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73 Cards in this Set
- Front
- Back
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There is increasing evidence that chronic kidney disease (CKD) can affect hepatic drug metabolism by decreasing the activity of drug-metabolizing enzymes, such as cytochrome P450 (CYP) enzymes. Which of the following drugs metabolized by a CYP enzyme would you expect to have the largest decrease in clearance (due to decreased enzyme activity) in patients with CKD?
a.Chlorzoxazone (metabolized by CYP2E1) b.Voriconazole (metabolized by CYP2C19) c.Warfarin (metabolized by CYP2C9) d.The clearance of all of these drugs would be decreased in CKD. e.CKD will not affect the clearance of any of these drugs. |
c.Warfarin (metabolized by CYP2C9)
Answer C is correct because CYP2C9 activity has been shown to be decreased in patients with CKD (slide 34). Metabolism by CYP2E1 and CYP2C19 does not appear to be affected by CKD, so answers A and B are not correct. Answers D and E are not correct based on A-C. |
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Tacrine is extensively metabolized by CYP1A2. Which of the following drugs would you expect to interact with tacrine through CYP1A2 enzyme inhibition?
a.Fluconazole b.Fluvoxamine c.Omeprazole d.Phenytoin e.Rifampin |
b.Fluvoxamine
Answer B is correct – Fluvoxamine is a potent inhibitor of CYP1A2. Fluconazole is a strong inhibitor of CYP2C9, omeprazole is a substrate of CYP2C19 and a modest inducer of CYP1A2, phenytoin is a substrate and inducer of CYP2C9 and rifampin is an inducer of multiple CYP enzymes. |
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Which of the following statements regarding drug interactions is FALSE?
a. The inhibition of penicillin G renal tubular secretion by probenecid is an example of pharmacoenhancement. b. A pharmacodynamic drug interaction occurs when a precipitant drug causes an increase in the pharmacological effect of another drug due to an increase in plasma concentration. c. For a pro-drug that is activated by metabolism, an enzyme inhibitor will cause a decrease in drug effect. d. The time to onset of enzyme induction is generally slower than the onset of enzyme inhibition. e. Autoinduction occurs when a drug induces the enzyme responsible for its own metabolism. |
b. A pharmacodynamic drug interaction occurs when a precipitant drug causes an increase in the pharmacological effect of another drug due to an increase in plasma concentration.
Answer B is correct – A pharmacodynamic interaction always involves a change in the concentration-effect profile (slide 81) and is not due simply to a change in drug concentrations (a pharmacokinetic interaction). Answer A is an example of pharmacoenhancement. If a drug is metabolized into the active moiety, then inhibition of that process will decrease drug effect. The time to onset is slower for enzyme induction compared to enzyme inhibition due to the time required for synthesis of new enzyme. Finally, Autoinduction is when a drug induces its own metabolism. |
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A drug interaction study was conducted to determine the extent to which the pharmacokinetics of a CYP3A-metabolized drug was altered by co-administration of a potential precipitant. The pharmacokinetics of the object drug was evaluated in the absence (Control) and presence (during co-administration) of the potential precipitant, which was administered for 14 days. Select the statement that most closely describes the data shown in the following table.
Control (baseline) AUC (ng hr/ml) 672.5 T ½ (hours) 6.2 During Co-administration AUC (ng hr/ml) 2353.8 T ½ (hours) 19.8 a. The data are consistent with grapefruit juice mediated inhibition of a drug metabolized by CYP3A enzymes. b. It appears that the precipitant co-administered is an enzyme inducer. c. The precipitant is most likely a ligand (activator) of the PXR nuclear receptor. d. The directional change (but not necessarily the magnitude) in AUC is consistent with what you would expect for this object drug with ketoconazole co-administration. e. The directional change (but not necessarily the magnitude) in AUC is consistent with what you would expect for this object drug with St. John’s wort co-administration. |
d. The directional change (but not necessarily the magnitude) in AUC is consistent with what you would expect for this object drug with ketoconazole co-administration.
Answer D is correct because ketoconazole is an inhibitor of CYP3A, thus an increase in AUC would be expected during co-administration. Enzyme induction, such as with St. John’s wort or other PXR ligands including rifampin, would cause a decrease in the AUC (B, C and E). Grapefruit Juice (A) can cause an increase in the AUC of a drug metabolized by CYP3A, but it has no effect on the half-life (effect is limited to intestinal metabolism). |
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Refer to Case D
Which of the following chest pain scenarios would be most indicative of stable angina? a.Chest pain occurring on wakening in the morning b.Shortness of breath and chest burning/tightness while climbing 2 flights of stairs c.Chest pain with radiation to left arm while a passenger in a car d.Chest pain occurring while relaxing watching television. |
b.Shortness of breath and chest burning/tightness while climbing 2 flights of stairs
a. Chest pain occurring in the morning without any activity may be an acute coronary syndrome in progress b. Correct answer that fits description of stable angina. Symptoms occur with exertion in a predictable fashion. c. Chest pain occurring without increased oxygen demand may indicate an ACS (MI etc) d. Chest pain at rest is more consistent with unstable angina pectoris |
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Refer to Case D
BR undergoes a treadmill exercise test and develops ECG changes indicative of ischemia. Which of the following ECG changes is most likely in a patient experiencing myocardial ischemia? a.Prolonged PR interval b.Prolonged QT interval c.ST-Segment depression d.Q waves |
c.ST-Segment depression
a. Incorrect, Indicative of first degree AV block b. Incorrect, Indicative of prolonged repolarization of the ventricle tissue c. Correct, ST- segment depression is indicative of ischemia d. Incorrect, the vast majority of abnormal Q waves are due to myocardial infarction |
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Refer to Case D
Which of the following is the best short-term goal for BR? a.Optimize drugs to prevent angina symptoms with daily activity b.Increase his simvastatin to obtain an LDL goal less than 100 mg/dl c.Increase his lisinopril to lower his systolic blood pressure to goal d.Increase his metformin to lower his HgA1c |
a.Optimize drugs to prevent angina symptoms with daily activity
a. The best answer, There is room to increase his atenolol to lower his resting heart rate and you could add a nitrate for symptomatic relief. b. Incorrect, Decreasing his LDL is a secondary goal but relieving the anginal symptoms are top priority. c. Incorrect, The patient’s blood pressure is within goal range. d. Incorrect, HgA1c is not associated with anginal symptoms and his HgA1c is already in an acceptable range. |
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Refer to Case D
It is decided that a nitrate will be added to BR’s medicine regimen. Which of the following nitrate regimens is most appropriate of BR? a.Isosorbide dinitrate (ISDN) 10mg po every 6 hours b.Isosorbide mononitrate (Imdur) 30mg po daily c.Isosorbide mononitrate (Ismo) 20 mg po at bedtime d.Nitroglycerin ointment ½ inch to chest every 8 hours |
b. Isosorbide mononitrate (Imdur) 30mg po daily
a. Incorrect, ISDN every 6 hours does not allow for a nitrate free interval b. Best answer, this dosage form lasts about 12 hours and allows a nitrate free interval c. Incorrect, This dosage form is usually given bid d. Incorrect, Usually reserved for patients unable to tolerate po, also every 8 hour dosing does not provide a nitrate free interval |
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Refer to Case E
Which of the following is the best plan for JM? a.Increase the metoprolol to 200 mg daily b.Suggest that he quits the exercise program to avoid the symptoms c.Add Warfarin 5 mg daily d.Add sublingual nitroglycerin 0.4 mg before exercise |
d.Add sublingual nitroglycerin 0.4 mg before exercise
a. Incorrect, his heart rate resting and during exercise are acceptable and increasing the drug may not add to exercise capacity b. Incorrect, ACC/AHA guidelines encourage exercise 7 days per week in stable angina patients. c. Incorrect, the addition of warfarin would increase risk of bleeding and there is no evidence that this would decrease frequency of anginal symptoms d. Correct, Prophylactic sublingual nitrates may allow JM to participate in his exercise plan |
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Refer to Case E
JM understands that chronic stable angina is a manifestation of an imbalance of myocardial supply and demand. However, he is not sure why he takes metoprolol. Which of the following is the best explanation for him taking metoprolol? a.Metoprolol decreases both myocardial supply and demand b.Metoprolol decreases myocardial supply c.Metoprolol decreases LDL levels which increase risk for atherosclerotic lesions d.Metoprolol decreases myocardial demand |
d.Metoprolol decreases myocardial demand
a. Incorrect, beta blockers have no significant effects on coronary blood flow to the myocardium b. Incorrect, beta blockers have minimal effects on coronary blood flow to the myocardium c. Incorrect, positive LDL findings have not been associated with beta blockers and they are suspected of having detrimental lipid side effects in certain patients. d. Correct, Beta blockade reduces myocardial oxygen demand |
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A 35 year old man enters your clinic with a diagnosis of variant/prinzmetal angina. He has a non significant past medical history and jogs 3 miles on 5 days per week. Which of the following is the best therapy for S.D.?
a.Amlodipine daily b.Aspirin daily c.Ranolazine BID d.Metoprolol daily |
a.Amlodipine daily
a. Correct, Calcium channel blockers are drugs of choice for variant/prinzmetal angina b. Incorrect, will not reduce the risk of vasospams c. Incorrect, Indicated for angina refractory to maximum traditional therapy (BB, CCB’s, Nitrates, etc) d. Incorrect, may worsen symptoms |
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PM is a 57 year old woman with chronic stable angina. She currently takes Atenolol 50 mg QAM, Isosorbide dinitrate 20 mg tid, and Verapamil (Calan, Covera) 180 mg XR QPM but is still experiencing symptoms. Her heart rate is 76 bpm and BP is 141/92 mmHg. She reports that he sometimes misses his evening medications Which of the following would be the most INCORRECT strategy for this patient?
a. Add Ranolazine 500 mg po bid b. Increase the dose of Atenolol to 100 mg daily c. Add Nitroglycerin 0.3 mg sublingual tablets prn d. Replace Isosorbide dinitrate with Isosorbide mononitrate (Imdur) 60 mg daily |
a. Add Ranolazine 500 mg po bid
a. Correct, In the presence of CYP3A4 substrates/inhibitors like verapamil it would not be recommended to initiate ranolazine b. If the heart rate allows for increasing the dose this would be reasonable c. If needed this would be reasonable for relief of anginal symptoms d. Replacing the twice daily dosed drug with a once daily drug of the same class would be convenient if desired by the patient or practitioner |
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Which of the following High Density Lipoprotein (HDL) values would be counted as a risk factor for the development of coronary heart disease (CHD)?
A. 34 mg/dL B. 42 mg/dL C. 54 mg/dL D. 62 mg/dL |
A. 34 mg/dL
Based on epidemiological data such as the Framingham Heart Study, HDL<40 mg/dl counts as a risk factor for heart disease. Contrarily, HDL≥60 mg/dl is protective and subtracts one risk factor. |
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C is a 63 year old male with the following lipid profile: Total Cholesterol = 240 mg/dl; Low Density Lipoprotein = 154 mg/dl; High Density Lipoprotein (HDL) = 36 mg/dl; Triglycerides = 250 mg/dl. Which of the following classes would be the most INAPPROPRIATE drug therapy?
A. Bile acid sequestrants B. Statins C. Nicotinic acid D. Clofibrate |
A. Bile acid sequestrants
Bile acid sequestrants are not recommended in people with elevated triglycerides because they can cause increased triglyceride levels. Any of the other drugs listed below can be used. |
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In a patient on a potent CYP3A4 inhibitor which of the following statins would be the most appropriate drug therapy:
A. simvastatin B. atorvastatin C. pravastatin D. ezetimibe |
C. pravastatin
Simvastatin and atorvastatin are both metabolized by this enzyme, making A and B false. Therefore, potent inhibitors (such as amiodarone) will increase concentrations and likelihood for myopathy if A or B is used. Pravastatin is renally eliminated and would be an appropriate choice. Ezetimibe is not a statin. |
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DB is a 55 yo man who presents to your clinic for follow-up after initiation of dyslipidemia management. His prior medical history is significant for hypertension, diabetes, and eczema. Both of his parents have established coronary disease (father experienced MI at 44 years of age). DB is a non-smoker and consumes 1 glass of red wine every day for the past 7 years. Meds include hydrochlorothiazide 25 mg qd, simvastatin (Zocor) 40 mg qd, aspirin 81 mg qd. His lipids are as follows: TC=200 mg/dl; LDL=128 mg/dl; HDL=40mg/dl; TG=150 mg/dl. His BP is 128/85 mmHg.
What is DB’s LDL goal and why? A. <100 mg/dl, because his 10-yr CVD risk is >20% B. <130 mg/dl, because his 10-yr CVD risk is 10-20% C. <160 mg/dl, because his 10-yr CVD risk is <10% D. < 190 mg/dl, because he does not yet have coronary heart disease |
A. <100 mg/dl, because his 10-yr CVD risk is >20%
Although this man has 2+ risk factors (age, family history of premature heart disease, hypertension), Framingham risk scoring is not necessary since he has the CVD risk equivalent of DM. This automatically puts his 10-yr risk >20% and in the category with the LDL goal < 100 mg/dl. |
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DB is a 55 yo man who presents to your clinic for follow-up after initiation of dyslipidemia management. His prior medical history is significant for hypertension, diabetes, and eczema. Both of his parents have established coronary disease (father experienced MI at 44 years of age). DB is a non-smoker and consumes 1 glass of red wine every day for the past 7 years. Meds include hydrochlorothiazide 25 mg qd, simvastatin (Zocor) 40 mg qd, aspirin 81 mg qd. His lipids are as follows: TC=200 mg/dl; LDL=128 mg/dl; HDL=40mg/dl; TG=150 mg/dl. His BP is 128/85 mmHg.
Which of the following strategies below is the most likely to help DB achieve his LDL goal? A. Increase simvastatin to 80 mg qd B. Switch simvastatin to atorvastatin 40 mg qd C. Switch simvastatin to gemfibrozil 600 mg bid D. Add ezetimibe 10 mg qd to his current regimen E. None of the above |
D. Add ezetimibe 10 mg qd to his current regimen
This man needs an additional 22% LDL lowering to meet his LDL goal. Doubling simvastatin (A) is only likely to give him an additional 6-7% LDL lowering. Switching to atorvastatin 80 mg (B) constitutes the equivalents of 1 dose doubling and is likely to give him an additional 6-7% LDL lowering. Changing to a fibrate (C) is not reasonable since fibrates have less LDL lowering effect than statins, and his HDL and TGs are fine. Addition of ezetimibe (D) is the most likely to result in close to the 22% target. |
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JT is a 52 year old male who was released from the hospital 2 weeks ago after having an acute myocardial infarction. His lipid panel is TC=243 mg/dl; LDL=124 mg/dl; HDL=44 mg/dl; TG= 141 mg/dl. Which of the following is the most appropriate treatment for TT?
A. Pravastatin 40 mg qd B. Atorvastatin 10 mg qd C. Atorvastatin 80 mg qd D. Simvastatin 20 mg qd |
C. Atorvastatin 80 mg qd
Recent ACS puts this patient in the highest risk category with and LDL goal of <70 mg/dl. Furthermore, in clinical studies atorvastatin 80 mg has been shown to be superior in event reduction compared with low to moderate statin doses in stable CVD and ACS. Although A, B, and D are reasonable, (C) is the best option. |
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FJ is a 64 year old man with a long (many years) history of chronic kidney disease, hypertension, diabetes, and asthma. During a routine follow-up clinic visit, the following labs were noted: Na 142 meq/L, K 5.4 meq/L, Cl 105 meq/L, CO2 25 meq/L, BUN 20
mg/dl, Cr 2.5 mg/dl, Hgb 9.3 Gm/dl, Hct 28%, MCV 82 μm3, Alb 2.4 Gm/dl, Ca 10.5 mg/dl, phosphate 5.5 mg/dl, Fe 90 mcg/dl, TIBC 460 μg/dl, Transferrin sat’n 14%, Ferritin 15 ng/ml. The patient has no specific complaints but his vital signs are as follows: BP 170/100 mm Hg, P 82, RR16, T 37°C. Patient is 6’0” and 185 lbs. Which of the following represent the best initial therapy for management of this patient’s hypertension? a. a calcium channel blocker such as verapamil (Calan) or diltiazem (Cardizem). a. a beta blocker such as metoprolol (Lopressor). c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril) d. hypertension is a benign condition in this patient and does not need to be treated. |
c. an ACE inhibitor such as ramipril (Altace) or lisinopril (Zestril)
Selection “c” is correct; please see objective 6. Selection “a” represents a reasonable antihypertensive strategy but not for initial therapy. Selection “b” is incorrect since this patient has asthma. Please see slides 23 and 24. I would hope that an explanation of selection “d” would not be necessary. |
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Refer to Case F
To address her risk of cardiovascular disease (CVD) over the next 10 years, you perform a Framingham Risk Score (FRS) but also consider her other traditional risk factors in your overall assessment. Which of the following statements is correct? a. FRS should not be calculated because she already has a CAD risk equivalent b. FRS should be calculated; her 10-year risk is 13% according to FRS c. FRS should not be calculated because it has limitations in women d. FRS should be calculated; her 10-year risk is 2% according to FRS e. A and C are both correct |
d. FRS should be calculated; her 10-year risk is 2% according to FRS
a. Incorrect. CAD risk equivalents include known PAD, AAA, symptomatic carotid disease, and diabetes. This patient has none of these and therefore FRS should be performed. b. Incorrect. FRS should be performed but her risk is not 13%. c. Incorrect. Despite its limitations in some populations (e.g., African Americans, children, and women) the FRS provides an estimate of CAD risk that can be used to inform therapeutic decision making. Other factors such as strength of family history and concomitant diseases should also be assessed. d. Correct. Consideration of her age, total cholesterol, smoking status, HDL, and SBP add up to 13 points and put her at 2% according to FRS. |
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Refer to Case F
According to NCEP guidelines, what is the patient’s risk category? a. High (LDL goal <100 mg/dL, <70 mg/dL is optional) b. Moderately high (LDL goal <130 mg/dL, <100 mg/dL is optional) c. Moderate (LDL goal <130 mg/dL) d. Low (LDL goal <160 mg/dL) e. None of the above |
c. Moderate (LDL goal <130 mg/dL)
a. Incorrect. She is not high risk based on FRS, and this is the LDL goal fo rpeople with established CVD or CAD risk equivalents. b. Incorrect. She is not moderately high risk (10-20%) based on FRS. c. Correct. She is moderate risk by FRS (<10%) with an LDL goal of <130 mg/dL. d. Incorrect. Low risk is 0-1 risk factor and she has 2+ risk factors that modify her LDL goals. Because of her additional risk factors for CAD and the limitations of FRS in women, you are more inclined to think she has a higher risk of a cardiovascular event than suggested by FRS alone. Therefore, in addition to therapeutic lifestyle changes, you recommend lipid-lowering therapy. She is willing to consider both therapeutic lifestyle changes and pharmacologic therapy. |
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Refer to Case F
Because of her additional risk factors for CVD and the limitations of FRS in women, you believe she has a higher risk of a cardiovascular event than suggested by FRS alone. Therefore, in addition to therapeutic lifestyle changes, you recommend lipid-lowering therapy. She is willing to consider both therapeutic lifestyle changes and pharmacologic therapy. Which of the following would be appropriate therapeutic lifestyle changes for this patient? a. Plant sterol spread b. Supplemental fiber c. Weight loss d. At least 30 minutes of exercise daily e. All of the above are appropriate |
e. All of the above are appropriate
Correct. All of the above are recommended lifestyle changes according to NCEP ATP III guidelines and would be appropriate to implement in this patient. |
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Refer to Case F
Because of her additional risk factors for CVD and the limitations of FRS in women, you believe she has a higher risk of a cardiovascular event than suggested by FRS alone. Therefore, in addition to therapeutic lifestyle changes, you recommend lipid-lowering therapy. She is willing to consider both therapeutic lifestyle changes and pharmacologic therapy. Which of the following would be most appropriate in this patient and why? a. Pravastatin 10 mg (expected LDL reduction ~20%) b. Simvastatin 20 mg (expected LDL reduction ~35%) c. Atorvastatin 80 mg (high-dose statins superior to moderate doses in endpoint trials) d. Ezetimibe 10 mg (expected LDL reduction ~20%) e. Simvastatin/ezetimibe 10 mg/10 mg (expected LDL reduction ~45%) |
b. Simvastatin 20 mg (expected LDL reduction ~35%)
a. Incorrect. NCEP ATPIII guidelines recommend that starting doses of statins be chosen that will cause a 30-40% LDL reduction. The approximate LDL reduction of 20% expected with pravastatin is insufficient. b. Correct. NCEP ATPIII guidelines recommend that starting doses of statins be chosen that will cause a 30-40% LDL reduction. This will be achieved with simvastatin 20 mg. c. Incorrect. NCEP ATPIII guidelines recommend that starting doses of statins be chosen that will cause a 30-40% LDL reduction. While intensive statin therapy is superior to moderate doses in endpoint trails of high-risk individuals, the aggressive goals for LDL are reserved for high- risk and very high-risk individuals. Our patient does not meet those criteria. d. Incorrect. NCEP ATPIII guidelines recommend that starting doses of be chosen that will cause a 30-40% LDL reduction. This is not likely to be achieved with ezetemibe. Secondly, there are no outcomes data with ezetimibe and statins are the drug of choice unless contraindicated. Our patient has no contraindications. e. Incorrect. While this regimen is likely to achieve a 30-40% LDL reduction, there is no rationale for combination therapy in statin-naïve patients. This regimen has not been studied in clinical outcomes studies and this regimen is expensive. The combination might be used for “statin-sparing effects” in people intolerant of high-dose statins or in people that are cholesterol “absorbers” that have an inadequate statin response. |
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Refer to Case F and previous continuation
She is started on your recommended intervention and asked to obtain a follow-up lipid profile and liver function tests in 6 weeks. The patient calls the office 1 week later saying she is having aches and pains “everywhere.” She admits to starting a yoga class, but she also read the information from her pharmacy that the prescribed intervention can cause severe muscle problems and is worried. However, she also is worried about her cholesterol. Which of the following is the best option? a. Reassure her of the safety of the drug and ask her to continue at her present dose b. Stop the drug and continue only lifestyle modification c. Switch the regimen to a fibrate at LDL lowering. Furthermore, d. Change to a different drug in the same drug class |
d. Change to a different drug in the same drug class
a. Incorrect. While it is true that statin myalgia may be benign and there is an alternative potential etiology (yoga), it is not the best option to continue the regimen without follow- up. An alternative approach would be to check a CK, temporarily discontinue the statin and rechallenge after symptoms resolve, or lower the dose. b. Incorrect. While lifestyle modification might get her to goal, she is unlikely to be able to adhere to all required lifestyle modifications. In addition, there is a high suspicion that the myalgia has an alternative etiology (yoga); therefore, causation should be established before discontinuing a potentially life-saving intervention. c. Incorrect. While fibrates are a reasonable alternative to statins in some patients, statins are more effective fibrates may also cause myalgia. Causation should be established before discontinuing the statin and switching to a fibrate. d. Correct. Statins vary in their properties. There is some suggestion that if myalgia occurs with one statin it would be appropriate to lower the dose or switch to another statin. |
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Which of the following statements is correct?
a. Niacin should not be used in diabetics because of its adverse effects on glucose control. b. Fenofibrate is contraindicated in patients with elevated triglycerides. c. Atorvastatin is more effective at lowering LDL than all other statins. d. Ezetimibe is contraindicated in patients taking potent CYP3A4 inhibitors. e. None of the above are correct. |
e. None of the above are correct.
a. Incorrect. While niacin may adversely affect glucose control, this effect is usually transient and can be overcome by adjusting other medications. In fact, niacin is very effective in mixed dyslipidemia (low HDL, high LDL, high TGs) which is common in patients with diabetes. b. Incorrect. Fibrates are among the best drugs to lower TGs. Bile acid resins are contraindicated in hypertriglyceridemia. c. Incorrect. Statins are equally effective at lowering LDL if used in equipotent doses. For example, atorvastatin 10 mg = simvastatin 20 mg = pravastatin 40 mg. d. Incorrect. This is not a contraindication to ezetemibe therapy. |
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Which of the following drugs, taking into account the route of administration,
metabolism pathway and oral bioavailability, would you expect to have the GREATEST potential for an interaction with grapefruit juice? a. Alfentanil administered intravenously. Alfentanil is predominately metabolized by CYP3A4 and has oral bioavailability of approximately 30%. b. Alprazolam administered orally. Alprazolam is predominately metabolized by CYP3A4 and has oral bioavailability of approximately 90%. c. Chlorzoxazone administered orally. Chlorzoxazone is predominately metabolized by CYP2E1 and has oral bioavailability of approximately 65%. d. Midazolam administered intravenously. Midazolam is predominately metabolized by CYP3A4 and has oral bioavailability of approximately 30%. e. Nifedipine administered orally. Nifedipine is predominately metabolized by CYP3A4 and has oral bioavailability of approximately 50%. f. Tacrine administered orally. Tacrine is predominately metabolized by CYP1A2 and has oral bioavailability of approximately 30%. |
e. Nifedipine administered orally. Nifedipine is predominately metabolized by CYP3A4 and has oral bioavailability of approximately 50%.
Answer E is correct. Grapefruit juice predominately affects drugs (e.g., nifedipine) metabolized by intestinal CYP3A4 with poor to moderate bioavailability. Alprazolam is predominately metabolized by CYP3A4 but has high bioavailability (grapefruit juice was shown to have no affect on alprazolam pharmacokinetics). Chlorzoxazone and tacrine are not metabolized by CYP3A4, so the potential for an interaction is limited. Grapefruit juice would not affect the pharmacokinetics of alfentanil or midazolam when administered IV, but would have a relevant effect on the pharmacokinetics of these drugs when given orally (approximate 2-fold increase in AUC for both). |
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S-Warfarin is extensively metabolized by CYP2C9. Which of the following drugs would you expect to interact with warfarin because of strong, competitive CYP2C9 enzyme inhibition?
a. Fluconazole b. Fluvoxamine c. Omeprazole d. Phenytoin e. Rifampin |
a. Fluconazole
Answer A is correct – fluconazole is a strong inhibitor of CYP2C9. Fluvoxamine is a potent inhibitor of CYP1A2, omeprazole is a substrate of CYP2C19 and a modest inducer of CYP1A2, phenytoin is a substrate and inducer of CYP2C9 and rifampin is an inducer of multiple CYP enzymes. |
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Which of the following statements regarding St. John’s wort drug interactions is/are TRUE?
a. St. John’s wort is a more potent enzyme inducer than rifampin. b. The effect of St. John’s wort is more pronounced on intestinal CYP3A4 metabolism compared to hepatic CYP3A4 metabolism. c. St. John’s wort increases tolbutamide (CYP2C9) clearance in healthy volunteers. d. Two of the above statements are true. e. All of the statements above are true. f. None of the above statements are true. |
b. The effect of St. John’s wort is more pronounced on intestinal CYP3A4 metabolism compared to hepatic CYP3A4 metabolism.
Answer B is correct – St. John’s wort, which causes induction of CYP3A enzymes through activation of the PXR receptor, has a more pronounced effect on intestinal metabolism and a comparatively mild effect on hepatic metabolism (slide 75). St. John’s wort is a much less potent inducer than rifampin and because St. John’s wort does not induce CYP2C9, it does not alter the clearance of tolbutamide (slide 74). |
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Which of the following statements concerning drug-drug interactions is/are
TRUE? a. The time to maximum effect for an interaction mediated by enzyme inhibition is dependent on the time required for the substrate drug to reach steady-state. b. An interaction mediated through enzyme induction will result in reduced effect from a pharmacologically active metabolite formed via the induced pathway. c. The time of offset for an enzyme inhibition interaction is not influenced by the half-life of the inhibitor. d. Inhibition of intestinal CYP3A4 results in decreased bioavailability for drugs that are metabolized by CYP3A4 and undergo extensive first pass metabolism. e. None of the above are true. |
a. The time to maximum effect for an interaction mediated by enzyme inhibition is dependent on the time required for the substrate drug to reach steady-state.
Answer A is correct (see slide 42). Answer B is not correct because the effect would be increased because more metabolite is formed via the induced pathway. Answer C is not correct because the time of offset is dependent on the half-life of the inhibitor (slide 42). Answer D is not correct because bioavailability would be increased. |
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Refer to Case G
This patient asks you about adding a phosphodiesterase (PDE) inhibitor for his erectile dysfunction (which he has not discussed with his doctor). Based on his current drug regimen... a. He may separate a PDE inhibitor from his SL NTG by 1 hour to increase the absorption of the SL NTG b. PDE inhibitors may be safely used with SL NTG but not with long acting nitrates c. The hypertensive effect of the PDE inhibitor will be blunted by his beta blocker d. PDE inhibitors are contraindicated within 24-48 hours of nitrate use e. PDE inhibitors can be stored in the same container as SL NTG. |
d. PDE inhibitors are contraindicated within 24-48 hours of nitrate use
Patients with angina have a Rx for SL NTG PRN. A is incorrect; should this patient require SL NTG prn or be prescribed scheduled long-acting NTG in the future, it would be contraindicated within 24-48 hours of the sildenafil (depending on the specific ED medication). B is incorrect, they are contraindicated in combination with any nitrate. C is incorrect, PDE inhibitors can cause HYPOTENSION, which will not be remedied by a beta blocker. E is incorrect, SL NTG should not be stored with other medications because the NTG may adsorb to other dosage forms |
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Refer to Case G
Which of the following interventions below would be most appropriate to lower the risk of cardiovascular events in this patient? a. add long-acting nitroglycerin b. add clopidogrel c. add aspirin d. add amlodipine e. add niacin |
c. add aspirin
A is incorrect, NTG improves symptoms but does not have an effect on survival. B is incorrect since this patient should be able to take aspirin. D is incorrect, amlodipine does not offer survival benefits. E is incorrect, although lipid lowering therapy is recommended, statin medications specifically are recommended for this purpose because of evidence supporting its use in this clinical setting. |
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Refer to Case H
Which is the best option to improve the control of this patient’s angina symptoms? a. Add amlodipine b. Add verapamil c. Increase copidogrel d. Add ramipril e. Increase atenolol |
a. Add amlodipine
A is correct due to low heart rate. Verapamil should not be added to atenolol. C and D do not affect symptoms. Atenolol should not be titrated upward due to borderline HR. |
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Refer to Case H
Which of the following is most likely a potential side effect of this patient’s current drug regimen for chronic stable angina? a. Tachycardia b. Low blood glucose c. Constipation d. Peripheral edema e. Fatigue |
e. Fatigue
Beta blockers cause bradycardia, not tachycardia. They cause hyperglycemia, not hypoglycemia, though they can mask symptoms of low blood sugar if it occurs. Verapamil and amlodipine cause constipation and edema, respectively. Fatigue due to beta blockade is correct. |
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Refer to Case H
Assuming that no changes have been made to her original drug regimen, which of the following changes would be most appropriate in the event the patient’s asthma worsens? a. Add felodipine b. discontinue atenolol, add felodipine c. Add diltiazem d. discontinue atenolol, add diltiazem e. Decrease atenolol dose |
d. discontinue atenolol, add diltiazem
A, would not alleviate aggravation of asthma by beta blocker. B, felodipine should not be used as monotherapy due to potential for reflex tachycardia. C, diltiazem should not be added to beta blocker therapy. E, would not improve her angina control. |
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Chronic stable angina is a manifestation of an imbalance between myocardial oxygen supply and demand. Which of the following medications work to prevent angina symptoms by decreasing myocardial oxygen demand only (minimal effect on myocardial oxygen supply)?
a. Amlodipine b. Metoprolol c. Aspirin d. Ramipril e. Isosorbide mononitrate |
b. Metoprolol
A, incorrect, calcium channel blockers increase supply and have a net effect to reduce demand. C, incorrect, aspirin is not given to reduce the symptoms of angina. D, incorrect, ramipril is not given to reduce the symptoms of angina. E is not correct because, nitrates both increase supply and decrease demand. |
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BV is a 60 yo WM with a PMH of angina, HTN, and hyperlipidemia. He arrives at your pharmacy with a new prescription for Viagra (sildenafil). Before filling the patient’s
prescription, he asks you to check for any “problems” with his drugs, considering the medications he has on file at your store. His profile lists the following medications: Lisinopril 10mg daily, Lipitor (atorvastatin) 40mg at bedtime, NTG 0.4mg SL PRN, warfarin (Coumadin) 5mg daily, and Zetia (ezetimibe) 10mg daily. What is your main concern, upon doing a review of this patient’s medications? a. Lisinopril may be at suboptimal dose to control HTN in this high-risk cardiac patient. b. Zetia should be taken at bedtime for optimal LDL lowering. c. Viagra is contraindicated with use of nitrates. d. Vytorin may be a more suitable option for this patient, as it may lower the patient’s prescription cost. |
c. Viagra is contraindicated with use of nitrates.
Correct Answer: c Phosphodiesterase 5 inhibitors are contraindicated with the use of nitrates. |
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BV is a 60 yo WM with a PMH of angina, HTN, and hyperlipidemia. He arrives at your pharmacy with a new prescription for Viagra (sildenafil). Before filling the patient’s
prescription, he asks you to check for any “problems” with his drugs, considering the medications he has on file at your store. His profile lists the following medications: Lisinopril 10mg daily, Lipitor (atorvastatin) 40mg at bedtime, NTG 0.4mg SL PRN, warfarin (Coumadin) 5mg daily, and Zetia (ezetimibe) 10mg daily. BV asks you to explain some alternatives for treating ED. He is not sure that he wants to take Viagra, and he wonders what options are available to him. Which of the following would be most appropriate for this patient at this time? a. Vacuum Erection Devices (VEDs) are safe to use and would be a suitable alternative for this patient. b. With proper education, pt may benefit from using a MUSE suppository to treat ED. c. Enzyte is an herbal supplement available over the counter, and is likely to be safe when taken with patient’s other medications. d. Patient may need to visit his urologist to determine if he is a candidate for penile prosthesis. |
b. With proper education, pt may benefit from using a MUSE suppository to treat ED.
Correct Answer: b A vacuum erection device is not suitable for this patient, who is on warfarin; VED can cause painful bruising. MUSE is a successful alternative, if provided to patient with proper education. Enzyte is not approved by the FDA and is therefore not properly studied. Penile prosthesis is a last resort, and patient would benefit from a trial of MUSE first, before being considered for surgery. |
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Refer to Case I
RH’s cardiologist wishes to make a change to this patient’s drug regimen to help control his symptoms. Which of the following adjustments to this patient’s therapy is most appropriate for this purpose? a. d/c atenolol, start amlodipine b. d/c atenolol, start isosorbide c. increase atenolol dose d. add verapamil to atenolol e. add felodipine |
e. add felodipine
a. Dihydropyridines calcium channel blockers should not be administered as monotherapy for the treatment of angina due to reflex increases in heart rate which may blunt the response to treatment or aggravate symptoms. b. dinitrate Isosorbide should not be used as monotherapy unless there are compelling reasons that prevent this patient from receiveing beta blockers and/or calcium channel blockers, which are not present in this patient. One of the reasons for this include the development of tolerance which would require the patient have a nitrate-free interval in therapy where their symptoms were not being prophylactically treated. c. This would be ill-advised since the patient’s pulse is already at 60 bpm. d. This would be inappropriate since these two agents added together would lower the heart rate as well and potentially cause AV block and both have negative inotropic effects. e. This adjustment would be appropriate, since it would allow dual drug therapy without the issues mentioned above. |
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Refer to Case I
Which of the following interventions specific to ischemic heart disease would most likely improve this patient’s survival? a. d/c HCTZ, start ramipril b. add clopidogrel c. d/c aspirin, add clopidogrel d. d/c HCTZ, add amlodipine e. add amlodipine |
a. d/c HCTZ, start ramipril
a. Since this patient has documented CAD and concomitant HTN, it would be prudent to treat this patient with and ACEI for his HTN since it is also recommended in patients with ischemic heart disease who have other compelling indications (diabetes, hypertension, etc.) b. It is not recommended to add clopidgrel to aspirin therapy for chronic stable angina c. Aspirin is first line treatment barring contraindications, and therefore the patient should not be taken off of aspirin. He does not have contraindications (asthma is not aspirin-induced, no allergy, etc.) d. Although this adjustment might bring symptom relief, this will not improve Survival e. Although this adjustment might bring symptom relief, this will not improve Survival |
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Refer to Case I
Which of the following potential adverse effects of atenolol will most likely result in an adverse outcome for this patient? a. Tachycardia b. Hypoglycemia c. Constipation d. Peripheral edema e. Worsening asthma |
a. Beta-blockers and aspirin are not expected to cause tachycardia
b. Although beta-blockers can mask the signs of hypoglycemia, they do not cause hypoglycemia. c. This is common with verapamil, but not usually a concern with beta-blockers (diarrhea more likely) d. This is common with DHP CCBs, not beta-blockers e. This can occur with beta-blocker treatment. Higher doses of even cardioselective beta-blockers can cause worsening asthma so this patient should be monitored carefully. Patient may also require larger doses of albuterol for acute attacks to overcome beta-receptor blockade |
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Which of these is not a counseling point to emphasize to patients receiving SL NTG?
a. Store in a cool, dry place b. Sitting or standing enhances the effects of SL nitroglycerin c. Call 911 if SL nitroglycerin not effective after 5 minutes d. Keep extra tablets in pill box with prophylactic medications SL NTG tablets should be stored in their original containers (or containers made especially to hold a few NTG tablets) away from other medications since other tablets can absorb the NTG. e. Do not replace fiberglass plug with other material, such as cotton |
d. Keep extra tablets in pill box with prophylactic medications SL NTG tablets should be stored in their original containers (or containers made especially to hold a few NTG tablets) away from other medications since other tablets can absorb the NTG.
All other statements are necessary counseling points. |
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NH is a 52 yo female with the following lipid profile: TC=200 mg/dl; LDL=120 mg/dl;
HDL=50mg/dl; TG=160 mg/dl. Her doctor told her that her “bad cholesterol and good cholesterol look great.” With regard to HDL, levels lower than which of the following are generally associated with a higher risk for CAD? a. 20 mg/dL b. 30 mg/dL c. 40 mg/dL d. 50 mg/dL |
c. 40 mg/dL
Based on epidemiological data such as the Framingham Heart Study, HDL<40 mg/dl counts as a risk factor for heart disease. Contrarily, HDL≥60 mg/dl is protective and subtracts one risk factor. |
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TR is a 60 yo male with the following lipid profiles: TC=240 mg/dl; LDL=154 mg/dl; HDL=36 mg/dl; TG=250 mg/dl. Which of the following should not be used as
monotherapy in his case? a. Bile acid sequestrants b. Statins c. Nicotinic acid d. Clofibrate |
a. Bile acid sequestrants
Bile acid sequestrants are contraindicated in people with elevated triglycerides because they can cause increased triglyceride levels. Any of the other drugs listed below can be used. |
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The risk of myopathy is increased when simvastatin (Zocor) is concomitantly used with:
a. Potent inhibitors of CYP2C9 b. Potent inhibitors of CYP3A4 c. Both a and b d. Neither a nor b |
b. Potent inhibitors of CYP3A4
Simvastatin is not metabolized by 2C9 making A and C false. Simvastatin is a metabolized 3A4. Therefore, potent inhibitors (such as amiodarone) will increase simvastatin concentrations and likelihood for myopathy. |
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DB is a 55 yo man who presents to your clinic for follow-up after initiation of dyslipidemia management. His prior medical history is significant for hypertension, diabetes, and eczema.Both of his parents have established coronary disease (father experienced MI at 44 years of age).
DB is a non-smoker and consumes 1 glass of red wine every day for the past 7 years. Meds include hydrochlorothiazide 25 mg qd, simvastatin (Zocor) 40 mg qd, aspirin 81 mg qd. His lipids are as follows: TC=200 mg/dl; LDL=128 mg/dl; HDL=40mg/dl; TG=150 mg/dl. His BP is 128/85 mmHg. What is DB’s LDL goal and why? a. <100 mg/dl, because his 10-yr CVD risk is >20% b. <130 mg/dl, because his 10-yr CVD risk is 10-20% c. <160 mg/dl, because his 10-yr CVD risk is <10% d. None of the above |
a. <100 mg/dl, because his 10-yr CVD risk is >20%
Although this man has 2+ risk factors (age, family history of premature heart disease, hypertension), Framingham risk scoring is not necessary since he has the CVD risk equivalent of DM. This automatically puts his 10-yr risk >20% and in the category with the LDL goal < 100 mg/dl. |
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DB is a 55 yo man who presents to your clinic for follow-up after initiation of dyslipidemia management. His prior medical history is significant for hypertension, diabetes, and eczema.Both of his parents have established coronary disease (father experienced MI at 44 years of age).
DB is a non-smoker and consumes 1 glass of red wine every day for the past 7 years. Meds include hydrochlorothiazide 25 mg qd, simvastatin (Zocor) 40 mg qd, aspirin 81 mg qd. His lipids are as follows: TC=200 mg/dl; LDL=128 mg/dl; HDL=40mg/dl; TG=150 mg/dl. His BP is 128/85 mmHg. Which of the following is most likely to help DB achieve his LDL goal? a. Increase simvastatin to 80 mg qd b. Switch simvastatin to atorvastatin 80 mg qd c. Switch simvastatin to gemfibrozil 600 mg bid d. Add ezetimibe 10 mg qd to his current regimen e. None of the above |
d. Add ezetimibe 10 mg qd to his current regimen
This man needs an additional 22% LDL lowering to meet his LDL goal. Doubling simvastatin (A) is only likely to give him an additional 6-7% LDL lowering. Switching to atorvastatin 80 mg (B) constitutes the equivalents of 2 dose doublings and is likely to give him an additional 12-14% LDL lowering. Changing to a fibrate (C) is not reasonable since fibrates have less LDL lowering effect than statins, and his HDL and TGs are fine. Addition of ezetimibe (D) is the most likely to result in close to the 22% target. |
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Which of the following is true regarding the hepatic effects of statins:
a. AST/ALT (transaminase) elevations to ≥ 3 times the upper limit of normal occurs in 1-3% of patients taking higher doses of statins b. Transaminase elevations resolve spontaneously in 70% of people with continued treatment c. Marked elevations in transaminases are rare and the risk increases with interacting drugs, co-morbidities, and high doses d. The rate of acute liver failure with statins is 1 in 1 million and is the same as the rate in general population e. All of the above are true |
e. All of the above are true
Based on the National Lipid Associations review of the literature and FDA Adverse Event Reporting System, all of the above are true. |
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A 75 year-old man with a history of coronary artery disease (CAD) and a TIA (transient ischemic attack) presently on simvastatin 40 mg has a CVA (cerebrovascular accident). Six weeks prior to his CVA, he has the following lipid profile:
Total Cholesterol: 150 mg/dL Triglycerides: 155 mg/dL HDL: 34 mg/dL LDL: 86 mg/dL Glucose: 116 mg/dL CRP: 2.5 mg/L His blood pressure is normal. He is a non-smoker, exercises 5 times per week, has a BMI of 26 kg/m2 and waist circumference of 36 inches. Which of the following characteristics of this patient places him in the very high risk category according to the update of the NCEP ATPIII guidelines? A. Recent history of CVA B. History of TIA C. CAD with metabolic syndrome D. Recurrent CVA with an LDL < 100mg/dl |
C. CAD with metabolic syndrome
Answer C: According to the recent the 2004 update of the NCEP ATPIII guidelines, very high risk is defined as patients with ACS, or patients with CVD plus diabetes or metabolic syndrome or other major risk factors, especially cigarette smoking. This patient has 3 of the 5 criteria for the metabolic syndrome, i.e., HDL <40 mg/dl, TGs ≥150 mg/dl, and glucose ≥100 mg/dl. |
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When adding high-dose extended-release niacin to a statin, which one of the following side-effects is most likely to occur?
A. Elevation in fasting serum glucose B. Decreased serum uric acid levels C. Increased platelet counts D. All of the above |
A. Elevation in fasting serum glucose
Answer A: Niacin therapy can antagonize glycemic control in the short term. High-dose niacin can increase the proximal tubular re-uptake of urate, thereby increasing uric acid levels in the blood (making it a relative contraindication in gout). Dermal flushing and pruritis are well-known side effects of niacin. High-dose niacin does not increase platelets. |
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Going from atorvastatin 10 mg to atorvastatin 40 mg will likely provide
approximately how much additional LDL lowering? A. 7% B. 17% C. 27% D. 37% E. 47% |
B. 17%
Answer B: This is two doublings of the statin dose (10 mg -> 20 mg, 20 mg -> 40mg). Each doubling of a statin dose is likely to give ~7% additional LDL lowering, therefore the closest answer is B |
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A diabetic patient on simvastatin 20 mg qd has the following lipid profile:
Total Cholesterol: 200 mg/dL Triglycerides: 250 mg/dL HDL: 37 mg/dL LDL: 100 mg/dL Which of the following is likely to produce the greatest beneficial changes on the patients HDL and triglycerides? A. Ezetimibe 10 mg qd B. Simvastatin 40 mg qd C. Fenofibrate 145 mg qd D. Colesevelam 3.75 gm qd |
C. Fenofibrate 145 mg qd
Answer C: Fibrates increase HDL by 10-20% and lower triglycerides by ~30%, and are superior to ezetimibe. Doubling the statin dose is not likely to improve HDL. Colesevelam is contraindicated in hypertriglyceridemia because it is a bile acid sequestrant and can increased triglycerides. This class of drugs also has little effect on HDL. |
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TH is a 62 year-old woman with chronic stable angina, dyslipidemia, hypertension, obesity, 40 pack-year smoking history (2 packs/day for 20 years), and history of myocardial infarction (MI) (1998). She is without complaints and states that her chest pain symptoms are effectively controlled with sublingual nitroglycerin, which she uses about 2 times per month. Her other medications include metoprolol 100 mg twice daily, simvastatin 10 mg qhs, and aspirin 81 mg daily. Vital signs: T 37oC, HR 50 beats/min, BP 111/74 mmHg, RR 14 breaths/min. Physical exam is unremarkable. Labs are as follows: electrolytes, BUN and creatinine are within normal limits; fasting glucose 107 mg/dL; Total cholesterol 168 mg/dL, LDL 85 mg/dL, HDL 60 mg/dl, triglycerides 115 mg/dL; ALT 20 mg/dL.
The physician states that she is doing well and he does want not to make any changes. Which of the following is the best reply? A. I agree B. decrease metoprolol dose C. add perindopril D. add amlodipine E. stop simvastatin |
C. add perindopril
Answer C: Please see 5th objective. This patient has several risk factors for a cardiovascular event, most notably the history of MI, and should receive an ACE inhibitor unless contraindicated. The patient does have a low heart rate, but it is still within the target range of 50-60 beats per minute, and more importantly she does not have symptoms of bradycardia. Her angina symptoms are effectively managed with a short-acting nitrate and are infrequent: addition of amlodipine might be considered if her symptoms were poorly controlled, disabling or she had symptoms more frequently than twice a month. Attainment of goal LDL is not an indication for discontinuing the statin, especially as she is at higher risk (it could be argued that she might benefit from LDL reduction to < 70 mg/dL). |
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RP is a 79 year-old male smoker with diabetes, moderate peripheral vascular disease, heart failure (ejection fraction [EF] is 33%), and newly diagnosed stable angina. Which of the following would be the most appropriate regimen for this patient?
A. verapamil, sublingual nitroglycerin, aspirin, atorvastatin, trandolapril B. metoprolol, sublingual nitroglycerin, aspirin, simvastatin, ramipril C. isosorbide mononitrate, sublingual nitroglycerin, aspirin, pravastatin, trandolapril D. amlodipine, sublingual nitroglycerin, aspirin, atorvastatin, perindopril |
B. metoprolol, sublingual nitroglycerin, aspirin, simvastatin, ramipril
Answer B: Please see 5th and 7th objectives. Verapamil may worsen left ventricular function in patients with heart failure, whereas heart failure is a compelling indication for the beta-blocker (even though he also has diabetes and peripheral vascular disease). Isosorbide mononitrate would not be appropriate for initial therapy because it does not provide 24 hour antianginal coverage and it can cause reflex tachycardia. Amlodipine is generally not recommended for monotherapy because it can increase heart rate. |
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JR is a 52 year-old male with stable angina, dyslipidemia, hypertension, and poorly controlled asthma who presents to clinic complaining of increasing frequency of chest pain episodes (on a daily basis). He takes verapamil SR 240 mg daily, sublingual nitroglycerin 0.4 mg prn chest pain, clopidogrel 75 mg daily, fluticasone/salmeterol and albuterol as needed. He does not report any dizziness or constipation. Heart rate is 54 beats/min and blood pressure is 110/78 mmHg. Physical examination and labs are unremarkable. What would be the best approach to manage JR’s angina symptoms?
A. increase verapamil dose to 360 mg daily B. discontinue verapamil and start atenolol 25 mg daily C. add sustained release nifedipine 30 mg daily D. add ramipril 2.5 mg daily E. add sustained release isosorbide mononitrate 30 mg daily |
E. add sustained release isosorbide mononitrate 30 mg daily
Answer E: Please see 5th and 7th objectives. Increasing verapamil might be ill-advised given that his heart rate is in the mid-50’s, despite the fact that she does not have bradycardia symptoms. Single-drug therapy is not likely to be adequate for daily symptoms; therefore, addition of a nitrate would be the most appropriate in the setting of ineffective non-DHP CCB antianginal therapy. Ramipril does not provide symptomatic relief. Changing anti-anginals would require titration to effect for the alternative drug, and beta-blockers are relatively contraindicated in poorly controlled asthma. |
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SK is a 63 year-old woman with stable angina and a history of myocardial infarction. She takes metoprolol, amlodipine, and sublingual nitroglycerin with excellent symptom control. Based on the following choices, treatment of this patient with metoprolol:
1 improves her symptoms by increasing oxygen supply 2 improves her symptoms by decreasing oxygen demand 3 reduces her risk of death A. 2 only B. 1 and 2 C. 2 and 3 D. 1, 2, and 3 |
C. 2 and 3
Answer C: Please see 4th objective. Beta-blockers do not improve oxygen supply; beta-blockers provide symptom relief by decreasing heart rate, and consequently, myocardial oxygen demand. The patient has a history of MI which is a compelling indication for beta-blocker therapy due to the survival benefits in this population. |
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JW is a 46 year-old man with no past medical history and takes no medications. He presents to the clinic complaining of exertional chest pain that resolves with rest. It occurs about 3 times per week and has been present for a few months. He has no other complaints and no remarkable physical findings. Heart rate is 75 beats/min and blood pressure is 124/83 mmHg. His lipid panel reveals: Total cholesterol 200 mg/dl, LDL 110 mg/dl, HDL 55 mg/dl, triglycerides 175 mg/dl. Stress electrocardiogram (ECG) reveals 2 mm ST-depression. It is decided that he will be managed with atenolol 25 mg daily, sublingual nitroglycerin 0.4 mg prn, aspirin 325 mg daily, and atorvastatin 10 mg daily. JW returns 1 month later and frequency of his symptoms are unchanged. Physical and resting electrocardiographic findings are normal. Heart rate is 65 beats/min and blood pressure is 119/80 mmHg. What changes would you recommend?
A. add diltiazem 180 mg daily B. increase atenolol to 50 mg daily C. add isosorbide mononitrate 30 mg daily D. add amlodipine 5 mg daily |
B. increase atenolol to 50 mg daily
Answer B: Please see 5th and 7th objectives. Diltiazem will cause additive heart-rate lowering effects and therefore should be used cautiously in combination with beta-blockers. Additionally, the beta-blocker dose has not been maximized; therefore this is the most appropriate course of action. Addition of amlodipine or isosorbide mononitrate might be considered if the patient’s heart rate was in the target range for beta-blocker efficacy (50-60 beats per minute). |
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11.Which of the following is an example of “Pharmacoenhancement” or boosting?
a.Phenytoin (Dilantin) and valproic acid (Depakote). b.Probenecid (Benemid) and penicillin. c.Ritonavir (Norvir) and lopinavir (Kaletra). d.Two of the above are examples of Pharmacoenhancement or boosting . e.All of the above are examples of Pharmacoenhancement or boosting . |
d.Two of the above are examples of Pharmacoenhancement or boosting .
Answer A is not correct, this is an example of a drug-drug interaction and not boosting. Answers B and C are both correct, probenecid and ritonavir are given for the purposes of altering the pharmacokinetics of penicillin and lopinavir, respectively. Thus, answer D is the correct choice. |
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11.Which of the following statements is/are TRUE?
a.Enzyme inducing drugs (e.g., rifampin [Rifadin]) generally decrease bioavailability of drugs metabolized by the affected enzyme(s). b.St. John’s wort has the greatest effect on drugs that are metabolized by CYP1A2. c.A binding or chelation interaction generally results in increased bioavailability of the affected agents. d.Two of the above are true. e.Three of the above are true. |
a.Enzyme inducing drugs (e.g., rifampin [Rifadin]) generally decrease bioavailability of drugs metabolized by the affected enzyme(s).
Answer A is correct because rifampin (Rifadin) increases metabolism, which will increase first-pass metabolism and decrease bioavailability. Answer B is not correct because St. John’s wort has the greatest effect on CYP3A-metabolized drugs. Answer C is not correct because binding or chelation interactions reduce drug absorption and therefore cause decreased bioavailability. |
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1.A 42-year-old man was diagnosed with type 2 diabetes mellitus 4 years ago. His blood pressure is normal on an ACE inhibitor, and body mass index is 27. He is a lifelong nonsmoker, exercises vigorously, and has no significant family history. He has no symptoms suggestive of ischemic heart disease, cerebrovascular disease, or peripheral vascular disease. Which one of the following statements is true about his ATP III risk status?
a.He belongs to the low-risk group b.The projected 10-year risk is likely to be less than 10% c.The projected 10-year risk is likely to be 10–20% d.The projected 10-year risk is likely to be > 20%, or equivalent to an individual with CHD |
d.The projected 10-year risk is likely to be > 20%, or equivalent to an individual with CHD
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1.A 42-year-old obese, normotensive man is admitted for an elective left carotid endarterectomy. He has no history of smoking or alcohol consumption. A recent treadmill test was negative for provocable ischemia. His mother was recently diagnosed with "mild diabetes mellitus" but is not on treatment for the same. There is no family history of coronary artery disease. Physical examination is normal except for a waist circumference of 43 inches and a left carotid bruit. His serum LDL-C is 108 mg/dL, HDL-C is 33 mg/dL, triglycerides are 266 mg/dL, and thyroid profile is normal. Appropriate treatment for this individual include(s):
a.Lifestyle modification—regular exercise and weight reduction b.Prescribing a statin at a dose that will provide 30–40% LDL-C reduction c.Consider adding niacin if HDL-C remains low and triglycerides remain high d.Any of the above |
d.Any of the above
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LB is a 45-year-old man who works with you at the hospital. He shows you his cholesterol screening results (fasting) and asks for your opinion. He is 6’3”, 165 lbs, is a smoker, and has no evidence of CAD. His BP is 118/64. His father died of an MI in his mid-40s. He is not taking any medications. His lipid panel follows:
TC 254 mg/dl LDL 175 mg/dl HDL 35 mg/dl TG 220 mg/dl Which of the following is true regarding therapy for LB? a.Colestipol (Colestid) may be helpful in this patient since he is young, relatively healthy, and not taking any other medications. b.Gemfibrozil (Lopid) should be tried because of its benefits in isolated low-HDL according to the VA-HIT study. c.It is unlikely that he would attain his goal HDL with HMG-CoA reductase inhibitor therapy alone. d.He doesn’t need drug therapy yet since TLC (therapeutic lifestyle changes) can be expected to correct his current level of dyslipidemia. |
c.It is unlikely that he would attain his goal HDL with HMG-CoA reductase inhibitor therapy alone.
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4.An LDL-C treatment goal of <70 mg/dL may be an acceptable option in:
a.A 55-year-old diabetic smoker who underwent coronary angiography and stenting 10 years ago. b.A 46-year-old obese, hypertensive individual immediately status post–percutaneous coronary intervention for admission for acute coronary syndrome. c.Both A and B. d.Neither A nor B. |
c.Both A and B.
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Refer to Case J
Which of the following is the best change to MM’s therapy? a.No change needed b.Increase simvastatin to 40 mg qhs c.Switch to atorvastatin 10 mg qd d.Add niacin and titrate dose |
b.Increase simvastatin to 40 mg qhs
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CS is a 54-year-old gentleman with a history of diabetes, hypertension and coronary artery disease who is referred to Shands hospital for “chest pain for 4 months” by his primary care physician. He states that the pain (“pressure-like”) is located in the substernum area and usually occurs when he walks about 2 blocks. The pain sometimes radiates to his left arm and goes away when he sits down. There is no change in ECG at rest, but on tread mill test, ECG shows a T-wave inversion. He is diagnosed with chronic stable angina.
CS’s current medication profile and vital signs are as follows: Aspirin 325 mg qd Atorvastatin (Lipitor) 20 mg qd Toprol XL (metoprolol) 50 mg qd Enalapril (Vasotec) 20 mg bid BP 150/76, P 60, RR 14, T afebrile Today his pertinent laboratory results are within normal limit. Which one of the following is the best to control his chronic stable angina at this time? a.Increase Toprol XL (metoprolol) to 100 mg qd b.Add diltiazem CD (Cardizem, Dilacor, and others) 180 mg qd c.Add amlodipine (Norvasc) 10 mg qd d. Add isosorbide mononitrate (Imdur and others) 30 mg qd |
c.Add amlodipine (Norvasc) 10 mg qd
a. Incorrect b/c his heart rate is at goal;60 bpm. b. Incorrect b/c heart rate is at goal. Adding diltiazem may lead to bradycardia. c. Correct. CS has high BP and low HR. Adding amlodipine results in decrease BP and slightly increase in heart rate. d. Incorrect. Long acting nitrates will not help to decrease his high blood pressure. |
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DT is a 55 yo female with no remarkable past medical history who presents to the emergency room complaining of “intermittent chronic chest pain.” She states that she has had chest pain for about 6 months. She also states that the pain is located in her substernal area and occasionally radiates to neck and left arm. When asked about the severity of the pain, she rates it as 6-7 out of 10. ECG reveals sick sinus syndrome and T-wave inversion on tread mill test. She is diagnosed with chronic stable angina. Her vitals today are BP 97/62, P 45, RR 13, and afebrile. Which one of the following options is the best choice for this patient?
a.Initiate Toprol XL (metoprolol) 50 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd b.Initiate diltiazem CD (Cardizem, Dilacor, and others) 180 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd c.Initiate amlodipine (Norvasc) 10 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd d.Initiate isosorbide mononitrate 30 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd |
d.Initiate isosorbide mononitrate 30 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd
a. Incorrect. DT has low BP and low HR. Adding Toprol XL will result in hypotension and worsening of sick sinus syndrome. b. Adding diltiazem will result in hypotension and worsening of sick sinus syndrome. c. Incorrect. Adding 10 mg of amlodipine will lead to hypotension. d. Correct. Long acting nitrate is good in low BP and low HR situation. Although long acting nitrates can decrease BP, it is transient. Also, long acting nitrates are not considered as antihypertensive agents. Because of reflex tachycardia, long acting nitrates will help to increase heart rate. |
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LB is 41 year old white male with a history of hypertension and NYHA class II congestive heart failure who presents to the emergency room with complaints of intermittent chest pain for 3 months. His symptoms are consistent with chronic stable angina and he is diagnosed as such. His heart failure has been quite stable with his current medication regimen for about 6 months. His echocardiogram today reveals an ejection fraction of 35%. His current drug regimen is as follows:
Lisinopril (Zestril, Prinivil) 20 mg qd Toprol XL (metoprolol) 50 mg qd Digoxin (Lanoxin) 0.125 mg qd Furosemide (Lasix) 40 mg qd Spironolactone (Aldactone) 25 mg qd His vitals are BP 142/85, P 75, RR 15 and afebrile. Which is the best option to treat the newly diagnosed chronic stable angina? a.Increase Toprol XL (metoprolol) to 100 mg qd with addition of sublingual nitroglycerin as needed and aspirin 325 mg qd b. Add diltiazem CD (Cardizem, Dilacor, and others) 180 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd c. Add amlodipine (Norvasc) 10 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd d. Add isosorbide mononitrate (Imdur and others) 30 mg qd with sublingual nitroglycerin as needed and aspirin 325 mg qd |
a.Increase Toprol XL (metoprolol) to 100 mg qd with addition of sublingual nitroglycerin as needed and aspirin 325 mg qd
a. Correct. LB’s BP is high and HR is not at goal. Also, Toprol XL has been shown to provide mortality benefit for the patients with heart failure. b. Incorrect. LB’s ejection fraction is 35%, which indicates he has left ventricular dysfunction. All calcium channel blockers except for amlodipine and probably felodipine can exacerbate LV dysfunction. c. Incorrect. Although amlodipine decreases BP, it does not decrease heart rate, which is not at goal for LB. d. Incorrect. LB’s BP and HR are not at goals. Long acting nitrates transiently decreases BP and increases heart rate. Therefore, it will not help reduce both BP and HR to the targets for LB. |
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LB is a 45 year old man who works with you at the hospital. He shows you his cholesterol
screening results (fasting) and asks for your opinion. He is 6’3”, 165 lbs, is a non-smoker, and has no evidence of coronary artery disease. His BP is 118/64 mmHg. His father died of a myocardial infarction in his mid-40s. He is not taking any medications. His lipid panel follows: TC 254 mg/dl LDL 175 mg/dl HDL 35 mg/dl TG 220 mg/dl Which of the following is true about LB? a. His LDL goal is < 100 mg/dl b. His LDL goal is < 130 mg/dl c. His LDL goal is < 160 mg/dl d. His LDL goal is < 190 mg/dl |
b. His LDL goal is < 130 mg/dl
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LB is a 45 year old man who works with you at the hospital. He shows you his cholesterol
screening results (fasting) and asks for your opinion. He is 6’3”, 165 lbs, is a non-smoker, and has no evidence of coronary artery disease. His BP is 118/64 mmHg. His father died of a myocardial infarction in his mid-40s. He is not taking any medications. His lipid panel follows: TC 254 mg/dl LDL 175 mg/dl HDL 35 mg/dl TG 220 mg/dl Which of the following is true regarding therapy for LB? a. Colestipol (Colestid) may be helpful in this patient since he is young, relatively healthy, and not taking any other medications. b. Gemfibrozil (Lopid) should be tried because of its benefits in isolated low-HDL according to the VA-HIT study. c. It is unlikely that he would attain his goal HDL with HMG-CoA reductase inhibitor therapy alone. d. He doesn’t need drug therapy yet since therapeeutic lifestyle changes can be expected to correct his current level of dyslipidemia. |
c. It is unlikely that he would attain his goal HDL with HMG-CoA reductase inhibitor
therapy alone. |
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BR is a 72 year old man with hypertension, dyslipidemia, and type 2 DM. He presents to the
clinic for follow-up of his dyslipidemia. He is without complaints and reports good drug compliance. His current medications are: Insulin NPH 44 units qam and 34 units qhs Simvastatin (Zocor) 40 mg qhs Atenolol (Tenormin) 50 mg qd Lisinopril (Zestril, Prinivil) 10 mg qd He weighs 120 lbs; BP is 114/60 mm Hg, and his HR 72 beats/min Labs: TC 177 mg/dl LDL 89 mg/dl HDL 30 mg/dl TG 290 mg/dl ALT 24 IU/l HgA1c 6.9 % Gluc 116 mg/dl Which of the following plans of action is best? a. Continue current regimen b. Add gemfibrozil (Lopid) 600 mg bid c. Improve blood sugar control d. Increase simvastatin (Zocor) dose |
b. Add gemfibrozil (Lopid) 600 mg bid
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Refer to Case M
Which of the following is the best change to MM’s therapy? a. No change needed; he has reached the goal of therapy. b. Increase simvastatin to 40 mg qhs c. Switch to atorvastatin 20 mg qd d. Add niacin and titrate dose |
d. Add niacin and titrate dose
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JT is a 55 year old white male who presents to his primary care physician with substernal chest
pressure that radiates to his left arm with exertion. JT’s past medical history is significant for hypertension and hyperlipidemia. His current medications include perindopril (Aceon) 8mg qd, simvastatin (Zocor) 40 mg qhs, and aspirin 325 mg qd. BP: 144/86 mmHg HR 80 beats/min TC: 190 mg/dL LDL: 95 mg/dL TG: 149 mg/dL HDL: 42 mg/dL An exercise treadmill test reveals 2mm ST segment depression in leads V4-6 after walking 6 minutes and coronary catheterization reveals an 80% occlusion of the left anterior descending coronary artery. JT is diagnosed with chronic stable angina. Which of following would be the best recommendation regarding JT’s pharmacologic regimen? a. Change perindopril (Aceon) to atenolol (Tenormin) 100 mg qd, add sublingual nitroglycerin prn. b. Add atenolol (Tenormin) 100 mg qd and sublingual nitroglycerin prn. c. Add amlodipine (Norvasc) 10 mg qd and sublingual nitroglycerin prn. d. Add sublingual nitroglycerin prn. |
b. Add atenolol (Tenormin) 100 mg qd and sublingual nitroglycerin prn.
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Which of the following is correct counseling information for JT on short-acting nitrates?
a. Nitroglycerin should be taken only after an episode of chest pain begins. b. Nitroglycerin works primarily by dilating the coronary arteries. c. He should not take more than 3 nitroglycerin tablets per chest pain episode. d. Nitroglycerin may cause dizziness or headache. |
d. Nitroglycerin may cause dizziness or headache.
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JA is 60 year old woman with a history of bronchospastic asthma, hypertension, and chronic
stable angina. She reports increased episodes of chest pain, particularly when she takes her dog for a walk. Her current medications include : ASA 325 mg qd, benazepril (Lotensin) 10 mg qd, verapamil SR (Calan, others) 120 mg qd, nitroglycerin 0.4 mg sublingual prn, fluticasone/salmeterol (Advair) 2puffs bid, and albuterol (Proventil, others) 2puffs q4-6h prn. Her blood pressure is 132/84 mmHg and heart rate is 72 betas/minute. The most appropriate pharmacotherapeutic plan for long term management of her angina is: a. D/C verapamil (Calan, Verelan, others) and start atenolol 100 mg qd. b. Increase verapamil (Calan, Verelan, others) to 240 mg qd. c. Start isosorbide mononitrate (Ismo, Imdur, others) 20 mg bid. d. D/C verapamil (Calan, Verelan, others) and start nifedipine XL (Procardia XL) 30 mg qd. |
b. Increase verapamil (Calan, Verelan, others) to 240 mg qd.
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