Pharmacotherapy Exam 1 - Ar, Asthma, Copd

Front 1

Christina is an otherwise healthy 40-year-old woman who complains of sneezing and runny nose during the May – June grass pollen season. The symptoms interfere with her work and she has trouble sleeping. She often has eye symptoms, but never complains of stuffiness. Which of the following would be the most effective treatment for her to begin just before the season and to continue daily throughout the season?
a. Fluticasone furoate nasal spray (Veramyst).
b. Montelukast tablets (Singulair).
c. Ipratropium bromide nasal spray (Atrovent).
d. Loratadine tablets (Claritin).
e. Cromolyn nasal spray (Nasalcrom).

Back 1

a.
Nasal steroids are the most effective drug treatment for nasal symptoms (slides 17 & 18) and fluticasone furoate is also effective for eye symptoms (slide 27).

Front 2

Alex is a 16-year-old high school student who wheezes when he runs around the track in physical education class. He has to do this twice a week. He never has asthma symptoms any other time except when he gets a bad cold. Which of the following would be the best recommendation for this patient?
a. Two puffs of cromolyn MDI before running.
b. Two puffs of pirbuterol MDI (Maxair Autohaler) before running.
c. Two puffs of albuterol HFA MDI (Pro-Air HFA®) when he begins to wheeze.
d. A 10 mg montelukast tablet 2 hr before running.
e. Two puffs of mometasone DPI (Asmanex Twisthaler) once daily throughout the school semester.

Back 2

b.
An inhaled beta-2 selective agonist taken before vigorous exercise is the most effective prevention for exercise-induced bronchospasm (slide 18 and reading assignment -- page 3, IV-A-3-b).

Front 3

Sonja is a 10-year old with persistent asthma. She has been well controlled on HFA fluticasone 110 µg/puff MDI (Flovent) 2 puffs BID and 2 puffs of HFA albuterol MDI (Proventil HFA) PRN which she requires about once a week. This week she catches a cold and begins to cough. She uses the albuterol MDI and gets relief for 4-6 hours. Her mother calls her physician to let him know that Sonja is having an exacerbation. Which of the following would be the best recommendation for the physician to make?
a. Add a short course of oral prednisone for 5 days.
b. Add oral dextromethorphan (Robitussin-DM) PRN cough.
c. Continue using the albuterol PRN but call back if it is needed more than four times a day.
d. Change fluticasone MDI to maintenance therapy with a combination product containing fluticasone and salmeterol (Advair).
e. Add montelukast (Singulair).

Back 3

c.
Albuterol is working effectively. Patient is bronchodilator responsive.

Front 4

Dee Dee is a 30-year-old woman with mild persistent asthma. She experiences wheezing, unrelated to exercise, about 3-4 times per week, wakes up from cough at night about once a week and uses albuterol MDI for each of these episodes and gets complete relief. She does not exercise since it causes chest tightness. At her clinic visit today, she was asymptomatic. Her FEV1 was 80% predicted and it increased to 88% after albuterol. Her physician prescribed budesonide+formoterol HFA MDI (Symbicort) 160 µg/puff, 2 puffs twice a day as maintenance therapy to achieve greater asthma control. She gave her a free sample containing 60 puffs and told her to fill the prescription if the sample decreased her need for albuterol. Why is Symbicort a poor choice for this patient?
a. It is not available in a DPI, only HFA MDI.
b. The long-acting beta agonist, formoterol, in Symbicort has a slow onset of action.
c. The inhaled corticosteroid, budesonide, in Symbicort has high affinity for the glucocorticoid receptor, which increases the risk of systemic adverse effects.
d. In mild persistent asthma, adding a long-acting beta agonist to an inhaled corticosteroid provides no additional benefit.
e. Only the formoterol component of Symbicort is required for this patient since she always gets complete relief from albuterol and formoterol DPI (Foradil Aerolizer) is much less expensive than Symbicort.

Back 4

d.
Addition of a LABA to ICS is only indicated in patients with moderate or severe persistent asthma (Primer – page 7, B-3-d and slide 11). This patient has mild persistent asthma.

Front 5

Which of the following is most likely to occur when giving a beta blocker for hypertension to a patient with intermittent asthma who uses albuterol MDI PRN and gets complete relief?
a. Albuterol may antagonize the anti-hypertensive effects of a beta blocker.
b. The beta blocker might increase the effects of albuterol on the heart, causing tachycardia.
c. Albuterol may potentiate the anti-hypertensive effect of a beta blocker and cause hypotension.
d. The beta blocker may increase the frequency of asthma symptoms.
e. Beta blockers antagonize the effects of long-acting beta agonists such as salmeterol but not short-acting beta-2 selective agonists, such as albuterol.

Back 5

d.
By decreasing sympathetic activity, the parasympathetic activity in the airways can cause bronchospasm (Primer -- page 14, VII-A and slide 21).

Front 6

Which of the following is most effective in reducing the frequency of exacerbations in patients with severe COPD (FEV1<50%)?
a. Fluticasone propionate+salmeterol DPI (Advair Diskus).
b. Cromolyn nebulizer solution
c. Montelukast (Singulair tablets).
d. Formoterol DPI (Foradil Aerolyzer).
e. Ipratropium bromide (Atrovent).

Back 6

a.
(slides 16 and 17)

Front 7

Which of the following drugs used for COPD would most likely cause thrush?
a. Slow release oral theophylline.
b. Tiotropium inhaler (Spiriva Handihaler).
c. High dose fluticasone+salmeterol combination product (e.g. Advair 500/50 BID).
d. Salmeterol dry powder inhaler (Serevent Diskus).
e. Ipratropium MDI (Atrovent).

Back 7

c.
Thrush is a dose-related topical side effect. (Adverse effects of ICS listed in Asthma Primer -- page 7, 5-a.)

Front 8

Gilda, a 70-year-old woman with moderately severe COPD (post bronchodilator FEV1 of 52% predicted), is taking tiotropium DPI (Spiriva Handihaler) once daily. She stopped smoking several years ago. This regimen has increased her exercise tolerance but she still feels short of breath several times a day and has to use albuterol+ipratropium MDI (Combivent) each time. It does give her some relief. Which of the following would most likely provide more benefit?
a. Add formoterol (Foradil) twice daily to the tiotropium.
b. Add once daily oral montelukast (Singulair).
c. Add mometasone DPI (Asmanex Twisthaler).
d. Increase the tiotropium to twice daily.
e. Change tiotropium to a combination product containing fluticasone and salmeterol.

Back 8

a.
Since the patient is not well controlled on a long-acting inhaled anticholinergic, adding a LABA may provide added relief (discussed in class and in reading assignment – page 11, Figure 7 under “moderate”).

Front 9

Which of the following would most likely cause insomnia in a patient with
allergic rhinitis if taken in the evening or at bedtime?
a. Fluticasone furoate nasal spray (Veramyst).
b. Diphenhydramine (Benadryl).
c. Loratadine + pseudoephedrine tablets (Claritin-D 12 hr).
d. Oral phenylephrine tablets (Sudafed-PE).
e. Montelukast tablets (Singulair).

Back 9

c.
Pseudoephedrine distributes into the CNS and can cause
insomnia, nervousness and irritability (slide 13) especially if taken in the
evening.

Front 10

Randall is a 20-year-old college school student who coughs when he runs
around the track in physical education class. He has to do this three times a week. He never has asthma symptoms any other time except when he gets a bad cold. Which of the following would be the BEST recommendation for
this patient?
a. Dextromethorphan (Robitussin-DM) before running.
b. Take 2 puffs of HFA albuterol MDI (ProAir) before running.
c. Take 2 puffs of pirbuterol MDI (Maxair Autohaler) when he begins to
wheeze.
d. Take a 10 mg montelukast tablet 1 hr before running.
e. Take 2 puffs of mometasone (Asmanex Twisthaler) once daily throughout
the school semester.

Back 10

b.
An inhaled beta-2 selective agonists taken before vigorous
exercise is the most effective prevention for exercise-induced
bronchospasm (slide 19 and reading assignment page 3 – IV – A-3-b).

Front 11

Patricia is an 8-year old with persistent asthma. She has been well controlled on budesonide (Pulmicort Flexhaler), 1 puff BID and PRN generic CFC albuterol MDI which she uses about once a week. This week she catches a cold and begins to cough. She uses the albuterol MDI but gets no relief. She calls her physician to let him know that she is having an exacerbation. Which of the following would be the best recommendation?
a. Add a short course of oral prednisone for 5 days.
b. Continue using the albuterol PRN but call back if it is needed more than four times a day.
c. Add montelukast (Singulair).
d. Change budesonide to maintenance therapy with a combination product containing fluticasone and salmeterol (Advair).
e. Add oral dextromethorphan (Robitussin-DM) PRN cough.

Back 11

a.
Patient is not responsive to albuterol (reading assignment –
page 4-B-3)

Front 12

Which of the following is most likely to occur when giving a beta blocker for hypertension to a patient with asthma who has intermittent asthma and uses albuterol MDI PRN?
a. Albuterol may antagonize the anti-hypertensive effects of a beta blocker.
b. The beta blocker might increase the effects of albuterol on the heart,
causing tachycardia.
c. The beta blocker is likely to decrease the bronchodilator effects of albuterol.
d. Albuterol may potentiate the anti-hypertensive effect of a beta blocker and
cause hypotension.
e. Beta blockers antagonize the effects of long-acting beta agonists such as
salmeterol but not short-acting beta-2 selective agonists, such as albuterol.

Back 12

c.
Albuterol is a beta-2 selective agonist and the beta blocker can antagonize the agonist effect (Primer, pg 14).

Front 13

Which of the following is the BEST choice for improving airflow and decreasing hyperinflation when used as maintenance medication in a patient with COPD characterized by dyspnea every day?
a. Budesonide DPI (Pulmicort Flexhaler).
b. Cromolyn nebulizer solution.
c. Montelukast (Singulair tablets).
d. Formoterol DPI (Foradil Aerolyzer).
e. Ipratropium bromide (Atrovent).

Back 13

d.
Bronchodilators do decrease hyperinflation and symptoms,
whereas inhaled steroids do not (reading assignment, pg 2691)

Front 14

Which of the following drug(s) used for COPD has (ve) the greatest potential produce cardiac arrhythmias, seizures and death?
a. High dose fluticasone + salmeterol combination product (e.g. Advair 500/50 BID).
b. Slow release oral theophylline.
c. Tiotropium inhaler (Spiriva Handihaler).
d. Salmeterol dry powder inhaler (Serevent Diskus).
e. Ipratropium MDI (Atrovent).

Back 14

b.
These are adverse effects at plasma concentrations > 20 μg/ml. Also, Theo-24 dose dumps when taken with food, increasing potential for
serious adverse effects (Primer, pg 12).

Front 15

Sarah is an otherwise healthy 31-year-old who complains of sneezing and runny nose during the January – February tree pollen season in Gainesville. The symptoms require her to use a large amount of Kleenex each day and she has trouble sleeping. She never has eye symptoms or nasal stuffiness. Which of the following would be the most effective treatment for her to take throughout the
season?
a. Cromolyn nasal spray (Nasalcrom).
b. Loratadine tablets (Claritin).
c. Pseudoephedrine tablets (Sudafed).
d. Budesonide nasal spray (Rhinocort Aqua).
e. Montelukast tablets (Singulair).

Back 15

d.
Nasal steroids are most effective for all symptoms except eye symptoms
(slides 16 & 21) and Sarah doesn’t have eye symptoms.

Front 16

Which of the following is most likely to occur when giving a beta blocker for hypertension to a patient with asthma whose asthma is well controlled on the combination of fluticasone and salmeterol (Advair Diskus)?
a. The beta blocker might decrease the bronchodilator effects of salmeterol.
b. The beta blocker might increase the effects of salmeterol on the heart, causing tachycardia.
c. The beta blocker might decrease the effects of fluticasone on mast cells,
lymphocytes and eosinophils.
d. The beta blocker might increase systemic absorption of fluticasone.
e. Beta blockers antagonize the effects of short-acting beta agonists such as albuterol
but not long-acting beta-2 selective agonists, such as salmeterol.

Back 16

a.
Salmeterol is a beta-2 selective agonist and the beta blocker can antagonize
the agonist effect.

Front 17

Which of the following would be most effective for a patient with seasonal allergic
rhinitis who only sneezes?
a. Fluticasone nasal spray (Flonase®) taken “PRN” during the season.
b. Ipratropium nasal spray (Atrovent®) taken daily throughout the season.
c. Cetirizine tablets (Zyrtec®) taken once daily all year.
d. Mometasone nasal spray (Nasonex®) taken daily throughout the season.
e. Loratadine tablets (Claritin®) taken once daily during the season.

Back 17

d.
Correct because intranasal steroids are the most effective treatment for allergic rhinitis and only should be taken during the season in a patient with seasonal allergic rhinitis.

Front 18

Jeff is a 45-year-old with allergic rhinitis and hypertension. His rhinitis symptoms consist of nasal stuffiness alone. His blood pressure is well controlled on metoprolol (Lopressor®). Why would Zyrtec-D (cetirizine + pseudoephedrine) not be a good choice for this patient?
a. The alpha-adrenergic receptor stimulating effects of pseudoephedrine may
increase his blood pressure.
b. The alpha-adrenergic receptor blocking effects of pseudoephedrine may
decrease his blood pressure too much.
c. The cetirizine may cause urinary hesitancy through an anticholinergic side
effect.
d. The beta-2 adrenergic stimulating effects of pseudoephedrine may antagonize the antihypertensive effects of metoprolol.
e. Cetirizine is less potent than other antihistamines.

Back 18

a.
Correct – described in the reading and in the lecture.

Front 19

Why does levalbuterol nebulizer solution (Xopenex) have no advantage over
racemic albuterol nebulizer solution as a quick relief medication for acute asthma
symptoms?
a. All of the beneficial and adverse effects are derived from the S-albuterol
isomer.
b. Both the R- and S-isomers are required for bronchodilatation
c. All of the beneficial and adverse effects are derived from the R-albuterol
isomer.
d. The S-isomer antagonizes the bronchodilator effects of the R- isomer
e. Levalbuterol causes a greater increase in heart rate than racemic albuterol

Back 19

c.
Correct because the actions are only related to the R-isomer.

Front 20

Which of the following drug classes may worsen asthma in an aspirin-sensitive
asthmatic?
a. A leukotriene receptor antagonist
b. An alpha1 receptor agonist.
c. A H1 histamine receptor antagonist.
d. An anticholinergic
e. A non-steroidal anti-inflammatory agent (NSAID).

Back 20

e.
NSAIDs are cross-reactive with ASA because both inhibit the formation of the protective PGDZ in patients with ASA-induced bronchospasm.

Front 21

Patrick is an 18-year-old UF freshman with moderate persistent asthma. Which
of the following would be the LEAST EFFECTIVE choice for initial controller therapy?
a. Budesonide dry powder inhaler for oral inhalation (Pulmicort Turbuhaler®) 2
actuations BID.
b. Salmeterol dry powder inhaler for oral inhalation (Serevent Diskus®) 1
actuation BID.
c. Fluticasone+salmeterol dry powder inhaler for oral inhalation (Advair-250®) 1
actuation BID.
d. Budesonide dry powder inhaler (Pulmicort Turbuhaler) 1 actuation twice a day and slow-release theophylline in individualized doses.
e. Montelukast (Singulair) 10 mg hs and budesonide dry powder inhaler (Pulmicort Turbuhaler) 1 actuation BID.

Back 21

b.
Long-acting beta agonists should never be used alone for
treating persistent asthma. A slide during the lecture demonstrates this principle.

Front 22

Which of the following has the greatest potential to cause tachycardia in elderly
patients?
a. Ipratropium MDI (Atrovent) 2 puffs “PRN”.
b. Tiotropium (Spiriva).
c. Nebulized budesonide (Pulmicort Respules).
d. Albuterol MDI (Proventil HFA, Ventolin HFA) 2 puffs “PRN”.
e. High doses of prednisone for 5 days.

Back 22

d.
Pointed out in the Primer to be a side effect in elderly patients

Front 23

How does omalizumab (Xolair®) reduce asthma symptoms?
a. Inhibits mast cell release of mediators.
b. Binds circulating IgE.
c. Binds IL-5.
d. Inhibits cyclooxygenase-1.
e. Activates adenyl cyclase.

Back 23

b.

(Cromolyn inhibits mast cell release of mediators)
(NSAIDS Inhibits cyclooxygenase-1)
(Albuterol & salmeterol work by activating adenyl cyclase)

Front 24

Mrs. Kahn is a 70-year-old with COPD who smokes. She gets short of breath whenever she walks. Her FEV1 was 60% predicted. She was prescribed tiotropium (Spiriva) 1 puff qd and albuterol MDI PRN. At today’s visit, she reports that she stopped smoking and is better but still gets short of breath when
she walks outside. Which of the following would be the best choice?
a. Add salmeterol inhaler (Serevent) 1 puff BID.
b. Change albuterol to Combivent MDI (albuterol +i pratropium) 2 puffs PRN
c. Add budesonide nebulizer suspension (Pulmicort Respules) 0.5 mg BID.
d. Add Advair(fluticasone + salmeterol) 1 actuation twice a day.
e. Add montelukast (Singulair) 10 mg hs.

Back 24

a.
A long-acting beta-agonist and long-acting anticholinergic
should be combined if either is not effective alone.

Front 25

How does formoterol dry powder inhaler (Foradil Aerolizer) reduce shortness of breath?
a. Stimulates M3 receptors.
b. Stimulates beta-2 adrenergic receptors.
c. Inhibits phosphodiesterase
d. Inhibits cytokines.
e. Decreases neutrophils in the airways.

Back 25

b.

- tiotropium does (a)
- theophylline does (c)
- steroids work indirectly to do (d)
- no current drug does (e)

Front 26

Which of the following would be most effective for a patient with allergic rhinitis
who only sneezes during the fall ragweed season? The patient has no other
symptoms of allergic rhinitis and does not have asthma.
a. Mometasone nasal spray (Nasonex®) taken “PRN” during the season.
b. Cetirizine tablets (Zyrtec®) taken once daily all year.
c. Desloratadine tablets (Clarinex®) taken once daily during the season.
d. Ipratropium nasal spray (Atrovent®) taken daily throughout the season.
e. Fluticasone nasal spray (Flonase®) taken daily throughout the season.

Back 26

e.

Front 27

Jeff is a 45-year-old with allergic rhinitis and hypertension. He does not have asthma or benign prostatic hypertrophy (BPH). His rhinitis symptoms consist of clear, watery rhinorrhea alone on some days and nasal stuffiness alone on other
days. There is no consistent pattern to these symptoms, but they occur all year. His hypertension is borderline controlled on metoprolol tablets (Lopressor), a beta-1-
selective adrenergic blocker, taken daily. His physician prescribes dust mite
covers for his pillow and mattress, and Zyrtec-D 12 hour (cetirizine 5 mg and
pseudoephedrine 120 mg in a slow release tablet), 1 tablet twice daily. Which of the following is the most compelling reason for the pharmacist filling the
prescription for Zyrtec to call the prescriber?
a. The alpha-adrenergic receptor stimulating effects of pseudoephedrine may
increase his blood pressure.
b. The alpha-adrenergic receptor blocking effects of pseudoephedrine may
increase his blood pressure.
c. The cetirizine may cause urinary hesitancy through an anticholinergic side effect.
d. The H1-receptor blocking effects of cetirizine will not be effective for nasal stuffiness.
e. The beta-2-adrenergic stimulating effects of pseudoephedrine may antagonize the antihypertensive effects of metoprolol.

Back 27

a.

Front 28

Which of the following would be the best choice to try first for a 57-year-old
woman with mild perennial allergic rhinitis and mild persistent asthma. Her
rhinitis symptoms consist of nasal stuffiness alone during the day and never
interfere with her sleep. Her asthma symptoms consist of mild wheezing during
the day 3-4 times/week and always respond to “PRN” albuterol MDI. She is not
taking estrogen replacement therapy and does not have hypertension.
a. Beclomethasone nasal spray (Beconase AQ) taken once daily and beclomethasone MDI for oral inhalation (QVAR) taken twice daily.
b. Montelukast tablets (Singulair) and budesonide nasal spray (Rhinocort-AQ)
both taken once daily.
c. Montelukast tablets (Singulair) taken once daily.
d. Budesonide dry powder inhaler for oral inhalation (Pulmicort Turbuhaler)
and slow-release pseudoephedrine capsules (Sudafed) both taken twice
daily.
e. Fluticasone nasal spray (Flonase) taken once daily.

Back 28

c.

Front 29

Why does levalbuterol nebulizer solution (Xopenex®) have no advantage over
racemic albuterol nebulizer solution as a quick relief medication for acute asthma
symptoms?
a. All of the beneficial and adverse effects are derived from the S-albuterol isomer. When given in equimolar doses, levalbuterol and racemic albuterol have the same effects.
b. All of the beneficial and adverse effects are derived from the R-albuterol
isomer. When given in equimolar doses, levalbuterol and racemic albuterol
have the same effects.
c. Both the R and S isomers are required for bronchodilatation but levalbuterol lacks the S isomer.
d. Both the R and S isomers are required for bronchodilatation, but levalbuterol lacks the R isomer.
e. At equimolar doses, levalbuterol causes a significantly greater increase in
heart rate than racemic albuterol.

Back 29

b.

Front 30

What is the mechanism by which ibuprofen (Advil), a non-steroidal antiinflammatory
agent (NSAID), may induce a life-threatening asthma attack in a patient with a history of experiencing bronchospasm when taking normal doses
of aspirin?
a. IgE-mediated release of mediators from mast cells.
b. Histamine release from eosinophils.
c. Blocking of the leukotriene receptor.
d. Inhibition of the cyclooxygenase-1 (COX-1) pathway of arachidonic acid
metabolism.
e. Inhibition of the 5-lipoxygenase (5LO) pathway of arachidonic acid
metabolism.

Back 30

d.

Front 31

Phil is a 22-year-old pharmacy student with mild persistent asthma. He never
wakes up from asthma, but has symptoms almost daily. He does not have
exercise-induced bronchospasm. He uses his albuterol MDI whenever he feels
tight in the chest and it always gives him complete relief. Which of the following
would be the best choice for his physician to make?
a. Salmeterol dry powder inhaler for oral inhalation (Serevent Diskus) 1
actuation BID.
b. Budesonide dry powder inhaler for oral inhalation (Pulmicort Turbuhaler) 2
actuations “PRN”.
c. Fluticasone+salmeterol dry powder inhaler for oral inhalation (Advair-100) 1
actuation BID.
d. Budesonide dry powder inhaler for oral inhalation (Pulmicort Turbuhaler) 1
actuation twice a day along with montelukast tablets once daily.
e. Budesonide dry powder inhaler for oral inhalation (Pulmicort Turbuhaler) 1
actuation twice a day.

Back 31

e.

Front 32

Food decreases the GI absorption of which of the following drug products?
a. Montelukast tablets (Singulair).
b. Zafirlukast tablets (Accolate).
c. Prednisolone oral liquid (Orapred).
d. Theo-24 brand of slow-release theophylline.
e. Albuterol slow release oral capsules (Volmax).

Back 32

b.

Front 33

Dr. Ram is a 66-year-old with COPD. About 6 months ago he stopped smoking because he got short of breath whenever he walked too fast or for any distance. At that time his FEV1 was 50% predicted and increased to 55% after albuterol. In
addition to smoking cessation, he was treated with Combivent® MDI (albuterol + ipratropium) 2 puffs “PRN”. At today’s visit, he reports to his physician
that he is a little better but still gets short of breath when he walks outside.
Which of the following would be the best recommendation that his physician can
make?
a. Give Combivent QID.
b. Add fluticasone MDI for oral inhalation (Flovent), 2 x 220 μg/puff BID.
c. Replace the Combivent with tiotropium (Spiriva HandiHaler) dry powder
inhaler for oral inhalation, 1 actuation each morning and do not use shortacting
bronchodilators “PRN”.
d. Change Combivent to albuterol “PRN” and add tiotropium dry powder
inhaler for oral inhalation (Spiriva HandiHaler), 1 actuation Q24h.
e. Add slow-release theophylline, titrating the dose by blood level.

Back 33

d.

Front 34

Which of the following is the most important benefit of adding inhaled corticosteroids in patients with COPD who remain symptomatic on long-acting bronchodilators?
a. Prevent the annual decline in FEV1.
b. Decrease eosinophil release of proteases and prevent further destruction.
c. Reduce the frequency of exacerbations.
d. Reduces the need for long-acting bronchodilators.
e. Increase functional residual capacity during exercise.

Back 34

c.