Study Guide For Final Pharmacology Hypertension

Study Guide for Final Pharmacology
Hypertension:
 Normal and abnormal based on JNC guidelines

Normal- 120/80
Prehypertension- 120-139/80-89
Hypertension I- 140/159
Hypertension II- >160/>100
 Treatment goals
No diabetes no CKD: >60 150/90 <60 140/90
Diabetes no CKD: <140/90
CKD w/wo Diabetes: <140/90
 First line therapy / Second line therapy

Lifestyle modifications: Smoking Cessation, Control blood glucose and lipids, Diet, Eat healthy
(i.e., DASH diet) Moderate alcohol consumption, Reduce sodium intake to no more than 2,400
mg/day, Physical activity, Moderate-to-vigorous activity 3-4 days a week averaging 40 min per
session.
The preferred first-line and later-line medications to four classes: thiazide-type diuretics, calcium
channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin
receptor blockers (ARBs). Second- and third-line alternatives can include higher doses or
combinations of agents in these four classes.
Thiazide diuretic: HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg
triamterene 100mg K+ sparing – spironolactone 25-50mg, amiloride 5-10mg, triamterene 100mg
furosemide 20-80mg twice daily, torsemide 10-40mg.
Calcium channel blocker (CCBs): Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg,
Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 times daily or ER 240-
480mg.
ACE inhibitor (ACEIs) lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- 10mg,
trandolapril 2-8mg
Angiotensin receptor blocker (ARBs): candesartan 8-32mg, valsartan 80-320mg, losartan 50-
100mg, olmesartan 20-40mg, telmisartan 20-80mg,
Prior to using beta blockers, aldosterone antagonist or other classes of agents, JNC-8 recommends patients first receive
a dose adjustment and combination of the four first-line agents. Triple therapy with an ACEI/ARB, CCB, and thiazide-
type diuretic would precede use of a beta blocker, aldosterone antagonist or other alternative agent.
HTN Meds:
 Best treatment for different race

African Americans have a higher and earlier HTN incidence.
 Reduced response to monotherapy, beta blockers, ACEIs, and ARBs
 Equal response if mixed with diuretic.
 BiDil (hydralazine-isosorbide dinitrate) is the first drug suggested for African-American patients
specifically.
Copyright © 2016 F. A. Davis Company
Blacks- Calcium channel blockers (amlodipine, diltiazem, verapamil, nifedipine) and or Thiazides.
 Best treatment with comorbidity including diabetes

ACE inhibitors
 ACE therapy: Indications, mechanism of actions, S/E

o Diabetic patients – Reason for prescribing
o Concept of diabetic renal protection and ACE
ACE INHIBITORS (ACEIs) AND ARBs
■ Hypertension, diabetes (renal), chronic kidney disease (CKD), others.

■ Category C (fi rst trimester) and Category D (second to third trimesters).
■ ACE inhibition blocks conversion of angiotensin I to angiotensin II (potent
vasoconstrictor).
■ ARBs block angiotensin II (less aldosterone).
■ Black Box Warning: ACEI can cause death/injury to the developing fetus during
the second and third trimesters. Discontinue ACEIs and ARBs immediately if
pregnant.
ACEIs
■ Lisinopril (Zestril, Prinivil)
■ Combination: lisinopril and HCTZ (Zestoretic)
■ Benazepril (Lotensin)
■ Captopril (Capoten)
■ Enalapril (Vasotec)
ARBs
■ Losartan (Cozaar)
■ Irbesartan (Avapro)
■ Contraindication: ACEI-/ARB-associated angioedema, hereditary angio edema
Adverse Effects
■ Angioedema and anaphylactoid reactions
■ ACEI cough
■ Hyperkalemia
Pharma Notes
■ ACEI cough occurs within the fi rst few months of treatment. It is a dry and
hacking cough (without other symptoms of URI). Stop ACEI and switch to
an ARB.
■ First-line drug for hypertension in diabetics (diabetic nephropathy).
■ First-line drug for patients with (proteinuric) CKD.
■ Avoid using salt substitutes that contain potassium.
■ Captopril associated with agranulocytosis, neutropenia, leukopenia (rare).
Monitor CBC.
■ Both ACEIs and ARBs are excreted in breast milk (breastfeeding mothers
should avoid them).
CLINICAL TIP

Be careful prescribing ACEIs/ARBs to sexually active, reproductive-aged females who are not
consistently
using birth control (Category C and Category D during the second and third trimester
ALPHA-BLOCKERS
■ Hypertension with coexisting BPH.

■ Terazosin (Hytrin) 1 mg PO at bedtime (lowest dose).
Pharma Notes
■ Not a fi rst-line choice except for males with both hypertension and BPH.
■ Potent vasodilator. Common side effects are dizziness and hypotension. Give
at bedtime at very low dose and slowly titrate up. Careful with frail elderly
(risk of syncope and falls).
ACE therapy: Indications, mechanism of actions, S/E

Diabetic patients – Reason for prescribing (Improve insulin sensitivity)
Concept of diabetic renal protection and ACE
ACE inhibitors prevent the diabetic nephropathy by decreasing glomerular efferent arteriolar
resistance and reducing intraglomerular capillary pressure that cause improve in renal hemodynamics,
decrease proteinuria, and retarded glomerular hypertrophy and slower rate of decline GFR.
Indication:
 High blood pressure
 Coronary artery disease
 Heart failure
 Diabetes
 Certain chronic kidney diseases
 Heart attacks
 Scleroderma
 Migraines
Mechanism of action: Inhibits angiotensin converting enzyme, interfering with conversion of

angiotensin I to angiotensin II.
Side effect:
 Dry cough
 Increased blood-potassium level (hyperkalemia)
 Fatigue
 Dizziness
 Headaches
 Loss of taste
CCB:
Side effects: Dizziness, headaches, hypotension, syncope. These lead to HF with congestion,
SOB, cough, and palpitations, N/V, reflux, constipation, gynecomastia and sexual dysfunction
may occur, Hyperglycemia, photosensitivity and facial telangiectasia

Loop diuretics:
Side effect: Electrolyte imbalance, hypokalemia (Alkalosis Metabolic), hypercalcemia, hyponatremia,
hypomagnesemia, Glucose intolerance, hypotension due to the decrease volume, The average
potassium loss is 0.6 mEq/L
 CCB: Side effects
CALCIUM CHANNEL BLOCKERS
■ Hypertension, Raynauds phenomenon (first line)
■ Amlodipine (Norvasc)
■ Diltiazem (Cardizem)
■ Nifedipine (Procardia)
■ Verapamil (Calan): Do not mix with erythromycin and clarithromycin (drug
interaction)
Contraindications
– AV-block (second- to third-degree block)

– Bradycardia
– Congestive heart failure (CHF)
Pharma Notes
■ Educate patients to avoid grapefruit juice (toxicity results as it will increase
drug level).
■ Possible drug interactions: intraconazole, macrolides (except azithromycin).
Adverse Effects
■ Headache (vasodilation)
■ Peripheral edema (not due to fl uid overload)
■ Bradycardia
■ Heart failure and heart block
■ Hypotension, QT prolongation
■ Constipation is the most commonly reported side effect
 BB: Indications
o Side effects – main
o Use in other conditions than BP
o Drug/drug interaction, caution in respiratory
o Effects of rapid withdrawal
Beta-Blockers (Beta Antagonists)

■ Hypertension, post-myocardial infarction (fi rst line), angina, arrhythmias, migraineprophylaxis.
■ Adjunct treatment: hyperthyroidism/thyrotoxicosis (decreases heart rate, anxiety).
Migraine prophylaxis.
Non-cardioselective (blocks beta-1 and beta-2).
■ Propanolol immediate release (Inderal) or extended release (Inderal LA).

■ Timolol oral (Blocadren) or timolol ophthalmic drops (glaucoma).
■ Cardioselective (blocks beta-1 only).
Atenolol (Tenormin) daily.
Metoprolol immediate release (Lopressor) or extended release (Toprol XL).

Adverse Effects
■ Bronchospasm
■ Bradycardia
■ Depression, fatigue (careful with elderly)
■ Erectile dysfunction (ED)
■ Blunts hypoglycemic response (warn diabetic patients)
Contraindications:
Asthma (causes bronchoconstriction)
COPD (causes bronchoconstriction)
Chronic bronchitis (causes bronchoconstriction).
Emphysema (causes bronchoconstriction).
Bradycardia and AV-block (second- to third-degree block; Table 3.2).
Drug Class and Generic and Trade Names Contraindications
ACE Inhibitors Avoid potassium supplements

Lisinopril (Zestril) Careful with potassium-sparing diuretics
Captoril (Capoten) ACE inhibitor cough—new onset of dry cough (not accompanied by URI
symptoms)
 ARBs: Treatment and Race

ARBs
Valsartan (Diovan)
Losartan (Cozaar)
First-line choice for diabetics
First-line choice for mild to moderate renal disease
Potassium-sparing diuretics
Triamterene (Dyrenium)
Triamterene + HCTZ (Dyazide)
Amiloride (Midamor)
Higher risk of hyperkalemia if combined with ACEI or ARBs
and with severe renal disease
Diuretics may worsen urinary incontinence
Beta Blockers: Propranolol (Inderal), atenolol(Tenormin), metoprolol (Lopressor),

pindolol (Visken). Contraindicated if patient has chronic lung diseases (asthma,
COPD, emphysema, chronic bronchitis) Do not discontinue beta-blockers abruptly due to severe
rebound (hypertensive crisis)
Sildenafi l (Viagra) Do not mix with nitrates (nitroglycerine, isosorbide dinitrate)

and some alpha-blockers. Erection greater than 4 hours—refer to ED
Tadalafi l (Cialis) Do not give within 3 to 6 months of an MI, stroke
 Loop diuretics: Side effect, labs

Thiazide Diuretics
■ Uncomplicated hypertension (first line), heart failure (first line), edema.
■ Hypertension accompanied by osteoporosis.
■ Hydrochlorothiazide (HCTZ) 12.5 to 25 mg PO daily.
■ Chlorthalidone 12.5 to 25 mg PO daily.
■ Indapamide (Lozol) PO daily.
Adverse Effects
■ Hyperglycemia (careful with diabetics).
■ Elevates triglycerides and LDL (careful if preexisting hypertriglyceremia).
■ Elevates uric acid (can precipitate a gout attack).
■ Hypokalemia (muscle weakness, arrythymia).
■ Patients with both hypertension and osteoporosis have an extra benefi t
from thiazides.
■ Thiazide diuretics decrease calcium excretion by the kidneys and stimulate
osteoclast formation.
■ Patients with serious sulfa allergies should avoid thiazide diuretics.
Potassium-sparing diuretics such as triamterene and amiloride (Midamor)
are the alternative options for these patients.
■ Chlorthalidone is longer acting and more potent than HCTZ.
Potassium-Sparing Diuretics
■ Hypertension, alternative diuretic for patients with severe sulfa allergy.
■ Triamterene (Dyrenium).
■ Amiloride (Midamor).
Combination: triamterene and HCTZ (Dyazide), amiloride and HCTZ

(Moduretic).
■ Black Box Warning: Hyperkalemias, which can be fatal. Higher risk with renal
impairment, diabetes, elderly, severely ill.
■ Monitor serum potassium frequently (baseline, during, dose changes, illness).
Pharma Notes
■ Do not give potassium supplement. Avoid using salt substitutes that contain
potassium.
■ Be careful with combinations of ACEI/angiotensin-receptor blockers
(ARBs); increases risk of hyperkalemia.
■ Avoid with severe renal disease (increases risk of hyperkalemia).
Loop Diuretics
■ Edema from heart failure, cirrhosis, renal disease, hypertension.
■ Loop diuretics are excreted via the loop of Henle of the kidneys and are more
potent than HCTZ.
■ Furosemide (Lasix) PO BID.
■ Bumetanide (Bumex).
■ More potent than thiazides, but with shorter duration of action (BID).
■ Black Box Warning: excessive amounts of furosemide may lead to profound diuresis.
Medical supervision required, individualized dose schedule.
Adverse Effect
■ Electrolytes (hypokalemia, hyponatremia/low sodium, low levels of chlorine).
■ Hypovolemia and hypotension (dizziness, lightheadedness).
■ Pancreatitis, jaundice, rash.
■ Ototoxicity (worsens aminoglycoside ototoxicity effect if combined).
Aldosterone Antagonists
■ Hirsuitism, hypertension, severe heart failure

■ Spironolactone (Aldactone)
Hirsuitism, hypertension, severe heart failure
■ Spironolactone (Aldactone)
Pharma Notes
■ Adverse effects are galactorrhea and hyperkalemia. Spironolactone is
rarely used to treat hypertension in primary care due to adverse effects and
higher risk of certain cancers.
■ Black Box Warning: increases risk of both benign and malignant tumors.
 Digitalis: Side effect, labs, toxicity, drug/drug interaction

Cardiac Glycosides: Digoxin (Lanoxin)
■ Treats atrial fi brillation.

– Digoxin has a narrow therapeutic range (0.5–2.0 ng/mL). Not a fi rst-line drug for heart rate control
in atrial fi brillation.
■ Signs and symptoms of digoxin overdose:

– Initial symptoms are gastrointestinal (anorexia, nausea/vomiting, abdominal
pain). Others are arrhythmias, confusion, and visual changes (yellowish green
tinged-color vision, scotomas).
– Severe toxicity is treated with digoxin-binding antibodies (Digibind).
■ What laboratory test should be ordered if digoxin toxicity is suspected?

– Order a digoxin level, electrolytes (potassium, magnesium, calcium), c reatinine,
and serial EKGs.
■ Potassium values (adult to elderly):

Critical: Less than 2.5 or greater than 6.5 mEq/L.
Normal: 3.5 to 5.0 mEq/L.
A patient has an INR of 8.0. Physical examination is negative for petechiae, bleeding
gums, bruising, or dark stools. What is the best treatment plan for this patient?
– INR between 5.0 and 9.0 (without bleeding): Hold the warfarin for 1 to 2 doses.
Recheck INR every 2 to 3 days until it is stable (INR between 2.0 and 3.0). Another
option is to hold the warfarin and add a small dose of oral vitamin K. Limit and/
or avoid high vitamin K foods (green leafy vegetables, broccoli, brussels sprouts,
cabbage). After the INR becomes stable, recheck it monthly.*
INR values below 2.0 increase stroke risk sixfold.

■ There is a higher risk of hemorrhage with high INRs in the elderly (age greater than
70 years).
■ Mayonnaise, canola oil, and soybean oil also have high levels of vitamin K.
 Nitroglycerines: Dosage, Side effects, patient education

Dosage: tab 2.5mg,5mg, 10 mg give 2.5 to 5 mg SL Q5 to 10 mints, max 3 doses in 15
to 30 mints.
Side effects: Orthostatic hypotension, syncope, tachycardia, throbbing headache, less
common N/V, incontinence bowels and urinary, dysuria, impotence, no allergic rash,
flushing.
Patient education:
 Serum cholesterol: Prevention
1. ACE inhibitors are the drug of choice in treating hypertension in diabetic patients because they:
A. Improve insulin sensitivity
B. Improve renal hemodynamics
C. Reduce the production of angiotensin II
D. All of the above
2. Despite good blood pressure control, a NP might change a patient’s drug from an ACEI to an angiotensin II
receptor blocker (ARB) because the ARB:
A. Is stronger than the ACEI
B. Does not produce a dry, hacky cough
C. Has no effect on the renal system
D. Reduces sodium and water retention
3. ACE inhibitors are useful in a variety of disorders. Which of the following statements are true about both
its usefulness in the disorder and the reason for its use?
A. Stable angina because it decreases the thickening of vascular walls to decreased
MOD.
B. Heart failure because it reduces remodeling of injured myocardial tissues.
C. Both A and B are true and the reasons are correct
D. Both A and B are true but the reasons are wrong
E. Neither A nor B are true
4. Patient teaching related to amlodipine (a Calcium Channel Blocker) includes:

A. Increase calcium intake to prevent osteoporosis from calcium blockade.
B. Do not crush the tablet; it must be given in liquid form if the patient has trouble
swallowing it.
C. Avoid grapefruit juice as it affects the metabolism of this drug., also avoid ETOH
and NSAIDS.
D. Rise slowly from a supine position to reduce orthostatic hypotension.
5. Larry has heart failure which is being treated with digoxin because it exhibits:
A. Negative inotropism
B. Positive chronotropism
C. Both A and B
D. Neither A nor B
6. Furosemide is added to a treatment regimen for heart failure which includes digoxin. Monitoring for this
combination includes:
A. Hemoglobin
B. Serum potassium
C. Blood urea nitrogen
D. Serum glucose
7.Which of the following create higher risk for digoxin toxicity? Both the cause and the reason for it must be
correct.
A. Older adults due to reduced renal function
B. Administration of aldosterone antagonist diuretics due to decreased potassium
levels
C. Taking an antacid for GERD because it increases the absorption of digoxin
D. Doses between 0.25 and 0.5 mg/day
8. Serum digoxin levels are monitored for potential toxicity. Monitoring should occur:
A. Within 6 hours of the last dose
B. Because a reference point is needed in adjusting a dose
C. After three half-lives from the starting of the drug
D. When a patient has stable renal function
9. Isosorbide dinitrate is prescribed for a patient with chronic stable angina. This drug is administered twice
daily, but the schedule is 7 AM and 2 PM because:
A. It is a long-acting drug with potential for toxicity
B. Nitrate tolerance can develop
C. Orthostatic hypotension is a common adverse effect
D. It must be taken with milk or food
10. In teaching about the use of sublingual nitroglycerine, the patient should be instructed:
A. To swallow the tablet with a full glass of water
B. To place one tablet under the tongue if chest pain occurs and allow it to dissolve
C. To take one tablet every 5 minutes until the chest pain goes away
D. That it should “burn” when placed under the tongue or it is no longer effective
11. Janice has elevated LDL, VLDL, and triglyceride levels. Niaspan, an extended-release form of niacin, is
chosen to treat her hyperlipidemia. Due to its metabolism and excretion, which of the following labs should
be monitored?
A. Serum alanine aminotransferase
B. Serum amylase
C. Serum creatinine
D. Phenylketonuria
12. Niaspan is less likely to cause which side effect that is common to niacin?
A. Gastrointestinal irritation
B. Cutaneous flushing
C. Dehydration
D. Headaches
13. Which of the following statements is true?

A. Niacin is a B-complex vitamin and taking double the dose of the over-the-counter
vitamin will lower LDL and save money.
B. Niacin has been shown to reduce all-cause mortality for patients with CAD if
taken in prescription strength.
C. Niacin should be given on an empty stomach to avoid GI irritation.
D. All of the above
___ 1. Because primary hypertension has no identifiable cause, treatment is based on interfering with the
physiological mechanisms that regulate blood pressure. Thiazide diuretics treat hypertension because they:
1. Increase renin secretion
2. Decrease the production of aldosterone
3. Deplete body sodium and reduce fluid volume
4. Decrease blood viscosity
___ 2. Because of its action on various body systems, the patient taking a thiazide or loop diuretic may also need to
receive the following supplement:
1. Potassium
2. Calcium
3. Magnesium
4. Phosphates
___ 3. All patients with hypertension benefit from diuretic therapy, but those who benefit the most are:
1. Those with orthostatic hypertension
2. African Americans
3. Those with stable angina
4. Diabetics
___ 4. Beta blockers treat hypertension because they:

1. Reduce peripheral resistance
2. Vasoconstrict coronary arteries
3. Reduce norepinephrine
4. Reduce angiotensin II production
___ 5. Which of the following disease processes could be made worse by taking a nonselective beta blocker?
1. Asthma
2. Diabetes
3. Both might worsen
4. Beta blockade does not affect these disorders
___
6. Disease states in addition to hypertension in which beta blockade is a compelling indication for the use of beta
blockers include:
1. Heart failure
2. Angina
3. Myocardial infarction
4. Dyslipidemia

___ 7. Angiotensin-converting enzyme (ACE) inhibitors treat hypertension because they:
1. Reduce sodium and water retention
2. Decrease vasoconstriction
3. Increase vasodilation
4. All of the above
___ 8. Compelling indications for an ACE inhibitor as treatment for hypertension based on clinical trials includes:
1. Pregnancy
2. Renal parenchymal disease
3. Stable angina
4. Dyslipidemia
___ 9. An ACE inhibitor and what other class of drug may reduce proteinuria in patients with diabetes better than
either drug alone?
1. Beta blockers
2. Diuretics
3. Nondihydropyridine calcium channel blockers
4. Angiotensin II receptor blockers
___ 10. If not chosen as the first drug in hypertension treatment, which drug class should be added as a second step
because it will enhance the effects of most other agents?
1. ACE inhibitors
2. Beta blockers
3. Calcium channel blockers
4. Diuretics
___ 11. Treatment costs are important for patients with hypertension. Which of the following statements about cost is
NOT true?
1. Hypertension is a chronic disease where patients may be taking drugs for a long
time.
2. Most patients will require more than one drug to treat the hypertension.
3. The cost includes the price of any routine or special laboratory tests that a specific
drug may require.
4. Few antihypertensive drugs come in generic formulations.
___ 12. Caffeine, exercise, and smoking should be avoided for at least how many minutes before blood pressure
measurement?
1. 15
2. 30
3. 60
4. 90
___ 13. Blood pressure checks in children:

1. Should occur with their annual physical examinations after 6 years of age
2. Require a blood pressure cuff that is one-third the diameter of the child’s arm
3. Should be done during every health-care visit after 3 years of age
4. Require additional laboratory tests such as serum creatinine
___ 14. Lack of adherence to blood pressure management is very common. Reasons for this lack of adherence
include:
1. Lifestyle changes are difficult to achieve and maintain.
2. Adverse drug reactions are common and often fall into the categories more
associated with nonadherence.

3. Costs of drugs and monitoring with laboratory tests can be expensive.
4. All of the above
___ 15. Lifestyle modifications for patients with prehypertension or hypertension include:
1. Diet and increase exercise to achieve a BMI greater than 25.
2. Drink 4 ounces of red wine at least once per week.
3. Adopt the dietary approaches to stop hypertension (DASH) diet.
4. Increase potassium intake.
___ 16. Which diuretic agents typically do not need potassium supplementation?
1. The loop diuretics
2. The thiazide diuretics
3. The aldosterone inhibitors
4. They all need supplementation
___ 17. Aldactone family medications are frequently used when the hypertensive patient also has:
1. Hyperkalemia
2. Advancing liver dysfunction
3. The need for birth control
4. Rheumatoid arthritis
___ 18. Hypertensive African Americans are typically listed as not being as responsive to which drug groups?
1. ACE inhibitors
2. Calcium channel blockers
3. Diuretics
4. Bidil (hydralazine family of medications)
___ 19. What educational points concerning fluid intake must be covered with diuretic prescriptions?
1. Fluid should be restricted when on them.
2. Fluids should contain at least one salty item daily.
3. Fluid intake should remain near normal for optimal performance.
4. Avoidance of potassium-rich fluids is encouraged.
___ 20. What is a common side effect concern with hypertensive medications and all individuals, but especially the
elderly?
1. Risk of falls
2. Triggering of a hypertensive crisis
3. Erectile priapism
4. Risk for bladder cancer development
Diabetes: CH 33
 Sulfonylureas:Indications: Manage type 2 diabetes. Used in combination therapy. For insufficient

production of endogenous insulin.
Mechanism of action: Sulfonylureas cause an increase in insulin production.
Stimulates the beta cells of the pancreas to secrete more insulin.
■ First generation: Chlorpropamide (Diabenase) daily or BID. – Long half-life (12 hours). Not
commonly used due to high risk of severe hypoglycemia.
■ Second generation: Glipizide (Glucotrol, Glucotrol XL) maximum dose 40 mg/day, glyburide
(Diabeta) maximum dose 20 mg/day, glimepiride (Amaryl) maximum. dose 8 mg/day.

 Metformin (Biguanides) Indications for excessive production of glucose by the liver. Tissue
insensitive to insulin.
Mechanism of action: Metformin improves hepatic response to elevate BG and decrease glucose
production and decreases GI absorption and improve sensitivity by increasing peripheral glucose
uptake and utilization.
 Concept of GLP 1 agonists: Glucagon-Like Peptide-1 Receptor Agonists (GLP-1S). The first GLP 1
agonist receiving FDA approval was Exenatide (Byetta). Exenatide and the other GLP-1 medications
activate GLP-1 receptors, which decreases fasting and postprandial glucose levels. They increase
insulin synthesis and secretion in the presence of elevated glucose levels and improve first-pahse
insulin release, lowering glucagon, slowing gastric emptying, and reducing food intake. These drugs
are given with by subcutaneous injection for type -2 DM but are not substitute for insulin. They have
been noted to produce lower HB A1c levels of 0.5% to 1.5 % and weight loss.
Glucagon-like Peptide-1 Agonist (GLP-1)
 Exenatide (Byetta) and others
 Pharmacodynamics
 Promotes insulin release from pancreatic beta cells in the presence of elevated glucose
 Mimics natural incretins
 Slows glucose absorption from gut; promotes satiety
 Precautions and contraindications
 Acute pancreatitis noted in post-marketing surveillance
 Severe GI disease (colitis, Crohn’s)
 Pregnancy category C
 ADRs
 Pancreatitis
 GI: nausea, vomiting, diarrhea
 Drug interactions
 Increased international normalized ratio if administered with warfarin
 Digoxin
 Clinical use only for type 2 DM
 Add-on therapy is typical
 Combine with Metformin, sulfonylurea, others
 Monitoring
 Glycemic control and GI distress
 Potential site reactions
 Patient education
 Administration of SC injection for rapid release
 60 minutes before meals
 Dosed 6 hours apart
 If dose is missed, wait for next scheduled time.
 ADRs
 GI upset/nausea (major cause of noncompliance)
 Lifestyle
Drug Therapy Race/ethnic group

Obesity: Metformin DPP-4 and GLP-1 RA help with weight loss.

Coronary artery disease/HF: Intensive therapy with insulin reduces microvascular damage.
Angiotensin-converting enzyme (ACE) inhibitor, aspirin, and statin, Metformin.
Hyperlipidemia: statins
Hypertension: ACE inhibitors (ACEIs) or angiotensin II receptor blockers
Nephropathy: ACEIs
Neuropathy: tricyclic antidepressants, gabapentin
1. Sulfonylureas may be added to a treatment regimen for Type 2 diabetics when lifestyle modifications and
metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy
because they:
A. Increase endogenous insulin secretion
B. Have a significant risk for hypoglycemia
C. Address the insulin resistance found in Type 2 diabetics
D. Improve insulin binding to receptors
2. Metformin is a primary choice of drug to treat hyperglycemia in Type 2 diabetes because it:
A. Substitutes for insulin usually secreted by the pancreas
B. Decreases glycogenolysis by the liver
C. Increases the release of insulin from beta cells
D. Decreases peripheral glucose utilization
3. Prior to prescribing metformin, the provider should:

A. Draw a serum creatinine to assess renal function
B. Try the patient on insulin
C. Tell the patient to increase iodine intake
D. Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions
GLP-1 agonists:
A. Directly bind to a receptor in the pancreatic beta cell
B. Have been approved for monotherapy
C. Speed gastric emptying to decrease appetite
D. Can be given orally once daily
Type 1 diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90% of type 1 diabetics
have:
1. Autoantibodies to two tyrosine phosphatases
2. Mutation of the hepatic transcription factor on chromosome 12
3. A defective glucokinase molecule due to a defective gene on chromosome 7p
4. Mutation of the insulin promoter factor
___ 2. Type 2 diabetes is a complex disorder involving:

1. Absence of insulin production by the beta cells
2. A suboptimal response of insulin-sensitive tissues in the liver
3. Increased levels of glucagon-like peptide in the postprandial period
4. Too much fat uptake in the intestine
___ 3. Diagnostic criteria for diabetes include:

1. Fasting blood glucose greater than 140 mg/dl on two occasions
2. Postprandial blood glucose greater than 140 mg/dl
3. Fasting blood glucose 100 to 125 mg/dl on two occasions
4. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl
___ 4. Routine screening of asymptomatic adults for diabetes is appropriate for:

1. Individuals who are older than 45 and have a BMI of less than 25 kg/m2
2. Native Americans, African Americans, and Hispanics
3. Persons with HDL cholesterol greater than 100 mg/dl
4. Persons with prediabetes confirmed on at least two occasions
___ 5. Screening for children who meet the following criteria should begin at age 10 and occur every 3 years
thereafter:
1. BMI above the 85th percentile for age and sex
2. Family history of diabetes in first- or second-degree relative
3. Hypertension based on criteria for children
4. Any of the above
___ 6. Insulin is used to treat both types of diabetes. It acts by:

1. Increasing beta cell response to low blood-glucose levels
2. Stimulating hepatic glucose production
3. Increasing peripheral glucose uptake by skeletal muscle and fat
4. Improving the circulation of free fatty acids
___ 7. Adam has type 1 diabetes and plays tennis for his university. He exhibits a knowledge deficit about his insulin
and his diagnosis. He should be taught that:
1. He should increase his carbohydrate intake during times of exercise.
2. Each brand of insulin is equal in bioavailability, so buy the least expensive.
3. Alcohol produces hypoglycemia and can help control his diabetes when taken in
small amounts.
4. If he does not want to learn to give himself injections, he may substitute an oral
hypoglycemic to control his diabetes.
___ 8. Insulin preparations are divided into categories based on onset, duration, and intensity of action following
subcutaneous injection. Which of the following insulin preparations has the shortest onset and duration of
action?leina
1. Lispro
2. Glulisine
3. Glargine
4. Detemir
___ 9. The drug of choice for type 2 diabetics is metformin. Metformin:

1. Decreases glycogenolysis by the liver
2. Increases the release of insulin from beta cells
3. Increases intestinal uptake of glucose
4. Prevents weight gain associated with hyperglycemia
___ 10. Before prescribing metformin, the provider should:

1. Draw a serum creatinine level to assess renal function.
2. Try the patient on insulin.
3. Prescribe a thyroid preparation if the patient needs to lose weight.
4. All of the above
___ 11. Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications and
metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy
because they:
1. Increase endogenous insulin secretion
2. Have a significant risk for hypoglycemia
3. Address the insulin resistance found in type 2 diabetics
4. Improve insulin binding to receptors
___ 12. Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control.
Advantages of these drugs include:
1. Better reduction in glucose levels than other classes
2. Less weight gain than sulfonylureas
3. Low risk for hypoglycemia
4. Can be given twice daily
___ 13. Control targets for patients with diabetes include:

1. HbA1C between 7 and 8
2. Fasting blood glucose levels between 100 and 120 mg/dl
3. Blood pressure less than 130/80 mm Hg
4. LDL lipids less than 130 mg/dl
___ 14. Establishing glycemic targets is the first step in treatment of both types of diabetes. For type 1 diabetes:
1. Tight control/intensive therapy can be given to adults who are willing to test their
blood glucose at least twice daily.
2. Tight control is acceptable for older adults if they are without complications.
3. Plasma glucose levels are the same for children as adults.
4. Conventional therapy has a fasting plasma glucose target between 120 and 150
mg/dl.
___ 15. Treatment with insulin for type 1 diabetics:
1. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight
2. Divides the total doses into three injections based on meal size
3. Uses a total daily dose of insulin glargine given once daily with no other insulin
required
4. Is based on the level of blood glucose
___ 16. When the total daily insulin dose is split and given twice daily, which of the following rules may be followed?
1. Give two-thirds of the total dose in the morning and one-third in the evening.
2. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning and
two-thirds in the evening.
3. Give 50% of an insulin glargine dose in the morning and 50% in the evening.
4. Give long-acting insulin in the morning and short-acting insulin at bedtime.
___ 17. Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer
long-term complications of diabetes. Patients who should have such a target include:
1. Those with long-standing diabetes
2. Older adults
3. Those with no significant cardiovascular disease
4. Young children who are early in their disease
___ 18. Prevention of conversion from prediabetes to diabetes in young children must take highest priority and should
focus on:
1. Aggressive dietary manipulation to prevent obesity
2. Fostering LDL levels less than 100 mg/dl and total cholesterol less than 170 mg/dl
to prevent cardiovascular disease
3. Maintaining a blood pressure that is less than 80% based on weight and height to
prevent hypertension

4. All of the above
___ 19. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending
upon type of diabetes) are:
1. Metformin and insulin
2. Sulfonylureas and insulin glargine
3. Split-mixed dose insulin and GPL-1 agonists
4. Biguanides and insulin lispro
___ 20. Unlike most type 2 diabetics where obesity is a major issue, older adults with low body weight have higher
risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is:
1. Weight loss in previously overweight persons
2. Involuntary loss of 10% of body weight in less than 6 months
3. Decline in lean body mass over a 12-month period
4. Increase in central versus peripheral body adiposity
___ 21. The drugs recommended for older adults with type 2 diabetes include:
1. Second-generation sulfonylureas
2. Metformin
3. Pioglitazone
4. Third-generation sulfonylureas
___ 22. Ethnic groups differ in their risk for and presentation of diabetes. Hispanics:
1. Have a high incidence of obesity, elevated triglycerides, and hypertension
2. Do best with drugs that foster weight loss, such as metformin
3. Both 1 and 2
4. Neither 1 nor 2
___ 23. The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of
dying from cardiovascular disease. Treatments and targets that do not appear to decrease risk for micro- and
macro-vascular complications include:
1. Glycemic targets between 7% and 7.5%
2. Use of insulin in type 2 diabetics
3. Control of hypertension and hyperlipidemia
4. Stopping smoking
___ 24. All diabetic patients with known cardiovascular disease should be treated with:
1. Beta blockers to prevent MIs
2. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of
cardiovascular events
3. Sulfonylureas to decrease cardiovascular mortality
4. Pioglitazone to decrease atherosclerotic plaque buildup
___ 25. All diabetic patients with hyperlipidemia should be treated with:
1. HMG-CoA reductase inhibitors
2. Fibric acid derivatives
3. Nicotinic acid
4. Colestipol
___ 26. Both angiotensin converting enzyme inhibitors and some angiotensin II receptor blockers have been approved
in treating:
1. Hypertension in diabetic patients
2. Diabetic nephropathy
3. Both 1 and 2
4. Neither 1 nor 2
___ 27. Protein restriction helps slow the progression of albuminuria, glomerular filtration rate, decline, and end stage
renal disease in some patients with diabetes. It is useful for patients who:
1. Cannot tolerate angiotensin converting enzyme inhibitors or angiotensin receptor
blockers
2. Have uncontrolled hypertension
3. Have HbA1C levels above 7%
4. Show progression of diabetic nephropathy despite optimal glucose and blood
pressure control
___ 28. Diabetic autonomic neuropathy (DAN) is the earliest and most common complication of diabetes. Symptoms
associated with DAN include:
1. Resting tachycardia, exercise intolerance, and orthostatic hypotension
2. Gastroparesis, cold intolerance, and moist skin
3. Hyperglycemia, erectile dysfunction, and deficiency of free fatty acids
4. Pain, loss of sensation, and muscle weakness
___ 29. Drugs used to treat diabetic peripheral neuropathy include:

1. Metoclopramide
2. Cholinergic agonists
3. Cardioselective beta blockers
4. Gabapentin
___ 30. The American Diabetic Association has recommended which of the following tests for ongoing management
of diabetes?
1. Fasting blood glucose
2. HbA1C
3. Thyroid function tests
4. Electrocardiograms
___ 31. Allison is an 18-year-old college student with type 1 diabetes. She is on NPH twice daily and Novolog before
meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-
minute swimming class three times a week at 1 p.m. What is important for her to do with this change in
routine?
1. Delay eating the midday meal until after the swimming class.
2. Increase the morning dose of NPH insulin on days of the swimming class.
3. Adjust the morning insulin injection so that the peak occurs while swimming.
4. Check glucose level before, during, and after swimming.
___ 32. Allison is an 18-year-old college student with type 1 diabetes. Allison’s pre-meal BG at 11:30 a.m. is 130.
She eats an apple and has a sugar-free soft drink. At 1 p.m. before swimming her BG is 80. What should she
do?
1. Proceed with the swimming class.
2. Recheck her BG immediately.
3. Eat a granola bar or other snack with CHO.
4. Take an additional dose of insulin.
___ 33. Bart is a patient is a 67-year-old male with T2 DM. He is on glipizide and metformin. He presents to the clinic
with confusion, sluggishness, and extreme thirst. His wife tells you Bart does not follow his meal plan or
exercise regularly, and hasn’t checked his BG for 1 week. A random glucose is drawn and it is 500. What is a
likely diagnosis based on preliminary assessment?
1. Diabetic keto acidosis (DKA)

2. Hyperglycemic hyperosmolar syndrome (HHS)
3. Infection
4. Hypoglycemia
___ 34. What would one expected assessment finding be for hyperglycemic hyperosmolar syndrome?
1. Low hemoglobin
2. Ketones in the urine
3. Deep, labored breathing
4. pH of 7.35
___ 35. A patient on metformin and glipizide arrives at her 11:30 a.m. clinic appointment diaphoretic and dizzy. She
reports taking her medication this morning and ate a bagel and coffee for breakfast. BP is 110/70 and random
finger-stick glucose is 64. How should this patient be treated?
1. 12 oz apple juice with 1 tsp sugar
2. 10 oz diet soda
3. 8 oz milk or 4 oz orange juice
4. 4 cookies and 8 oz chocolate milk
Respiratory:
Asthma: CH 30
 Step up therapy
First determine severity of asthma symptoms.
Go to Step Therapy Chart and start at recommended step.
The Expert Panel 3 Guidelines prefer an aggressive approach to gaining quick control.
Asthma control is “the degree to which the manifestations of asthma are minimized by therapeutic
intervention and the goals of therapy are met” (NAEPP, 2007).
 Treatment cautions for hypertensive patients
 Best Bronchodilators for patients on BB
 ICS: Side effects, patient education (Beclomethasone, Budesonide (Pulmicort), Fluticasone.

Adverse Reactions
 Xerostomia
 Hoarseness
 Tongue and mouth irritation
 Flushing
 Dysgeusia (altered taste sensation)
 Dysmenorrhea
Less common Adverse Reactions
 Oral candidiasis
 Cataracts
 Bronchospasm
 HPA suppression
 Pulmonary infiltrates with eosinophilia
 Nasal irritation, itching, sneezing, and dryness
 Bloody nasal mucus or epistaxis.

Education: Patient need to be cautioned to rinse their mouths after inhaled steroid use to prevent
oral candidiasis.
 COPD: First line of tx

COPD: Rational Drug Selection and Suggested Therapies
 Bronchodilators
 Corticosteroids
 Oxygen
 Antibiotics
 Leukotrienes
 Alpha-Trypsin Augmentation Therapy
 Immunizations
 Smoking Cessation
COPD Therapies: Bronchodilators.
 Beta Agonists
 Short acting vs. long acting vs. ultralong acting
 Methalyxanthine
 Selective phosphodiesterase (PDE)
 Muscarinic Agents
 Reduce exacerbations and hospitalizations
COPD Therapies: Corticosteroids.
 Inhaled
 Work as both monotherapy and in combination with inhaled bronchodilators
 Oral
 Work for short-tem treatment as they shorten recovery time, improve lung function, and
decrease hypoxemia.
 Phosphodiesterase-4 Inhibitors
 Create bronchial relaxation and decrease activation of the immune response
COPD Therapies: Oxygen
 Used short term during acute exacerbations
 Used long term in chronically hypoxemic patients
 Should be saturated greater than 90%
 Improves exercise tolerance, neuropsychological functions, and quality of life.
COPD Therapies: Antibiotics
 Amoxicillin/clavulanic acid
 Double-strength sulfamethoxazole/trimethoprim
 Macrolide antibiotics
 Reduce exacerbations and improve quality of life
 Are under evaluation and may have consensus in the future
COPD Therapies: Leukotrines and Alpha-Trypsin Augmentation
 Leukotrienes
 No data to support use in COPD
 Alpha-Trypsin Augmentation
 Used in patients with emphysema related to genetic alpha1 antitrypsin deficiency
 Not used in patients with alpha1 antitrypsin deficiency
COPD Therapies: Immunizations
 Influenza vaccine
 Should be administered annually between October and January
 Pneumococcal vaccine
 Should be administered every 6 years regardless of age
COPD Therapies: Smoking Cessation
 Patients with COPD must stop smoking
 Smoking cessation benefits include ventilatory function returning to a nearly normal age-related
rate
COPD: Patient Education
 Discuss treatment plan and drug therapy
 Discuss reasons for taking the drug and drugs as part of the total treatment plan, and adherence
issues
 Focus on maintaining optimal pulmonary function and quality of life
 Teach self-management
 Community acquired pneumonia (CAP): antibiotic of choice for older adults

Community Acquired Pneumonia
Treatment:
Healthy adults, no risk factors
 Macrolide (level I evidence) (azithromycin or clarithromycin, erythromycin)
 Doxycyline if allergic
 Treat for a minimum of 5 days.
Adults with comorbidities or risk of drug-resistant streptococcus pneumonia
 Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)
 Beta lactam plus a macrolide (amoxicillin, amoxicillin/clavulanate, or cefpodoxime,
cefuroxime, or parenteral ceftriaxone followed by oral cefpodoxime
 Doxycycline may be used as an alternative to the macrolyde.
Adults more than age 60 years with comorbidities
 Outpatient treatment option
 Ceftriaxone (Rocephin) 1 gm daily via IV or intramuscular or levofloxacin 500 mg IV daily
 Switch to oral therapy once patient can tolerate oral medications.
Pregnant woman Treatment
 Main pathogens are S. pneumoniae, H. influenzae, M. pneumoniae, and viruses.
 Macrolides
 Pregnancy category B: erythromycin, azithromycin
 Pregnancy category category C: clarithromycin
 Comorbid conditions or recent antibiotics: b-lactam plus a macrolide
 Treatment of choice for antibiotic naives

The term applies to the administration of psychotropics in contexts ranging from the professional
medical treatment of patients to the non-medical abuse of any drug. In addition to not being
habituated, a drug-naïve person may have never received a particular drug.
 Rhinosinusitis: Types, first line therapy for each type

Acute bacterial rhinosinusitis
143. Which of the following findings is most consistent with the diagnosis of acute bacterial rhinosinusitis
(ABRS) in children?
A. upper respiratory tract infection symptoms persisting beyond 10 days
B. nasal discharge progresses from clear to purulent to clear without antibiotics
C. headaches and myalgias that resolve in 24 to 48 hours as the respiratory symptoms worsen
D. persistent cough
144. Double sickening is defined as (choose all that apply):
A. nasal discharge progressing from clear to purulent to clear without antibiotic use.
B. acute worsening of respiratory symptoms.
C. new fever occurring 6 to 7 days after signs of upper respiratory infection (URI).
D. persistent cough.
145. The most common causative bacterial pathogen in ABRS is:

A. M. pneumoniae.
B. S. pneumoniae.
C. M. catarrhalis.
D. unidentified virus.
146. Risk factors for ABRS include all of the following except:
A. viral infection.
B. environmental allergies.
C. tobacco smoke exposure.
D. beta-thalassemia minor.
147. Which of the following is a first-line therapy option for the treatment of ABRS in an otherwise well child?
A. amoxicillin-clavulanate
B. clindamycin with cefixime
C. doxycycline
D. levofloxacin
148. Which of the following represents a therapeutic option for ABRS in an otherwise well 7-year-old child
who has not had significant clinical improvement but is not worse after 72 hours of observation?
A. continued observation
B. oral levofloxacin
C. oral clindamycin and cefixime
D. injectable ceftriaxone
149. A 5-year-old girl presents with ABRS. She has a penicillin allergy but is otherwise well and is going to be
treated with an antimicrobial. You prescribe:
A. no medication; continue observation.
B. cefdinir.
C. levofloxacin.
D. amoxicillin.
14. Digoxin levels need to be monitored closely when the following medication is started:
A. Loratadine
B. Diphenhydramine
C. Ipratropium
D. Albuterol
15. Christy has exercise and mild persistent asthma and is prescribed two puffs of albuterol 15 minutes
before exercise and as needed for wheezing. One puff per day of beclomethasone (QVAR) is also prescribed.
Teaching regarding her inhalers includes:
A. Use one to two puffs of albuterol per day to prevent an attack with no more than
eight puffs per day
B. Beclomethasone needs to be used every day to treat her asthma
C. Report any systemic side effects she is experiencing, such as weight gain
D. Use the albuterol MDI immediately after her corticosteroid MDI to facilitate
bronchodilation

16. The bronchodilator of choice for patients taking propranolol is:
A. Albuterol
B. Pirbuterol
C. Formoterol
D. Ipratropium
17. When educating patients who are starting on inhaled corticosteroids, the provider should include:
A. They need to get any live vaccines before starting the medication.
B. Inhaled corticosteroids need to be used daily during asthma exacerbations to be
effective.
C. Patients should rinse their mouths out after using the inhaled corticosteroid to
prevent thrush.
D. They can triple the dose number of inhalations of medication during colds to
prevent needing systemic steroids.
18. Cough and cold medications that contain a sympathomimetic decongestant such as phenylephrine
should be used cautiously in what population:
A. Older adults
B. Hypertensive patients
C. Infants
D. All of the above
19. Harold, a 42-year-old African American, has moderate persistent asthma. Which of the following asthma
medications should be used cautiously, if at all?
A. Betamethasone, an inhaled corticosteroid
B. Salmeterol, an inhaled long-acting beta-agonist
C. Albuterol, a short-acting beta-agonist
D. Montelukast, a leukotriene modifier
20. Long-acting beta-agonists (LTBAs) received a Black Box warning from the U.S. Food and Drug
Administration due to the:
A. Risk of life-threatening dermatological reactions
B. Increased incidence of cardiac events when LTBAs are used
C. Increased risk of asthma-related deaths when LTBAs are used
D. Risk for life-threatening alterations in electrolytes
GI:
 Laxatives and pregnancy

 Pepto bismol: indications, side effects, caution
 Patient education regarding antacids
 PPI tx: Side effects, special labs
 Peptic ulcer disease therapy principles
10. Long-term use of proton pump inhibitors may lead to:
A. Hip fractures in at-risk persons
B. Vitamin B6 deficiency
C. Liver cancer
D. All of the above
Pharmacology:
Pharmacodynamics: The effect of drug on the body.
Pharmacokinetics:
1. Absorption: Movement of a drug from its site of administration into the blood.
2. Distribution: Movement of absorbed drug in bodily fluids throughout body to target tissues.
3. Metabolism: (Biotransformation) Chemical change of drug structure.
4. Excretion: (Elimination). Removal of the drug from the body by organs of elimination.
Most drugs are eliminated by the kidneys, also are eliminated by Lungs, GU tract, Sweat and
Saliva, Mammary glands (breast milk).
Factor that affect Renal Excretion: Kidney function, Age, Hydration, Cardiac output.
The process of absorption, distribution, metabolism, and elimination of a drug is known as:
A. pharmacodynamics.
B. drug interactions study.
C. pharmacokinetics.
D. therapeutic transformation.
The study of biochemical and physiological effects of drugs on the body or disease is called:
A. pharmacodynamics.
B. pharmacokinetics.
C. biotransformation.
D. bioavailability.
Factors affecting drug distribution

Distribution requires adequate blood supply, drug is distributed to areas of high blood flow first them areas
of low blood flow. In circulation (Distribution), drugs are bound to protein, some of the drug is not bound
and is called free drug. Free drug is active drug. Drugs exist in bound and unbound states, travel when
bound, cross when unbound. Low plasma proteins (low albumen) will result in more free drug circulation,
resulting in high risk for toxicity.
Properties that affect distribution:
 Molecular size and lipid: water solubility: Drugs can passively diffuse most readily when they are right
balance between water and lipid solubility.
 PH: The acidity of the environment which the drugs finds itself. PH affects ionization of the drug.
 Passive diffusion: transfer through partially permeable barriers, smaller molecules are better able to
diffuse that larger molecules. Molecules with molecular weight < 500 are best candidates for passive
diffusion.
 Protein binding: Drugs passively diffuse and distribute when they are unbound and uncharged. Drugs
can bind to a variety of proteins that are present in the bloodstream. These are often called plasma
proteins. Many plasma proteins are produced in the liver and their presence in the bloodstream
reflects liver function, nutritional status, and the effect the aging and disease. Albumin is a mayor
protein in a blood.
 Drug distribution is also influenced by transporters, membrane proteins that facilitate the movement
of molecules across the cell membranes. Transport system are often directional, and they can
transport drugs into or out of cells.
Prescribing considerations for pharmacokinetics CH 3
 Bioavailability: Percentage of drug that is absorbed and available to reach the target tissues.
 CYP 450 metabolism
 Renal elimination
 Dose-concentration curve
 Half-life
When deciding what drug in a class to prescribe, the pharmacokinetic properties of a drug may influence
drug selection. For example, the bioavailability of different formulations may influence prescribing. The
bioavailability of digoxin, for instance, varies between 60% and 100 % depending on the formulation used.
Because this drug has a very narrow therapeutic index, this difference in BA is critical in formulation choice.
Another consideration is metabolism. Different drugs in a class may use different cytochrome P450 (CYP450)
enzymes, which may influence metabolism or drug interactions. Drugs that are excreted almost exclusively
by the kidney may not be appropriate for a patient with decreased renal function, such as the older adult.
Therefore, a patient’s renal function and the pharmacokinetics of the drug need to be evaluated during a
drug selection process.
Therapeutic drug level: It usually take 4 to 5 ½ lives to get steady state blood levels.
Loading Dose: It takes 4 to 51/2 lives to totally eliminate a drug from the body.
Drug toxicity
Occurs when a person has accumulated too much of a drug in his bloodstream, leading to adverse effects on
the body. An increasing in a free drug cause drug toxicity.
Half-life in older adults

A drug’s half-life (T1/2), defined as the time required for the amount of drug in the body to be reduced by
one-half after a single dose of the medication is given, is often increased in older adults. As gastric acid
production decreases, stomach pH increases, potentially prolonging the initial breakdown of medication made
to dissolve in low pH. In addition, age-related decreases in GI blood flow, gastric motility, and gastric
emptying mean that medication stays in the gut longer, whereas decreased GI surface area can lead to erratic
absorption. The use of antacids in the elderly population complicates this situation by increasing stomach pH
further, potentially allowing the formation of an inactive drug-antacid compound and delivering drug to
absorption sites in the intestines at a variable rate; proton pump inhibitors and histamine- 2 receptor
antagonists also increase stomach pH.
When prescribing a medication, the clinician considers that half-life is the amount of time needed to decrease
the serum concentration of a drug by:
A. 25%.
B. 50%.
C. 75%.
D. 100%.
Which of the following medications for ED treatment has the longest half-life?
A. sildenafil (Viagra)
B. tadalafil (Cialis)
C. vardenafil (Levitra)
D. avanafil (Stendra)

Taking a high dose of aspirin or ibuprofen causes:
A. an increase in the drug’s half-life.
B. enhanced renal excretion of the drug.
C. a change in the drug’s mechanism of action.
D. a reduction of antiprostaglandin effect.
Biotransformation effect of drugs, Phase I and Phase II reactions

Factors that Influence Metabolism (Biotransformation)
 Age
 Genetically determined differences
 Pregnancy
 Liver disease
 Time of day
 Environment
 Diet
 Alcohol
 Drug interactions
Drug metabolism utilizes two types of reactions that prepare and tag molecules for excretion:
 Phase I: oxidation, hydrolysis, or reduction to increase water solubility of drug molecules.
 Phase II: conjugation or union of drug molecule with water-soluble substance and more easily
excreted by the kidneys. So, the presence or activity of these enzymes can influence the patterns of
drug activity and the duration of actions for drugs.
Phase I Enzymes: Cytochrome P450 Isoenzymes
 The majority of drugs are metabolized in the liver by the hepatic isoenzymes.
 Cytochrome P450 isoenzymes
 CYP 450
 Most common 1A2, 2C9, 2C19, 2D6, 3A4 (3A3/4)
CYP 450 Enzymes
 There are developmental differences in the isoenzymes.
 There are genetic differences in isoenzymes.
 Some disease states alter isoenzyme activity.
 For example, cystic fibrosis has altered CYP 2D9 activity.
Phase I Enzymes: CYP 450
 The enzymes may be slowed (inhibited) or increased (induced).
 Concurrent therapy with an inhibitor or inducer may alter the metabolism of a medication.
Compared with a healthy 40-year-old adult, CYP 450 isoenzyme levels can decrease by ___% in elderly adults after age 70.
A. 10
B. 20
C. 30
D. 40
Effects of Nicotines on receptors

Nicotine is a stimulant drug found in cigarettes, cigars, pipe tobacco, and smokeless
tobacco. Nicotine is highly addictive. Nicotine reaches the brain within 8 seconds of
inhalation. Its effects on the body include increased heart rate and blood pressure,
increased alertness, and reduced appetite.
Nicotine and Neurotransmitters:

Nicotine disrupts the normal relationship between the neurotransmitter acetylcholine and the receptors
acetylcholine binds to. These changes in the brain, detailed here with diagrams, can lead to addiction.
Normal acetylcholine and receptors
Nicotine affects the neurotransmitter acetylcholine and its receptor, which is the major neurotransmitter of the
brain. This receptor is located in many brain structures and body organs. It carries messages related to
respiration, heart rate, memory, alertness, and muscle movement.
Property of drugs receptor agonists CH 2

 Drug-receptor binding is reversible.
 Drug-receptor binding is selective.
 Drug-receptor binding is graded.
 The more receptors filled, the greater the pharmacological response.
 Drugs that bind to receptors may be agonists, partial agonists, or antagonistic.
Agonist are drugs that produces receptor stimulation and a conformational change every time they bind. Do
not need all of the available receptors to produce a maximum response. Some agonist can produce their
maximum response by binding to less than 10% of the available receptors. The receptors that are left over
and not needed for a response are called spare receptors.
Principle of drug dosage in children compared to adults. CH 50

Pharmacokinetics of drugs in children may differ from adults for several reasons: variability due to age,
gender, body composition, functionality of liver and kidneys and maturation of enzymatic systems
throughout the life span from neonates to adults are all potential sources of pharmacokinetic differences.
Dermatology:
 Tacrolimus (Protopic): Side effects, Caution

Immunomodulator for Atopic Dermatitis, short term or intermittent long term Tx, second line of Tx
after topical corticosteroids.
Side effects:
Burning, pruritus, tingling, headache, fever, flu-like, acne, folliculitis
Caution: Black Box warning regarding rare malignancy.
- Causes cancer, not recommended in nursing mothers. Use sunblock.
- d/c is lymphadenopathy, pregnancy category c, contraindicated in children less
than 2 years old.
 Tetracycline drug/food interaction

Must be taking on an empty stomach, poorly absorbed if taken with calcium-containing foods, milk,
antacids. Pregnant category D do not prescribe to lactating women or children under age 8 (may
cause staining teeth.
 Corticosteroids routes/potency
Nonspecific anti-inflammatory effects. Absorption varies by drug and vehicle used
o Ointments more occlusive, so more potent
o Creams less occlusive, less potent
o Lotions least potent
o High dose or over large areas may cause systemic steroid effects
Lotions have the most water, Ointments the most occlusive
 Impetigo: Presentation, treatment of choice

Impetigo is a contagious skin infection that usually consists of discrete purulent lesions. Its peak
incidence is among children 2 to 5 years old, although older children and adults can also be affected.
Impetigo skin lesions are nearly always caused by the gram-positive organisms group A streptococci,
Staphylococcus aureus, or a mix of both.
When impetigo results in a few lesions, topical therapy is indicated with mupirocin (Bactroban or
Centany) as the preferred agent. Mupirocin use is associated with higher cure rates compared with oral
erythromycin, and both are noted to be superior to penicillin. Retapamulin (Altabax) ointment is also
an effective, albeit more expensive, therapeutic option. Bacitracin and neomycin are less effective
topical treatments; use of these products is not recommended for the treatment of impetigo
13. When prescribing tacrolimus (Protopic) to treat atopic dermatitis patients should be informed that:
A. Tacrolimus is the most effective if it is used continuously for 4 to 6 months
B. Tacrolimus should be spread generously over the affected area
C. The FDA has issued a Black Box warning about the use of tacrolimus and the
development of cancer in animals and humans
D. The FDA recommends patients be screened for cancer before prescribing
tacrolimus

2. Topical immunomodulators such as pimecrolimus (Elidel) or tacrolimus (Protopic) are used for:
A. Short-term or intermittent treatment of atopic dermatitis
B. Topical treatment of fungal infections (Candida)
C. Chronic, inflammatory seborrheic dermatitis
D. Recalcitrant nodular acne
When choosing a topical corticosteroid cream to treat diaper dermatitis, the ideal medication would be:
A. Intermediate potency corticosteroid ointment (Kenalog)
B. A combination of a corticosteroid and an antifungal (Lotrisone)
C. A low potency corticosteroid cream applied sparingly (hydrocortisone 1%)
D. A high potency corticosteroid cream (Diprolene AF)
___ 3. Long-term treatment of moderate atopic dermatitis includes:

A. Topical corticosteroids and emollients
B. Topical corticosteroids alone
C. Topical antipruritics
D. Oral corticosteroids for exacerbations of atopic dermatitis
The most cost-effective treatment for two or three impetigo lesions on the face is:
A. Mupirocin ointment
B. Retapamulin (Altabax) ointment
C. Topical clindamycin solution
D. Oral amoxicillin/clavulanate (Augmentin)
When choosing a topical corticosteroid cream to treat diaper dermatitis, the ideal medication would be:
A. Intermediate potency corticosteroid ointment (Kenalog)
B. A combination of a corticosteroid and an antifungal (Lotrisone)
C. A low potency corticosteroid cream applied sparingly (hydrocortisone 1%)
D. A high potency corticosteroid cream (Diprolene AF)

___ 3. Long-term treatment of moderate atopic dermatitis includes:
A. Topical corticosteroids and emollients
B. Topical corticosteroids alone
C. Topical antipruritics
D. Oral corticosteroids for exacerbations of atopic dermatitis
Clinical features of bullous impetigo include:

A. intense itch.
B. vesicular lesions.
C. dermatomal pattern.
D. systemic symptoms such as fever and chills.
25. The likely causative organisms of nonbullous impetigo

in a 6-year-old child include:
A. H. influenzae and S. pneumoniae.
B. group A streptococcus and S. aureus.
C. M. catarrhalis and select viruses.
D. P. aeruginosa and select fungi.
26. The spectrum of antimicrobial activity of mupirocin

(Bactroban) includes:
A. primarily gram-negative organisms.
B. select gram-positive organisms.
C. Pseudomonas species and anaerobic organisms.
D. only organisms that do not produce beta-lactamase.
27. An impetigo lesion that becomes deeply ulcerated is

known as:
A. cellulitis.
B. erythema.
C. ecthyma.
D. empyema.
28. First-line treatment of impetigo with less than

5 lesions of 1-2 centimeters in diameter on the legs
in a 9-year-old girl is:
A. topical mupirocin.
B. topical neomycin.
C. oral cefixime.
D. oral doxycycline.
Mental:
 TCAs: Contraindication (Tricyclic Antidepressants: Amitriptyline, clomipramine, imipramine,

desipramine, nortriptyline and doxepin.
Amitriptyline (Elavil). In patients with cardiovascular disease causes cardiac arrhythmias, hypotension.
TCAs, in particular, may be associated with dose-dependent increases in bleeding risk.
In patients with mod-high suicidal risk because of narrow therapeutic index.
In elderly patients due to their anticholinergic side effects.
 SSRI Drugs: Treatment with anticoagulant (drug/drug interaction for each drug)
Drugs in this class: Paroxetine (Paxil), fluoxetine (Prozac), sertraline (zoloft), fluvoxamine (Luvox),
citalopram (Celexa) and escitalopram (Lexapro).

Fluoxetine is most likely significantly interact with Warfarin.
Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro)

increased risk of bleeding through several different mechanisms, such as impairment of platelet
aggregation, depletion of platelet serotonin levels, and reduction in platelet count. The bleeding risk
associated with antidepressants is not dose-dependent for all classes
 Types of drugs that resemble general anxiety disorder

SSRIs and SNRIs can be used for GAD, PTSD, obsessive-compulsive disorder and panic attacks. They
usually take 2-4 weeks to provide the full therapeutic effect. Start all antidepressants low and going slow.
Buspirone seems to be especially effective with patients who have generalized anxiety disorder.
David is a 34 year old who is starting on paroxetine (Paxil) for depression. David’s education regarding his
medication would include:
A. Paroxetine may cause intermittent diarrhea
B. He may experience sexual dysfunction beginning a month after he starts therapy
C. He may have constipation and he should increase fluids and fiber
D. Paroxetine has a long half-life so he may occasionally skip a dose
Jamison has been prescribed citalopram (Celexa) to treat his depression. Education regarding how quickly
SSRI antidepressants work would be:
A. Appetite and concentration improve in the first 1 to 2 weeks
B. Sleep should improve almost immediately upon starting citalopram
C. Full response to the SSRI may take 2 to 4 months after he reaches full therapeutic
dose
D. His dysphoric mood will improve in 1 to 2 weeks
9. The laboratory monitoring required when a patient is on an SSRI is:

A. Complete blood count every 3 to 4 months
B. Therapeutic blood levels every 6 months after steady state is achieved
C. Blood glucose every 3 to 4 months
D. 
There is no laboratory monitoring required

10. Jaycee has been on escitalopram (Lexapro) for a year and is willing to try tapering off of the SSRI. What
is the initial dosage adjustment when starting a taper off antidepressants?
A. Change dose to every other day dosing for a week
B. Reduce dose by 50% for 3 to 4 days
C. Reduce dose by 50% every other day
D. Escitalopram (Lexapro) can be stopped abruptly due to its long half-life
2. An appropriate first-line drug to try for mild to moderate generalized anxiety disorder would be:
A. Alprazolam (Xanax)
B. Diazepam (Valium)
C. Buspirone (Buspar)
D. Amitriptyline (Elavil)
Which of the following SSRIs is most likely to significantly interact with warfarin?
A. citalopram
B. paroxetine

C. fluoxetine
D. sertraline
Which of the following describes prescriptions for antidepressant medications written by primary care providers?
A. dose too high
B. dose too low
C. excessive length of therapy
D. appropriate length of therapy
GU:
 UTIs in males
Increased risk with enlarged prostate
Medication of choice for prostatitis IM ceftriaxone followed by oral doxycycline.
 Pregnancy and UTIs

Asymptomatic bacteriuria
Routine screening during pregnancy
Need follow-up urine culture every 2 weeks until delivery.
 Antibiotic of choice for female uncomplicated UTI (consider drug allergy)

Empirical treatment with TMP/SMX (trimethoprim/sulfamethoxazole) is the first-line treatment
choice when no complicating factors are present.
Alternative first-line treatment is ciprofloxacin (in adults).
Alternate or second-line therapy is cephalosporins (cephalexin, cefpodoxime, cefixime).
Nitrofurantoin may be used.
 Patient education for Phenazopyridine

- You should not use phenazopyridine if you have kidney disease, tell your doctor if you have liver
disease, diabetes or genetic enzyme deficiency.
- Take phenazopyridine after meal.
- Drink plenty of liquids while you are taking this medication.
- This medication will most likely darken the color of your urine to an orange or red color and
may also cause stains to your underwear that may be permanent.
- Phenazopyridine can also permanently stain soft contact lenses, and you should not wear them
while taking this medicine.
- Store at room temperature away from moisture and heat.
Sarah is a 25-year-old female who is 8 weeks pregnant and has a urinary tract infection. What would be the
appropriate antibiotic to prescribe for her?
A. Ciprofloxacin (Cipro)
B. Amoxicillin (Trimox)
C. Doxycycline
D. Trimethoprim-sulfamethoxazole (Septra)
Juanita is a 28-year-old pregnant woman at 38 weeks gestation who is diagnosed with a

lower urinary tract infection. She is healthy with no drug allergies. Appropriate first-line
therapy for her UTI would be:

A. Azithromycin
B. Trimethoprim/sulfamethoxazole
C. Amoxicillin
D. Ciprofloxacin
9. Monitoring for a pregnant woman who has had a urinary tract infection is:
A. Symptom resolution in 48 hours
B. Follow-up urine culture at completion of therapy
C. “Test of cure” urinary analysis at completion of therapy
D. Follow-up urine culture every 2 weeks until delivery
Sally is a 16-year-old female with a urinary tract infection. She is healthy, afebrile, with no use of
antibiotics in the previous 6 months and no drug allergies. An appropriate first-line antibiotic choice
for her would be:
A. Azithromycin
C. Ceftriaxone
D. Levofloxacin
Jamie is a 24-year-old female with a urinary tract infection. She is healthy, afebrile, and her
only drug allergy is sulfa, which gives her a rash. An appropriate first-line antibiotic choice for
her would be:
A. Azithromycin
C. Ceftriaxone
D. Ciprofloxacin
General:
 Macrolides: The drugs in the class (erythromycin, clarithromycin, dirithromycin (dynabac),

azithromycin.
Clinical use and dosing
Drug of choice for community-acquired pneumonia (mycoplasma)
Chlamydia
Pertussis
H. Pylori infections (clarithromycin)
Chronic bronchitis
Rational drug selection
Often as alternatives for PCN allergies
Increasing resistance
Not appropriate for treating AOM or sinusitis
Pharmacodynamics: erythromycin
Inhibits ribonucleic acid (RNA)-dependent protein synthesis
Weak bases, activity increases in alkaline media.
Atypical and intracellular organisms commonly resistant to beta-lactam antibiotics are often
susceptible.
Cross-resistance seen to all in class
 OTC Meds: Caution, patient education, special population
Caution:
- Inacurate dosing: Toxic levels due to overdose.
 Acetaminophen toxicity: Overuse, Combination medications.
- Decongestant medications in infants/young children
 Infant drops removed from market, Relabeled not to use under age 4 years.
Patient education:
- Read label and follow label instructions.
- Ask pharmacist or provider about drug interactions.
- Educate that OTC medications are real medications and can have all the same adverse drug
reactions as prescription medications.
- Do not drive or operate machinery if you take sedating OTC medications.
 Antihistamine: Types, side effect for each type. (H1 receptors antagonists).
1st Generation 1940s-50s: Diphenhydramine, carbinoxamine, chlorpheniramine, cyproheptadine.
Side effect: Sedation and drowsiness, and reduce mental alertness.
2Nd Generation 1980s Nonsedating antihistamine: Relief to allergy sufferers without drowsiness.
 Pregnancy
 Pregnancy Categories B and C
 Children
 Fexofenadine: is not recommended for children <6 years.
 Loratadine: May be prescribed to children as young as age 2.
 Cetirizine and desloratadine syrup: 6+ months
Second-Generation Antihistamine Adverse Effects
 Drowsiness is greatly reduced
 Minimal incidence of dry mouth (≤ 5%)
 Symptoms from First-generation antihistamines can be alleviated by switching to second-
generation
 Treatment for fibromyalgia

The condition is one of the most common central pain-related syndromes. Symptoms sometimes
begin after a physical trauma, surgery, infection or significant psychological stress. Fibromyalgia is
four to seven times more common in woman than in men. The presence of rheumatoid arthritis or
lupus increases the risk for fibromyalgia.
Tx:
- Pharmacotherapy to reduce pain and improve sleep. (Acetaminophen and NSAIDS).
- Trazodone to improve sleep latency and duration.
- Physical activity, flexibility exercises, progressive stretching, low impact activities.
- Stress management.
- Getting sufficient sleep
- Healthy lifestyle, eating healthy foods, limiting caffeine intake.
171. Fibromyalgia is caused by:

A. increased production of serotonin.
B. an autoimmune reaction following infection.
C. a genetic autoimmune disorder that targets neuronal axons.
D. a largely unknown mechanism.
172. Which of the following statements is most consistent with fibromyalgia?

A. It is predominantly diagnosed in African Americans.
B. It affects less than 1% of the general population.
C. It is four to seven times more common in women than in men.
D. It is most often initially diagnosed in adults younger
than 20 years old and older than 55 years old.
173. Fibromyalgia is more common in patients with:

A. type 2 diabetes.
B. rheumatoid arthritis and systemic lupus erythematosus.
C. migraine headaches.
D. COPD.
174. Which of the following is inconsistent with the clinical presentation of fibromyalgia?
A. widespread body aches
B. joint swelling
C. fatigue
D. cognitive changes
175. The diagnosis of fibromyalgia involves:

A. a CT scan of the head.
B. MRI of various joints throughout the body.
C. identifying multiple tender points throughout the body.
D. a positive ANA or RF test result.
176. When examining a patient with fibromyalgia, tender points:

A. are located only above the waist.
B. can be identified by applying enough pressure to blanch the nail bed of the examiner.
C. are easily identified through radiography.
D. can wax and wane throughout the day.
177. A diagnosis of fibromyalgia requires detecting at least how many tender points?
A. 4
B. 7
C. 11
D. 18
178. When discussing physical activity with a 40-year-old woman with fibromyalgia, you advise that:
A. limiting exercise is an important component of symptom management.
B. weight-bearing exercise would be most helpful.
C. physical activity aimed at increasing flexibility is an important part of treatment.
D. although possibly helpful in minimizing pain, physical activity usually significantly worsens fatigue.
179. Analgesic approaches used in the management of fibromyalgia include all of the following except:
A. acetaminophen.
B. NSAIDs.
C. fentanyl patch.
D. topical capsaicin.
180. Drug classes used in the treatment of fibromyalgia include all of the following except:
A. tricyclic antidepressants.
B. antiepileptics.
C. SSRIs.
D. opioids.
181. Which of the following medications is approved by the U.S. Food and Drug Administration (FDA) for pain
management in a person with fibromyalgia?
A. trazodone
B. nortriptyline
C. pregabalin
D. gabapentin
182. Patients with fibromyalgia should be encouraged to all of the following except
A. consider adopting a high-intensity aerobic activity such as jogging.
B. limit caffeine use.
C. utilize stress management techniques.
D. participate in a program of exercise focused on maintaining flexibility.
 Coumadin:
Drug interactions
Many drug-drug interactions
Antiplatelet drugs
Thrombolytic drugs
Anticoagulant effect may be decreased by Oral contraceptives, carbamazepine, etc.
Drug/Food interactions: Vitamin K-containing foods.
Juanita had a DVT and was on heparin in the hospital and was discharged on warfarin. She asks her primary
care provider NP why she was getting both medications while in the hospital. The best response is to:
A. Contact the hospitalist as this is not the normal guideline for proscribing these two
medications and she may have had a more complicated case
B. Explain that warfarin is often started while a patient is still on heparin because
warfarin takes a few days to reach effectiveness
C. Encourage the patient to contact the Customer Service department at the hospital
as this was most likely a medication error during her admission
D. Draw anticoagulation studies to make sure she does not have dangerously high
bleeding times
The average starting dose of warfarin is 5 mg daily. Higher doses of 7.5 mg daily should be considered in
which patients?
A. Pregnant women
B. Elderly men
C. Overweight or obese patients
D. Patients with multiple comorbidities
For patients taking warfarin INRs are best drawn:

A. Monthly throughout therapy
B. Three times a week throughout therapy
C. Two hours after the last dose of warfarin to get an accurate peak level
D. In the morning if the patient takes their warfarin at night
12. When writing a prescription for warfarin it is common to write ____ on the prescription.
A. OK to substitute for generic
B. The brand name of warfarin and Do Not Substitute
C. PRN refills
D. Refills for 1 year
13. When prescribing NSAIDS, a complete drug history should be conducted as NSAIDs interact with
these drugs:
A. Omeprazole, a proton pump inhibitor
B. Combined oral contraceptive
C. Diphenhydramine, an antihistamine
D. Warfarin, an anticoagulant
 Treatment Goals for HIV:

- Achieve maximal suppression of plasma viral load for as long as possible.
- Delay the development of medication resistance.
- Preserve CD4 T-cell numbers.
- Confer substantial clinical benefits, leading to reduction in morbidity and mortality.
The goals of treatment when prescribing antiretroviral medication to patients with HIV include:
A. Prevent vertical HIV transmission
B. Improve quality of life
C. Prolong survival
D. All of the above

3. Predictors for successful treatment with antiretroviral therapy (ART) in HIV-positive patients include:
A. They respond to low potency treatment regimen
B. They have demonstrated resistance in the past and should respond to newer ART
drugs
C. The patient is strictly adherent to the ART treatment regimen
D. Lower baseline CD4 T-cell count at baseline
4. The goal of antiretroviral therapy (ART) in HIV-positive patients is:

A. Maximum suppression of HIV replication
B. Eradication of HIV virus from the body
C. Determining a treatment regimen that is free of adverse effects
D. Suppression of CD4 T-cell count
14. Successful antiretroviral therapy (ART) in an HIV-positive patient is determined by:

A. Being able to stop ART therapy due to HIV virus eradication
B. Lowering HIV viral load to unmeasurable amounts
C. Individual measures of success based on their personal situation
D. Normal blood hematologic factors
 NP prescriptive authority, NP prescription considerations
 Pernicious anemia: Treatment

Pernicious Anemia (PA): Also has a low HGB concentrations cause of vitamin B12 deficiency due a
lack of intrinsic factor. Other causes include gastrectomy and gastric atrophy of parietal cells
associated with type A chronic gastritis.
Tx: Oral, intramuscular (IM), and intranasal vitamin B12 replacement.
Nutritional deficit: 1,000 mcg/day of cobalamin is given until normal B12 levels usually in 6 to 12
weeks.
Pernicious anemia: vitamin B12 therapy 1,000 mcg IM daily for 1 week followed by 100 to 1,000 mcg
IM weekly for a month
Parental, nasal, or oral therapy may be used once a patient’s B12 levels return to normal.
Parenteral: 1,000 mcg of vitamin B12 IM monthly
Nasal: 500 mcg of cyanocobalamin weekly
Oral: 1,000 mcg daily (least expensive)
.
Patients with pernicious anemia require treatment with:
A. Iron
B. Folic acid
C. Epogen alpha
D. Vitamin B12
____ 21. The first lab value indication that Vitamin B12 therapy is adequately treating pernicious anemia
is:
A. Hematocrit levels start to rise
B. Hemoglobin levels return to normal
C. Reticulocyte count begins to rise
D. Vitamin B12 levels return to normal
____ 22. Patients who are beginning therapy with Vitamin B12 need to be monitored for:
A. Hypertensive crisis that may occur in the first 36 hours
B. Hypokalemia that occurs in the first 48 hours
C. Leukopenia that occurs at 1 to 3 weeks of therapy
D. Thrombocytopenia that may occur at any time in therapy
.
The dosage of Vitamin B12 to initially treat pernicious anemia is:
A. Nasal cyanocobalamin 1 gram spray in each nostril daily x 1 week then weekly x 1
month
B. Vitamin B12 IM monthly
C. Vitamin B12 1,000 mcg IM daily x 1 week then 1,000 mg weekly for a month
D. Oral cobalamin 1,000 mcg daily
 Bisphosphonates: Mechanism of action

reduce bone resorption by inhibiting osteoclast activity
No longer used for preventative therapy!
First-line therapy for postmenopausal women with osteoporosis
First-line therapy for men older than age 70 years with osteoporosis
Bisphosphonates treat or prevent osteoporosis by:
A. Inhibiting osteoclastic activity
B. Fostering bone resorption
C. Enhancing calcium uptake in bone
D. Strengthening the osteoclastic proton pump
_ 3. Prophylactic use of bisphosphonates is recommended for patients with early osteopenia related to
long-term use of which of the following drugs?
A. Selective estrogen receptor modulators
B. Aspirin
C. Glucocorticoids
D. Calcium supplements
 Polypharmacy and older adults

As polypharmacy is frequent in older adults, healthcare providers must consider any potential drug-drug
interactions; routine monitoring of renal and hepatic function is also recommended.
Gout:
 S/S, Treatment regimen (acute and maintenance)

Acute gout presents:
acute onset of pain, erythema, decreased range of motion, and swelling of involved joint
Colichine: Start at first sign of gout flare
Low-dose (1.2 mg then 0.6 mg 1 hour later)
Improvement in pain starts in 12 hours
Preventive dosing
1.6 mg 3 to 4 days a week or daily
Off-label uses
Hepatic cirrhosis, primary biliary cirrhosis, refractory idiopathic thrombocytopenic
purpura, scleroderma, familial Mediterranean fever
Antigout drugs reduce the inflammatory process or prevent the synthesis of uric acid.
Colchicine
Allopurinol Preventive drug of choice for patients with urinary calculi, chronic tophaceous
gout, or high serum urate levels. Allopurinol or febuxostat is best for patients who
overproduce uric acid. works for patients with renal dysfunction. is the drug of choice in
patients with high ruate and secondary gout.
Febuxostat is used for chronic gout in patient with hyperuricemia.
Uricosuric drugs- not for acute attacks
Probenecid (Benemid) is used for patients who overproduce urate Sulfinpyrazone
(Anturane).
Henry presents to clinic with a significantly swollen painful great toe and is diagnosed with gout.
Of the following, which would be the best treatment for Henry?
A. High-dose colchicine
B. Low-dose colchicine
C. High-dose aspirin
D. Acetaminophen with codeine
____ 2. Patient education when prescribing colchicine includes:

A. Colchicine may be constipating
B. Colchicine always causes some degree of diarrhea
C. Mild muscle weakness is normal

D. Moderate amounts of alcohol are safe with colchicine
____ 3. Larry is taking allopurinol to prevent gout. Monitoring of a patient who is taking allopurinol
includes:
A. Complete blood count
B. Blood glucose
C. C-reactive protein
D. BUN, creatinine, and creatinine clearance
____ 4. Phil is starting treatment with febuxostat (Uloric). Education of patients starting febuxostat
includes:
A. Gout may worsen with therapy
B. Febuxostat may cause severe diarrhea
C. He should consume a high-calcium diet
D. He will need frequent CBC monitoring

Study Guide For Final Pharmacology Hypertension

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Study Guide for Final Pharmacology

 Normal and abnormal based on JNC guidelines

 First line therapy / Second line therapy

 Best treatment for different race

 Best treatment with comorbidity including diabetes

 ACE therapy: Indications, mechanism of actions, S/E

ACE INHIBITORS (ACEIs) AND ARBs

■ Hypertension, diabetes (renal), chronic kidney disease (CKD), others.

Copyright © 2016 F. A. Davis Company

■ Hypertension with coexisting BPH.

ACE therapy: Indications, mechanism of actions, S/E

Mechanism of action: Inhibits angiotensin converting enzyme, interfering with conversion of

Copyright © 2016 F. A. Davis Company

– AV-block (second- to third-degree block)

Beta-Blockers (Beta Antagonists)

■ Propanolol immediate release (Inderal) or extended release (Inderal LA).

Copyright © 2016 F. A. Davis Company

Drug Class and Generic and Trade Names Contraindications

ACE Inhibitors Avoid potassium supplements

 ARBs: Treatment and Race

Beta Blockers: Propranolol (Inderal), atenolol(Tenormin), metoprolol (Lopressor),

Sildenafi l (Viagra) Do not mix with nitrates (nitroglycerine, isosorbide dinitrate)

 Loop diuretics: Side effect, labs

Combination: triamterene and HCTZ (Dyazide), amiloride and HCTZ

■ Hirsuitism, hypertension, severe heart failure

 Digitalis: Side effect, labs, toxicity, drug/drug interaction

■ Treats atrial fi brillation.

■ Signs and symptoms of digoxin overdose:

■ What laboratory test should be ordered if digoxin toxicity is suspected?

■ Potassium values (adult to elderly):

INR values below 2.0 increase stroke risk sixfold.

 Nitroglycerines: Dosage, Side effects, patient education

Copyright © 2016 F. A. Davis Company

 Serum cholesterol: Prevention

4. Patient teaching related to amlodipine (a Calcium Channel Blocker) includes:

13. Which of the following statements is true?

___ 4. Beta blockers treat hypertension because they:

Copyright © 2016 F. A. Davis Company

___ 13. Blood pressure checks in children:

Copyright © 2016 F. A. Davis Company

 Sulfonylureas:Indications: Manage type 2 diabetes. Used in combination therapy. For insufficient

Copyright © 2016 F. A. Davis Company

Drug Therapy Race/ethnic group

Copyright © 2016 F. A. Davis Company

3. Prior to prescribing metformin, the provider should:

___ 2. Type 2 diabetes is a complex disorder involving:

___ 3. Diagnostic criteria for diabetes include:

___ 4. Routine screening of asymptomatic adults for diabetes is appropriate for:

___ 6. Insulin is used to treat both types of diabetes. It acts by:

___ 9. The drug of choice for type 2 diabetics is metformin. Metformin:

___ 10. Before prescribing metformin, the provider should:

___ 13. Control targets for patients with diabetes include:

Copyright © 2016 F. A. Davis Company

___ 29. Drugs used to treat diabetic peripheral neuropathy include:

Copyright © 2016 F. A. Davis Company

 Best Bronchodilators for patients on BB

 ICS: Side effects, patient education (Beclomethasone, Budesonide (Pulmicort), Fluticasone.

Copyright © 2016 F. A. Davis Company

 COPD: First line of tx

 Community acquired pneumonia (CAP): antibiotic of choice for older adults

 Treatment of choice for antibiotic naives

 Rhinosinusitis: Types, first line therapy for each type

145. The most common causative bacterial pathogen in ABRS is: