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2012 ACCP Clinical Pharmacy Challenge

Local Competition Exam Key
The following examination will consist of three (3) segments:
Trivia/Lightning
Participants will have the opportunity to answer up to 15 true-false or multiple-choice questions.
Each item answered correctly will be worth 75 points. The subject content for questions in this
segment will be selected from the following categories:

Pharmacology (including, but not limited to, mechanism of action, adverse effect
profiles, drug interactions, dosing, approved indications, and monitoring parameters)

Pharmacokinetics/Pharmacodynamics and/or Pharmacogenomics

Clinical Pharmacy History

Biostatistics

Health Outcomes

Clinical Case
Participants will be presented with a clinical case vignette (500 words or less) and a series of five
one-best-answer questions based on the information in the case text and/or supporting laboratory,
physical examination, and/or medical history information contained therein. Point values for each
question in this category will be assigned on the basis of difficulty (one 100-point item, two 200point items, and two 300-point items).
Jeopardy Style
Participants will have an opportunity to answer questions of varying point values (100, 200, or
300 points) in five predetermined categories and may answer as many as possible within the
allotted time. All items in this segment will be multiple choice. Items in the segment will be
selected from five (5) of the following categories:
Anticoagulation

Asthma/COPD

Biostatistics

Cardiovascular Disorders

Clinical Trial Design

Critical Care

Dermatology

Drug Information

Emergency Medicine

Endocrinology

Geriatrics

GI/Liver/Nutrition

Hematology/Oncology

Immunology/Transplantation

Infectious Diseases

Nephrology

Pain and Palliative Care

Pediatrics

Psychiatry/CNS Disorders

Vaccinations

Women’s Health

CNS = central nervous system; COPD = chronic obstructive pulmonary disease; GI =
gastrointestinal.

Follow the instructions given by your local faculty member or proctor for
each segment of the examination.
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Do NOT open the examination booklet until instructed to do so.

2012 ACCP Clinical Pharmacy Challenge
Local Competition Examination

Team/Individual ID ______________________

Total Score ________

For Administrative Use Only

Trivia/Lightning Section
This section consists of 15 items. Each correct answer is worth 75 points. Please circle your
answer for each question.
Question 1
Which diuretic would cause increased excretion of sodium, potassium, magnesium, and calcium
and would promote the reabsorption of uric acid?
1. Bumetanide
2. Hydrochlorothiazide (HCTZ)
3. Spironolactone
4. Triamterene
Answer: 1. Bumetanide
Rationale: The correct answer is bumetanide. HCTZ decreases the excretion of calcium.
Spironolactone and triamterene are potassium sparing.
Citation: Drugs for hypertension. Treat Guidel Med Lett 2009;7:1–10.
Question 2
Which antimicrobial has nearly equivalent oral and parenteral bioavailability?
1.
2.
3.
4.

Ampicillin
Cefuroxime
Linezolid
Vancomycin

Answer: 3. Linezolid
Rationale: Linezolid has a documented oral bioavailability of nearly 100%.
Citation: Linezolid [prescribing information]. New York: Pharmacia and Upjohn, 2012.
Question 3
Which drug would require a dosing adjustment for a documented creatinine clearance of less than
30 mL/minute?
1. Ceftriaxone
2. Metronidazole
3. Pantoprazole

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Phytonadione [prescribing information]. Available at http://www.asp. The rest do not need adjustments. Princeton. 4. Page 3 of 22 . Cyanocobalamin is vitamin B12 and is commonly used to treat pernicious anemia. Warfarin acts as an anticoagulant through inhibition of the vitamin K–dependent clotting factions II. IL: Hospira. Evidence-based management of anticoagulant therapy: antithrombotic: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition). Citation: Jeffreys M. VII. Cyanocobalamin Phytonadione Protamine Tocopherol Answer: 2. SSRIs Rationale: SSRIs are recognized by several resources as the first-line treatments (together with psychotherapy). Shulman S. Ranitidine Answer: 4. Question 4 Which agent is the best treatment option for a patient taking warfarin with an international normalized ratio of 11. Tocopherol is a form of vitamin E and has no role in reversing warfarin overdose.va. 2. 2011. Accessed February 24. and X.4. NJ: Sandoz. 3.141:e152S–e184S. 2004. Lake Forest. et al. Clinician’s Guide to Medications for PTSD.gov/professional/pages/clinicians-guide-to-medications-forptsd. Citation: Ranitidine [prescribing information]. Anticonvulsants Atypical antipsychotics Benzodiazepines Selective serotonin reuptake Inhibitors (SSRIs) Answer: 4. 2012. Witt DM. Administration of phytonadione is indicated in warfarin overdose. 2. Chest 2012. Protamine is used to reverse heparin overdose. Citations: Holbrook A. Phytonadione Rationale: The correct answer is phytonadione (vitamin K). Question 5 Which drug class is considered the pharmacologic first-line treatment of choice for posttraumatic stress disorder (PTSD)? 1. 4. IX. 3.ptsd.0 and no signs of bleeding? 1. Ranitidine Rationale: Dosage adjustments are only necessary for ranitidine with a creatinine clearance of 35 mL/minute. Department of Veterans Affairs.

if possible. 0. and psyllium are all acceptable options for symptom control for this type of diarrhea.medscape.2 0. Cholestyramine Diphenoxylate/atropine Kaolin-pectin Psyllium Answer: 2. Citation: Oral Lomotil. 4. what is the number needed to treat (NNT)for the new drug? 1. In addition. 3. Croup. 2. If 25 of 100 patients in the control group experience a fracture compared with 5 of 100 patients in the treatment group. Johnson DW. 2012. Question 8 A new osteoporosis drug is being tested to prevent fractures. Which medication would be most appropriate to recommend? 1. 3. which is used in bronchiolitis. Kaolin-pectin. With toxin-mediated diarrhea. Drug-Disease Contraindications. Accessed March 28. because of the increased risk of anticholinergic adverse effects in this population. 2. 4. Question 7 An elderly nursing home resident develops diarrhea that is caused by Clostridium difficile. Diphenoxylate/atropine Rationale: The correct answer is diphenoxylate/atropine. This is also true for 3% saline. 4. Oral dexamethasone Rationale: The correct answer is 1.371:329–39. Racemic epinephrine is first line but. Which agent is contraindicated? 1. oral dexamethasone (it is used to decrease pharyngeal inflammation). cholestyramine. Lancet 2008. this agent should be avoided in elderly patients. Citation: Bjornson C. Available at http://www. Oral dexamethasone Nebulized albuterol Nebulized racemic epinephrine Nebulized 3% saline Answer: 1.Question 6 A 5-year-old boy is given a diagnosis of mild croup.8 5 20 Page 4 of 22 . in severe episodes. use of agents to slow motility would be contraindicated.com/druginfo/dosage? drugid=6876&drugname=Lomotil+Oral&monotype=default. 2. Albuterol is beta-specific and will not help with edema in the upper airway. 3. not mild.

5 patients Rationale: The correct answer is 5. 2. Lancet Oncol 2008. 2. Citation: Shenhong W. OH: Bedford Laboratories. Studying a Study and Testing a Test: How to Read the Health Science Literature.05/0. and the OR (odds ratio) is 0. 52. Citation: Etomidate [prescribing information].2 (difference in event rates between drug and placebo = 0. which adverse effect should you discuss the potential development of? 1. Citation: Riegelman RK. Hirsch RP. Etomidate Rationale: The correct answer is etomidate. and/or decreasing vascular compliance. 35. Incidence and risk of hypertension with sorafenib in patients with cancer: a systematic review and meta-analysis. The exact etiology of hypertension is unclear. Question 9 Which sedative is most likely to cause transient adrenal insufficiency when used for rapid sequence intubation? 1. The other agents have no known effect on adrenal function or cortisol production. et al. 4. Question 10 A 70-year-old man with stage IV renal cell carcinoma is beginning sorafenib therapy. 3. effective management is critical to minimizing the long-term sequelae of treatment-induced hypertension. Hypertension Rationale: Hypertension may develop within the first few weeks of therapy or slowly over the continuance of therapy.05).2 (event rate drug/event rate placebo = 0. In consultation with the patient. Philadelphia: Lippincott-Raven. The NNT is calculated as 1/absolute risk reduction (ARR). The relative risk (RR) is 0. 3rd ed. Although trials continue to investigate the etiology of hypertension. increasing extracellular volume.2 (odds of event on drug/odds of event on placebo = [5/25]/[95/75]). 4. Etomidate Ketamine Midazolam Propofol Answer: 1. Chen JJ. In this case.Answer: 3. the ARR is 0. Bedford. 3. Kudelka A. but it may be the result of pressor stimulation responses. Question 11 Page 5 of 22 . 1996:33.25).25 − 0. 2004.9:117–23. Hypertension Neutropenia Peripheral neuropathy Renal failure Answer: 1.

E. 4. 2nd ed. Food and Drug Administration (FDA) approved for postherpetic neuralgia. Choices 3 and 4 are incorrect because neither affects phenytoin binding to albumin. Addition of isoniazid therapy Chronic alcohol abuse Stage II chronic kidney disease (CKD) Metabolic alkalosis secondary to diuretic therapy Answer: 2.P. Lidocaine 5% topical patch applied for 12 hours/day Rationale: The correct answer is lidocaine 5% patch applied for 12 hours/day. and Page 6 of 22 . ed.1 kcal/mL Answer: 4. 2. provides 1. Venlafaxine 25 mg orally 3 times/day Nortriptyline 25 mg orally at bedtime Diclofenac 1. 4. 4.S.3% topical patch applied twice daily Lidocaine 5% topical patch applied for 12 hours/day Answer: 4. Question 12 A propofol infusion provides the following amount of nutrition per volume: 1. Johannessen Landmark C.N.P. Curr Neuropharmacol 2010.Which condition may result in a decrease in total phenytoin concentration in patients who routinely take phenytoin? 1.8:254–67. 2007:63–4. resulting in an increase in phenytoin-free fraction. Citation: Gottschlich MM. 2. 3. 1.E.1 kcal of nutrition per milliliter to the patient.. potentially increasing the total phenytoin concentration. 2. The A.S. Citation: Johannessen SI. thus decreasing the total phenytoin protein bound concentration. 3. which is identical to a 10% intravenous lipid emulsion. Antiepileptic Drug Interactions – Principles and Clinical Implications.S. Lidocaine 5% patches are U. 3. Choice 1 is incorrect because the addition of isoniazid will decrease the metabolism of phenytoin. Chronic alcohol abuse Rationale: Choice 2 is correct because a decrease in liver function from chronic alcohol abuse will result in a decrease in albumin production. 10 kcal/mL 9 kcal/mL 4 kcal/mL 1. MD: A.N. propofol. Nutrition Support Core Curriculum: A Case-Based Approach-The Adult Patient. Silver Spring. Question 13 Which regimen is the MOST appropriate first-line therapy for the management of postherpetic neuralgia? 1.1 kcal/mL Rationale: An intravenous anaesthetic agent.

Pharmacologic management of neuropathic pain: evidence-based recommendations. Alemtuzumab is a humanized monoclonal antibody that has been approved for use in chronic lymphocytic leukemia and that has been used off-label for kidney transplant induction therapy. 2. Call RJ. Pain 2007. tolerogens. Citation: Krensky AM. 1. Tacrolimus is a calcineurin inhibitor.org/avp/Pharm3012_Riche_AVP.they provide analgesia within hours after application. 2006:chap 52. Diclofenac and other nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically effective for the management of neuropathic pain.30:477e–478e. CYP1A2 CYP2C9 CYP2C19 CYP3A4 Answer: 3. Bennett WM. 2012. Question 14 Which cytochrome P450 (CYP) isoenzyme is MOST likely responsible for the drug-drug interaction between clopidogrel and proton pump inhibitors? 1.132:237–51. 3. In: Brunton LL.pdf. Parker KL. Question 15 This agent allows lower maintenance doses or complete discontinuation of calcineurin inhibitors. Azathioprine is a purine antimetabolite that is used in conjunction with calcineurin inhibitors. 2. Lazo JS. Immunosuppressants. Citation: Riche DM. PPIs and Plavix: so. Available at http://www. and immunostimulants. Team/Individual ID _____________________________ For Administrative Use Only Trivia Segment Score ________ Page 7 of 22 . what to do now? Pharmacotherapy 2010. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. Accessed February 13. Citation: Dworkin RH. Sirolimus is a mammalian target of rapamycin inhibitor that is used in conjunction with or to replace calcineurin inhibitors in calcineurin inhibitor–“sparing” protocols. Venlafaxine and nortriptyline must be administered for at least 1–2 weeks before a therapeutic response is seen and therefore may not be considered first-line therapy. Sirolimus Rationale: The correct answer is sirolimus. 3. O’Connor AB. eds. 4. Vincenti F. CYP2C19 Rationale: Competitive inhibition of CYP2C19 by proton pump inhibitors decreases the availability of the active metabolite of clopidogrel and thereby decreases its effect on platelet function.pharmacotherapy. 4. New York: McGraw-Hill. Alemtuzumab Azathioprine Sirolimus Tacrolimus Answer: 3.

Clinical Case Segment Page 8 of 22 .You have reached the end of the Trivia/Lightning Segment of the exam. Do NOT proceed to the next segment of the exam until instructed to do so.

9 g/dL (99 g/L) Hematocrit 29.8 g/dL (28 g/L) White blood cell count 4500/microliter (4.0 mg/dL (1.7 mmol/L) Chloride 101 mEq/L (101 mmol/L) HCO3 23 mEq/L (23 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.73m2 Glucose.7 mmol/L) Hemoglobin A1c 7.2 mg/dL (282 micromoles/L) Estimated glomerular filtration rate (Modification of Diet in Renal Disease [MDRD]) 20 mL/minute/1.7 mmol/L) Serum creatinine (SCr) 3.5 x 109/L) Hemoglobin 9.8% Phosphate 6. He has knee pain when he plays golf. for which he self-medicates with over-the-counter naproxen. Medical History: Hypertension Diabetes mellitus Chronic kidney disease (CKD) secondary to hypertension Gout Gastroesophageal reflux disease (GERD) Benign prostatic hyperplasia (BPH) Osteoarthritis Current Medications: Glipizide 10 mg/day x 6 years Insulin glargine 15 units at bedtime x 3 months Enalapril 40 mg/day x 6 years Allopurinol 100 mg/day x 6 years Doxazosin 4 mg at bedtime x 2 years Ranitidine 75 mg/day x 5 years Calcium carbonate 500 mg 3 times/day with meals x 6 months Naproxen 250 mg twice daily x 2 weeks Recent Laboratory Values: Sodium 136 mEq/L (136 mmol/L) Potassium 4.296) Platelet count 175.5 mg/dL (2. He has had increasing fatigue during the past month that interferes with his daily activities.63 mmol/L) Albumin 2.6% (0.000/microliter (175 x 109/L) Ferritin 120 ng/mL (270 pmol/L) Transferrin saturation 23% Proceed to the following page to answer Clinical Case Questions 1–5. random 156 mg/dL (8. He is adherent to all of his prescribed therapy. including dietary restrictions. Case Vignette: A 66-year-old man presents to clinic for his routine visit.9 mmol/L) Calcium 10.7 mEq/L (4.This segment consists of a case vignette and five items based on the vignette information. Question 1 – 100 points Page 9 of 22 .

4.91 mmol/L) Answer: 1.The patient has which complication of CKD? 1. Available at http://www.htm. 3. Uremic platelet dysfunction cannot be determined by the patient’s laboratory results. Question 3 – 200 points A fasting lipid panel is to be obtained. Citation: KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation. Part 4.59 mmol/L) Less than 130 mg/dL (3. Anemia Rationale: According to the Kidney Disease Quality Outcomes Initiative (KDOQI) guidelines.59 mmol/L) Page 10 of 22 . Anemia Hyperkalemia Metabolic acidosis Uremic platelet dysfunction Answer: 1.5 g/dL in males.org/professionals/kdoqi/guidelines_ckd/p4_class_g2. 4. Potassium and serum bicarbonate values are all within the normal range for their assays. 3.org/professionals/KDOQI/guidelines_anemia/guide2. Citation: KDOQI Anemia Guidelines 2007. Less than 100 mg/dL (2. 2012.kidney. Accessed March 28.kidney. Definition and Classification of Stages of Chronic Kidney Disease. Less than 100 mg/dL (2.13 mmol/L) Less than 190 mg/dL (4. which categorizes him as having stage 4 CKD (GFR 15–29 mL/minute). What is this patient’s low-density lipoprotein (cholesterol) (LDL) goal? 1.htm#cpr11. 3. Classification. Accessed February 13. 2012. anemia is defined as a hemoglobin value of less than 13.36 mmol/L) Less than 160 mg/dL (4. Question 2 – 200 points This patient is best described as having which stage of CKD? 1. 2. 2. and Stratification. 4. Stage 1 Stage 2 Stage 3 Stage 4 Answer: 4. Stage 4 Rationale: The patient’s estimated glomerular filtration rate (eGFR) is 20 mL/minute. Available at http://www. 2.

Circulation 2003.org/guidelines/mbd/guide4. Continue calcium carbonate at the current dose and add sevelamer carbonate 800 mg 3 times/day. Citations: American Heart Association Councils on Kidney in Cardiovascular Disease. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day. if corrected for a low serum albumin using the correction equation (Ca. 2012.kdigo. Reference for conversion for LDL to SI units: Katz A.110:227–39.nih. Discontinue calcium carbonate. Available at http://www. Clinical Cardiology. He has an elevated calcium level. Question 4 – 300 points Which is the most appropriate adjustment to make in his phosphate binder therapy? 1. Circulation 2004. 4. N Engl J Med 2004. Answer: 2. he requires phosphate binder therapy. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day. Abeulo JG. Ferraro M. 2012. Available at http://www.357:797–805.nhlbi. Evaluation. and Treatment of High Blood Cholesterol in Adults. 3.8 (4-albumin). the LDL goal for this patient should be that of the highest risk group. Hypercalcemia can cause acute kidney injury through vasoconstriction of the afferent arterioles in the kidney. Continue calcium carbonate at the current dose and add aluminum hydroxide 600 mg 3 times/day.351:1548–63. Rationale: Because the patient has a serum phosphate value that is above the normal range. Normotensive ischemic acute renal failure.46 mg/dL. Aluminum should be avoided as long-term phosphate binder therapy.kdigo. Available at http://www. as evidenced by his laboratory values (10. Sluss PM.html#chap41. adj = SCa + 0. ATP 3 Final Report. 2009. so discontinuing the calciumbased binder is warranted in this patient. Available at http://www.108:2154–69.org/guidelines/mbd/guide4. with an alternate goal of less than 70. Laboratory reference values. would be estimated as 11. KDIGO CKD-MBD Guidelines.gov/guidelines/cholesterol/atp3full. Calcium-based binders are not recommended in hypercalcemia.nhlbi. Kidney disease as a risk factor for development of cardiovascular disease. Accessed March 28. 2012.pdf. Citations: KDIGO CKD-MBD Guidelines. Page 11 of 22 . Accessed March 28.nih. Accessed March 28.pdf. which. 2012. which is considered a coronary heart disease (CHD) risk equivalent. 2009. the LDL goal for the highest risk group is less than 100.5 mg/dL). For this reason. The Third Report of the Expert Panel on Detection. High Blood Pressure Research. In addition. N Engl J Med 2007. and Epidemiology and Prevention. 2.gov/guidelines/cholesterol/atp3upd04.html#chap41. NCEP Report: Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines.Rationale: CKD is considered a coronary artery disease risk equivalent. Accessed March 28. Based on the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines. Sevelamer is the best option in this patient. this patient has type 2 diabetes mellitus.

this causes a drop in GFR. 4. Do NOT proceed to the next segment of the exam until instructed to do so. which is the most common renal effect of NSAIDs. Choice 1 is incorrect because there is no direct toxic effect on the renal tubules. resulting in weight gain of 1–2 kg. Please circle your answer for each item. You have reached the end of the Clinical Case Segment. Constriction of the afferent arteriole Rationale: NSAIDs such as naproxen can cause many different types of injury to the kidney. Direct toxic effect on the renal tubules Constriction of the afferent arteriole Dilation of the efferent arteriole Decreased tubular reabsorption of sodium Answer: 2. resulting from a decreased production of vasodilatory prostaglandins. Normotensive ischemic acute renal failure. Page 12 of 22 . Edema and sodium retention are usually mild. Choice 4 is incorrect because the inhibition of PGE2 syntheses can lead to increased sodium reabsorption. 3. Citation: Abeulo JG. N Engl J Med 2007.Question 5 – 300 points By what mechanism could the patient’s choice of naproxen be adversely affecting his renal function? 1. Point values for each item are indicated below. which act on the afferent arterioles of the kidney.357:797– 805. In patients who rely on afferent arteriole vasodilation to maintain their GFR. causing peripheral edema. The most likely short-term problem with taking an NSAID for this patient is functional acute kidney injury. 2. Team/Individual ID _____________________________ Case Segment Score ________ For Administrative Use Only Jeopardy Segment This segment will consist of 15 items in five predetermined categories.

Hertzer NR. Haskal ZJ. 2. 4. et al.” In this statement. Cilostazol Rationale: The treatment of choice for patients experiencing leg pain caused by intermittent claudication is cilostazol. 3% 5% 7% 9% Answer: 4. Aspirin Cilostazol Clopidogrel Pentoxifylline Answer: 2.Cardiovascular Disorders Item 1 (100 points) The U. Society for Cardiovascular Angiography and Interventions.150:396–404. Pentoxifylline has been shown to be comparable to placebo. Society for Vascular Medicine and Biology. Citation: Hirsch AT. 9% Rationale: The USPSTF created a recommendation statement on the use of “Aspirin for the Prevention of Cardiovascular Disease. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity. the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have designated it a second-tier therapy. 2. the USPSTF balances the risk of CHD with the risk of bleeding in patients using aspirin for the primary prevention of CHD. Citation: U. Aspirin for the prevention of cardiovascular disease: U. The cut point for benefit in the male age group of 60–69 is having a 10-year CHD risk of 9% or more. Preventive Services Task Force. renal. therefore. Although aspirin and clopidogrel are used for peripheral arterial disease to reduce cardiovascular mortality. Preventive Services Task Force recommendation statement. mesenteric.S. Society of Interventional Radiology.S. 3. and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). 3. Item 2 (200 points) Which medication is considered the first-line agent for the treatment of leg pain secondary to intermittent claudication? 1. Preventive Services Task Force (USPSTF) recommends aspirin for the primary prevention of cardiovascular disease in a 62-year-old man when his 10-year CHD risk is equal to or greater than what level: 1. these agents have not shown a reduction in ischemic leg pain. 2011 ACCF/AHA Focused Update of Page 13 of 22 . 4. and abdominal aortic): executive summary: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery.S. Ann Intern Med 2009.

Rationale: Amiodarone reduces the clearance of digoxin by inhibiting P-glycoprotein. metoprolol succinate 25 mg orally once daily. requiring a proactive 50% reduction in digoxin. time course of development. Item 3 (300 points) A hemodynamically stable patient with systolic heart failure is initiated on amiodarone for an irregularly irregular rhythm.the Guideline for the Management of Patients with Peripheral Artery Disease (Updating the 2005 Guideline). An equipotent dose change from metoprolol succinate to tartrate is unnecessary in a hemodynamically stable patient with systolic heart failure. J Am Coll Cardiol 2011. 3. Change furosemide 40 mg orally to 20 mg intravenously daily. Decrease digoxin to 0. What medication adjustment should occur immediately? 1. The patient currently receives lisinopril 20 mg orally once daily. Amiodaronedigoxin interaction: clinical significance.58:2020–45. and an increase beyond the target dose is not needed.125 mg orally once daily.5 mg orally twice daily.4:111–6. Kannan R. Citation: Nademanee K. furosemide 40 mg orally once daily. 4. Hendrickson J. potential pharmacokinetic mechanisms and therapeutic implications. 2.125 mg orally once daily. J Am Coll Cardiol 1984. Switch metoprolol succinate 25 mg once daily to metoprolol tartrate 12.25 mg orally once daily. Decrease digoxin to 0. This drug interaction is predictable and clinically significant. and digoxin 0. This patient is currently receiving the target dose of lisinopril. An increase in furosemide is not necessary in a patient without edema or crackles. Kay I. Singh BN. Ookhtens M. Physical examination reveals no lower extremity edema or pulmonary crackles. Endocrinology Item 1 (100 points) Page 14 of 22 . Increase lisinopril to 40 mg orally once daily. Answer: 3.

Page 15 of 22 . North Chicago.6 mg/dL. Metformin 3.A 68-year-old woman with hypertension. Glipizide 2. Sitagliptin is not recommended as a first-line therapy because of the lack of compelling efficacy data. Which of the following is the most appropriate initial therapy? 1. osteoporosis. potassium 4. 4. Pioglitazone 4. The agent will likely provide the hemoglobin A1c reduction needed. it is contraindicated because of the patient’s elevated SCr.32:193–203.8%. Alendronate Calcium carbonate/vitamin D supplement Simvastatin Warfarin Answer: 2. serum creatinine (SCr) 1. chronic heart failure. thereby decreasing T3/T4 levels. and alanine aminotransferase 20 IU/L. 2011. and nonvalvular atrial fibrillation. which results in an increased TSH. Warfarin does not affect levothyroxine levels. Diabetes Care 2009. and she has been initiated on the following medications: Alendronate 70 mg once weekly Calcium carbonate 1200 mg/vitamin D 800 IU supplement daily Simvastatin 20 mg/day Warfarin 2. Sitagliptin Answer: 1.5 mg/day Her thyroid-stimulating hormone (TSH) level today is 6. et al. and stage 3 CKD has just received a diagnosis of type 2 diabetes mellitus.75 mg/day has been euthyroid for the past 4 years. Since her last clinic visit 6 months ago.9 mIU/L. however. There is no interaction between levothyroxine and alendronate or simvastatin. 2. Laboratory values include hemoglobin A1c 8. Although metformin is also a tier 1 therapy. aspartate aminotransferase 18 IU/L. Which medication most likely contributed to the loss of a euthyroid state? 1. a change in thyroid status can affect the metabolism of vitamin K–dependent clotting factors and precipitate a need for altered warfarin dosing. Citation: Synthroid® (Levothyroxine) [prescribing information]. and it has a relative contraindication in patients with heart failure. Citation: Nathan D. Pioglitazone is not a tier 1 therapy. IL: Abbott Laboratories. Glipizide Rationale: Glipizide is the only tier 1 American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) therapy listed. Calcium carbonate/vitamin D supplement Rationale: Calcium carbonate decreases the absorption of levothyroxine. Item 2 (200 points) A 65-year-old woman with hypothyroidism treated with levothyroxine 0. 3.0 mEq/L. and it is not contraindicated in this patient. ADA EASD Consensus Statement. she has been given diagnoses of hyperlipidemia.

Calcitonin 3. She has a history of vertebral-crush fractures caused by osteoporosis (T-score of −3. Morabito N. Although pain relief is believed to be a benefit with calcitonin. current practice is to manage pain and fracture risk separately. Alendronate 2. Which is the most appropriate initial treatment? 1. Pharmacological management of severe postmenopausal osteoporosis. Citation: Gaudio A. She has severe gastroesophageal reflux disease (GERD). Teriparatide 4. Drugs Aging 2005. Calcitonin is a fourth-line choice in this patient. Emergency Medicine Item 1 (100 points) Page 16 of 22 . Zoledronic acid Rationale: The correct answer is zoledronic acid for this patient because of the type of fracture and the presence of GERD.0 at spine). only an intravenous bisphosphonate would be an option. Zoledronic acid Answer: 4.Item 3 (300 points) A 72-year-old woman presents with lower back pain.22:405–17. Bisphosphonates such as an alendronate would be the initial choice. however. Teriparatide would be a second-line choice or first line if the T-score were −3. because this patient has severe GERD.5.

miosis. Bechtel LK. it is recommended that asystole and pulseless electrical activity not be shocked. Emerg Med Clin North Am 2008. Respiratory rate is 6 breaths/minute. but it can cause serotonin syndrome. fluoxetine is relatively safe. First-degree heart block 4. Oxycodone Rationale: Toxidromes are a collection of signs and symptoms. Ventricular fibrillation and ventricular tachycardia can be shocked. and decreased bowel sounds. Otto CW. temperature is 98. which would result in increased reflexes and temperature. Methylphenidate Answer: 2. et al. Anticholinergics (benztropine) would produce mydriasis. Question 3 (300 points) Assuming a potentially toxic ingestion for each of the substances listed. Both atrial fibrillation and first-degree heart block would be considered pulseless electrical activity in the above question because the victim has no pulse. in which situation would activated charcoal be expected to have the greatest benefit to decrease the chances of toxicity? Page 17 of 22 . mydriasis. Question 2 (200 points) A patient presents to the emergency department with sedation.25:715–39. Oxycodone 3.2°F (37. Ventricular fibrillation Rationale: The Advanced Cardiac Life Support (ACLS) Cardiac Arrest algorithm within the cardiopulmonary resuscitation and emergency cardiovascular care guidelines by the AHA has two major branches: rhythms that are amenable to shock and those that are not. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Asystole 2. Which medication would likely cause this collection of symptoms? 1. and hyperthermia.In which clinical situation would a shock be recommended during resuscitation efforts when there is no pulse? 1. Benztropine 2. Methylphenidate would cause agitation. Dobmeier SG. Citation: Neumar RW.2°C).122:S729–S767. Holstege CP. Atrial fibrillation 3. Critical care toxicology. not miosis. Circulation 2010. Link MS. All of the above are consistent with an opioid toxidrome. Ventricular fibrillation Answer: 4. Fluoxetine 4.

43:61–87. There are situations within this window when activated charcoal is not indicated. 4. including drugs that do not bind well to activated charcoal (lithium) or when there is a risk of aspiration (kerosene.1. Clin Toxicol 2005. Citation: American Academy of Clinical Toxicology and European Association of Poison Centers and Clinical Toxicologists. Psychiatry/CNS Disorders Page 18 of 22 . a hydrocarbon). 2. Position paper: single-dose activated charcoal. 3. Lithium ingestion 45 minutes ago Kerosene ingestion 5 minutes ago Acetaminophen 90 minutes ago Digoxin 52 minutes ago Answer: 4. Digoxin 52 minutes ago Rationale: Activated charcoal is most beneficial when used within 60 minutes of the ingestion.

New York: McGraw-Hill.com. Ethanol Rationale: Central nervous system stimulants do not result in medically serious signs. Li RM. 2011. Nicotine.accesspharmacy. 4. death may result from exhaustion or unknown causes if patients enter delirium tremens (5% of withdrawal population). 3. With ethanol.edu/content. Accessed March 29. Which drug poses the greatest risk of death because of withdrawal? 1.aspx?aID=7987625. Wells BG. eds. 2nd ed. 3rd ed. Wells BG. rarely does withdrawal result in death. Citations: Doering PL. Matzke GR. 6 months after the acute phase of her illness subsides Rationale: When treating the first depressive episode. New York: McGraw-Hill. DiPiro JT. Available at Page 19 of 22 . Feldman JM. http://0-www. American Psychiatric Association Practice Guidelines.com. Treatment of Patients with Major Depressive Disorder. Posey LM.aspx? aID=7987346. Yee GC. In: Talbert RL. Pharmacotherapy: A Pathophysiologic Approach. Wells BG. 2012 Item 2 (200 points) A 25-year-old woman is experiencing her first major depressive episode.Item 1 (100 points) A patient presents to the emergency department experiencing drug withdrawal. eds. Major depressive disorder. Matzke GR. http://0www. 8th ed. Stimulants. Citations: Jackson CW.midwestern.millennium. 3 months after the acute phase of her illness subsides 6 months after the acute phase of her illness subsides 1 year after the acute phase of her illness subsides 1 year from the onset of the depressive episode Answer: 2. Substance-Related Disorders: Alcohol. She was initiated on sertraline a few months ago and titrated up to 100 mg/day to achieve better control of symptoms. and Caffeine. Although morphine produces significant withdrawal signs and symptoms. Pharmacotherapy Principles and Practice. New York: McGraw-Hill. Chapter 74. 2.accesspharmacy. 4. 3. 8th ed. eds. 2010:664. Substance-Related Disorders: Overview and Depressants. 2011. DiPiro JT. Schwinghammer TL. Doering PL. What is the optimal duration of antidepressant therapy in this patient? 1. In: Talbert RL. Accessed March 29. Cates ME. Pharmacotherapy: A Pathophysiologic Approach. antidepressants must be given for an additional 4–9 months after the acute episode has resolved. Cocaine Amphetamines Morphine Ethanol Answer: 4.midwestern. 2012. In: Chisholm MA. and Hallucinogens.millennium. Posey LM. Yee GC.edu/content. 2. 2010. Chapter 75.

millennium. but when disease is more advanced and there is increasing degeneration of dopamine terminals. In: DiPiro JT. 7e: http://0-www. the concentration of dopamine in the basal ganglia is much more dependent on plasma levodopa levels. Item 3 (300 points) A 66-year-old man with a long-standing history of Parkinson disease (diagnosed 12 years ago) presents to the clinic for assessment.midwestern. This phenomenon may be explained by the observation that dopamine nerve terminals are able to store and release dopamine early in the course of disease. 2012. His current medications include carbidopa/levodopa 25–100 mg every 4 hours. Nelson MV.com/pracGuide/pracGuideChapToc_7. Pharmacotherapy: A Pathophysiologic Approach. Infectious Diseases Item 1 (100 points) Page 20 of 22 . Wells BG. Yee GC. A substantial number of patients develop levodopainduced complications within several years of starting this drug. Accessed March 28.5 mg 3 times/day. replacing sustained-release levodopa with regular levodopa in dyskinesias occurring in the late afternoon. abnormal postures of the extremities and trunk known as dystonia. 3. Talbert RL. Matzke GR. 2012. Swope DM.edu/content. Parkinson’s disease. and a variety of complex fluctuations in motor function.accesspharmacy. These include motor fluctuations (the wearing-off phenomenon).http://www. He experiences uncontrollable involuntary movements of his legs and arms that usually occur around the time for his next medication dose. using a dopamine agonist. 4. Ways to treat this include decreasing the levodopa dose. Citation: Chen JJ.com. involuntary movements known as dyskinesia. Which drug on his current profile is most likely causing this symptom? 1. and benztropine 2 mg/day. pramipexole 1.aspx. Benztropine Entacapone Levodopa Pramipexole Answer: 3. 2. or using levodopa dosing more frequently. eds.aspx?aID=3204031. Posey LM. entacapone 200 mg every 4 hours. Levodopa Rationale: The correct answer is levodopa. Accessed March 28.psychiatryonline.

His blood cultures are currently growing Candida spp. Wunderlink RG. 3. Ceftriaxone and azithromycin Rationale: The correct answer is ceftriaxone and azithromycin. 2007:109. except Candida glabrata and Candida krusei. et al. Candida glabrata Rationale: Fluconazole covers all Candida spp. Gilbert DN. Candida glabrata 4. Item 3 (300 points) A 30-year-old man with a history of poorly controlled schizophrenia secondary to poor adherence to his antipsychotic medications has newly diagnosed human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection. Doxycycline and azithromycin Ceftriaxone and azithromycin Moxifloxacin and ceftriaxone Vancomycin and ceftriaxone Answer: 2. et al. Moxifloxacin could be used alone and does not need to be added to ceftriaxone in this patient.48:503–35.44:S27–S72. Clin Infect Dis 2007. VA: Antimicrobial Therapy. Citations: Pappas PG. Page 21 of 22 . Candida albicans Answer: 3. The doxycycline and azithromycin combination does not have adequate coverage for S. Sperryville. Item 2 (200 points) A 44-year-old man is initiated on fluconazole for fungemia. et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Candida parapsilosis 2. If identified by culture. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of communityacquired pneumonia in adults. Vancomycin would only be used in health care–associated infections with risk of methicillin-resistant Staphylococcus aureus. which of species of Candida would warrant a change in antifungal therapy? 1. 2. Candida tropicalis 3. The Sanford Guide to Antimicrobial Therapy. pneumoniae.What is the most appropriate empiric treatment regimen for a patient with community-acquired pneumonia who needs admission to the general medical ward of a hospital? 1. Citation: Mandell LA. 4. Clin Infect Dis 2009. Anzueto A.

The HIV genotype reveals no significant mutations. ritonavir (Norvir) 100 mg by mouth once daily. U. 2012. ritonavir-boosted atazanavir.aidsinfo.075 x 109/L) HBV viral load – 500 copies/mL SCr and liver enzymes are within normal limits. Department of Health and Human Services (DHHS) guidelines. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. with tenofovir/emtricitabine (Truvada) as the preferred NRTIs. Which regimen would be the best recommendation for initial therapy in this patient? 1.S. and atazanavir (Reyataz) 300 mg by mouth once daily Rationale: According to U. Truvada is recommended as part of the HAART regimen in patients with hepatitis B coinfection. ritonavir 100 mg by mouth once daily. Moreover. 2011. 1–166. Accessed March 28. and atazanavir 300 mg by mouth once daily 4.His initial laboratory values are: HIV viral load – 625. Efavirenz would not be the best option given its potential to exacerbate psychotic symptoms in patients with a history of psychiatric illness. first-line highly active antiretroviral therapy (HAART) regimens should include a backbone of two nucleoside reverse transcriptase inhibitors (NRTIs). Efavirenz/tenofovir/emtricitabine 1 tablet by mouth once daily 2.000 copies/mL CD4 count – 75 cells/microliter (SI 0. or raltegravir. Team/Individual ID ______________________ Jeopardy Segment Score ________ For Administrative Use Only Page 22 of 22 . Tenofovir/emtricitabine 1 tablet by mouth once daily.pdf. January 10. Citation: Panel on Antiretroviral Guidelines for Adults and Adolescents. Abacavir/lamivudine 1 tablet by mouth once daily. Available at http://www. and atazanavir 300 mg by mouth once daily 3. ritonavir 100 mg by mouth once daily. In addition to the NRTI backbone of Truvada.nih. Tenofovir/emtricitabine 1 tablet by mouth once daily and lopinavir/ritonavir 400-mg/100mg tablet 2 tablets by mouth twice daily Answer: 2.S.gov/ContentFiles/AdultandAdolescentGL. Department of Health and Human Services. Tenofovir/emtricitabine (Truvada) 1 tablet by mouth once daily. the initial regimen should include efavirenz.