplyB.Inhale slowly over 10 secondsC.Rinse mouth after each useD.Take one tablet orally every evening
Inhale forcefully and deeply
Which of the following is the preferred initial long-term therapy for a patient with a history of COPD-related hospitalization and scores 1 point on the mMRC questionnaire?A.Budesonide-formoterol (Symbicort®) - ICS-LABAB.Salmeterol (Serevent® Diskus®) - LABAC.Umeclidinium (Incruse® Ellipta®) - LAMAD.Vilanterol-umeclidinium (Anoro® Ellipta®) - LABA-LAMA
Umeclidinium (Incruse® Ellipta®) - LAMA
A 60-year-old patient presents to the pulmonary clinic for his COPD follow-up visit. The patient is currently salmeterol (Serevent® Diskus®) once daily and albuterol as needed. He reports frequent symptoms of shortness of breath while performing activities of daily living and has had 2 separate exacerbations within the last 3 months. His lab results show blood eosinophil count of 350 cells/µL.Which of the following is the most appropriate recommendation to make?A.Add roflumilast (Daliresp®)B.Add umeclidinium (Incruse® Ellipta®)C.Change Serevent® Diskus® to budesonide-formoterol (Symbicort®)D.Change albuterol inhaler to a nebulizer
elevated eosinophils = think about adding ICS!!Change Serevent® Diskus® to budesonide-formoterol (Symbicort®)
Which of the following is an appropriate criterion for the use of long-term oxygen therapy in patients with COPD?A.FEV1 <40% with severe shortness of breath during exertionB.GOLD group D patientsC.Three of more hospitalizations for COPD exacerbations in the past 365 daysD.Resting SaO2 <88%
Resting SaO2 <88%