Advanced Pharmacology

Question 1

Advanced Pharmacology. John is a 57yo Caucasian male who presents for a routine visit for his hyperlipidemia. His PMH includes hyperlipidemia and hypertension. John has no family history of heart disease. He is a current smoker (1 PPD x 45 years) and he currently takes quinapril (Accupril) 20mg daily. Vitals include BP 165/90 x 2, HR 84, EKG shows normal sinus rhythm. Weight 210 lbs, ht 5’10”. Fasting labs include K 5.1 [3.5-4], Cr 1.1 [<1.5], Total Chol 190 [<200], LDL 160 [<100], HDL 42 [<40-low,>60-high], TG 150 [<160]. 10 year calculated ASCVD risk is 22.1% (Pooled Cohort Risk Estimator). Which of the following medications would you suggest to start?

No medications required
Fenofibrate (TriCor) 48 mg po daily
Simvastatin (Zocor) 10 mg po daily
Rosuvastatin (Crestor) 20 mg po daily

Question 2

A 45-year-old female presents to the clinic with complaints of recurrent episodes of wheezing, coughing, and shortness of breath, especially at night and during physical activity. She reports a history of asthma since childhood, with worsening symptoms over the past few months despite using her albuterol inhaler as needed. On examination, she has audible wheezing and decreased breath sounds on auscultation. Based on the patient’s history and examination findings, the nurse practitioner diagnoses persistent asthma and recommends initiating long-term controller therapy. Which of the following medications is the preferred choice for long-term controller therapy in this patient?

Salmeterol (Serevent)
Theophylline (Theo-Dur)
Fluticasone (Flovent)
Montelukast (Singulair)

Question 3

Josina is a 65 yo AA woman presents to clinic feeling tired for the last 3 months. She is able to complete some light housework and cook her dinners, but she has difficulty breathing when doing more activity such as grocery shopping and walking up stairs. She sleeps on 2 pillows at night to help with her breathing.

PMH: Heart failure Heart failure with reduced ejection fraction (class III, stage C), hypertension and arthritis.
Physical exam: Edema of her feet and ankles (2+) with some crackles noted in the lungs on inspiration
Medications: HCTZ (Hydrodiuril) 12.5mg daily, and ibuprofen (Advil / Motrin) 200 mg BID for arthritis in knee.
Vitals: height 5’2″, 63kg, BP 134/84, HR 78, EF 35% per echocardiogram.

In light of Josina’s heart failure (HFrEF), which of the following is most appropriate regarding the use of ARNI (angiotensin receptor neprilysin inhibitor) OR ACEI (angiotensin converting enzyme inhibitor) OR ARB (angiotensin receptor blocker)?

An ARNI (angiotensin receptor neprilysin inhibitor) OR ACEI (angiotensin converting enzyme inhibitor) OR ARB (angiotensin receptor blocker) should not be used in patients with edema.
An ARNI (angiotensin receptor neprilysin inhibitor) OR ACEI (angiotensin converting enzyme inhibitor) OR ARB (angiotensin receptor blocker) should be started only if her symptoms do not improve with the optimal use of diuretics.
An ARNI (angiotensin receptor neprilysin inhibitor) OR ACEI (angiotensin converting enzyme inhibitor) OR ARB (angiotensin receptor blocker) should be started because it can improve morbidity and mortality in patients with left ventricular (LV) dysfunction
An ARNI (angiotensin receptor neprilysin inhibitor) OR ACEI (angiotensin converting enzyme inhibitor) OR ARB (angiotensin receptor blocker) should not be used in African Americans with heart failure because they are less effective than other therapies.

Question 4

In which of the following patients with COPD should an antibiotic be used?

In a patient with COPD with increased coughing, increased volume and purulence of sputum
In a COPD patient being given a “corticosteroid burst” because corticosteroids may depress the immune system
In a COPD patient who is on at least 2 medications who are not responding to treatment
In all patients with COPD in order to prevent further respiratory decline

Question 5

Which of the following is true regarding second generation antihistamines (e.g., Levocetirizine (Xyzal), cetirizine (Zyrtec))

They are used in the prophylaxis and treatment of motion sickness
They are included in over the counter (OTC) products as sleep aids Advanced Pharmacology
They are often referred to as non-sedating antihistamines (NSAs)
They readily cross the blood brain barrier (BBB)

Question 6

Which of the following is a contraindication to the use of spironolactone?

Hyperkalemia
Tachycardia
Hypomagnesemia
Bradycardia

Question 7

A 55-year-old male presents to the clinic for a routine check-up. His blood pressure measurements over the past three visits have consistently been elevated, with readings averaging 160/95 mm Hg. According to the 2017 ACC/AHA guidelines, which of the following pharmacologic approaches would be most appropriate initial therapy in this patient? Advanced Pharmacology

Delay pharmacologic therapy and reevaluate in six months. Initiate lifestyle modifications in the interim period
Initiate therapy with two (2) first line antihypertensive agents from different classes along with lifestyle modifications
Start therapy with a single (1) first line antihypertensive agent along with lifestyle modifications
Initiate anticoagulation such as apixaban (Eliquis) based on patients age and blood pressure

Question 8

What is the medical term for the symptom requiring a person to sleep more upright in order to feel comfortable breathing?

Pulmonary congestion
Hepatojugular reflux
Paroxysmal nocturnal dyspnea
Orthopnea

Question 10

A 32-year-old female presents to the clinic with complaints of sneezing, nasal congestion, and itchy, watery eyes during the spring season. She reports experiencing similar symptoms for the past few years during the same time of the year. On examination, the nurse practitioner notes clear nasal discharge and nasal mucosal erythema. Based on the patient’s history and examination findings, the nurse practitioner suspects seasonal allergic rhinitis (AR). Which of the following pharmacological agents is recommended as initial monotherapy for the treatment of nasal symptoms of seasonal allergic rhinitis?

Intranasal corticosteroid (INCS)
Intranasal antihistamine
Leukotriene antagonist
Oral antihistamine

Question 11

A 35-year-old male presents to the emergency department with complaints of worsening symptoms despite adherence to high-dose inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA) combination therapy. He is talking in single words, sitting hunched forward, and using accessory muscles for breathing. His peak expiratory flow (PEF) is 40% of predicted. According to current GINA guidelines, what is the most appropriate initial management for this patient?

Refer immediately for endotracheal intubation and mechanical ventilation
Determine the patients specific phenotype and begin therapy for a biological agent such as Anti-IgE Therapy, Anti-IL-5 Therapy, Anti-IL-4/IL-13 Therapy or Anti-TSLP Therapy
Add an oral leukotriene receptor antagonist (LTRA) to the patients current therapy and observe for improvement
Administer nebulized short-acting beta-agonist (SABA) with ipratropium bromide, start oxygen therapy, and systemic corticosteroids.

Question 15

Kern, 72-year-old male presented at the hospital complaining of severe pain in his left leg, shortness of breath, and pleuritic type chest pain following a long drive from Connecticut to Florida with minimal stopping. The patient had a history of pulmonary embolism, degenerative joint disease, and previously was a chronic smoker. His vital signs were: temperature 38.4 °C, pulse 98 bpm, respiratory rate 20 breaths per minute, and blood pressure 138/90 mm Hg. Basic metabolic panel and complete blood count values were within the normal range. Kern is diagnosed with a new DVT.

Kern is given an appropriate loading dose (bolus) of heparin (Half-Life ≈ 1.5 hrs) and started on a heparin infusion at an initial rate of 18 units/kg/hr. Six hours after starting the initial infusion, Kern’s aPTT is 37 seconds. (Institution-specific therapeutic range is 46-70 seconds).

What should be done?

Decrease infusion by 2 units/hr/kg to a new rate of 16 units/kg/hr. Re-evaluate the aPTT 1.5 hours after the start of the new rate
Rebolus with 40 units / kg once and increase the infusion rate by 2 units/kg/hr to a new rate of 20 units/kg/hr, Re-evaluate the aPTT 6 hours after the start of the new rate.
Rebolus with 80 units/kg once and keep the current rate of infusion the same. Re-evaluate the aPTT in 1.5 hours
Do nothing at this time. Re-evaluate aPTT at approximately the same time the following day

Question 16

A 67-year-old man presents for lipid management. His history includes a prior myocardial infarction, ischemic stroke 5 years ago, hypertension, and chronic kidney disease (eGFR 40 mL/min/1.73 m²). He takes maximally tolerated atorvastatin 80 mg daily. His baseline LDL-C was 140 mg/dL. Today, his LDL-C is 65 mg/dL. According to the 2022 ACC Expert Consensus Decision Pathway (ECDP), for patients at very-high-risk ASCVD of future events, what is his recommended LDL-C goal, and what is the most appropriate next step?

LDL-C goal <55 mg/dL; add ezetimibe
LDL-C goal <70 mg/dL; continue current therapy
LDL-C goal <40 mg/dL; add a PCSK9 monoclonal antibody
LDL-C goal <100 mg/dL; continue current therapy

Question 17

John is a 57yo Caucasian male who presents for a routine visit for his hyperlipidemia. His PMH includes hyperlipidemia and hypertension. He has no family history of heart disease. He is a current smoker (1 PPD x 45 years) and he currently takes quinapril (Accupril) 20mg daily. Vitals include BP 165/90 x 2, HR 84, EKG shows normal sinus rhythm. Weight 210 lbs, ht 5’10”. Fasting labs include K 5.1 [3.5-4], Cr 1.1 [<1.5], Total Chol 190 [<200], LDL 160 [<100], HDL 42 [<40-low, >60-high], TG 150 [<160]. 10 year calculated ASCVD risk is 22.1% (Pooled Cohort Risk Estimator).

Which of the following medications would you suggest to start?

No medications required
Fenofibrate (TriCor) 48 mg po daily
Simvastatin (Zocor) 10 mg po daily
Rousavastatin (Crestor) 20 mg po daily

Question 18

A 76-year-old woman with Stage C HFrEF (EF 24%) and CKD stage 3b presents with increasing fatigue and mild nausea for 3 days. She denies chest pain, dyspnea, or edema. On medication review, she notes taking spironolactone (Aldactone) 25 mg daily, carvedilol (Coreg) 12.5 mg twice daily, sacubitril/valsartan (Entresto) 49/51 mg twice daily, empagliflozin (Jardiance) 10 mg daily, and furosemide (Lasix) 20 mg daily. She also began naproxen (Naprosyn / Aleve) twice daily for knee pain three weeks ago.

Vital signs: BP 102/58, HR 58. Exam: Euvolemic, lungs clear, mild bradycardia, no edema. Labs: Na 136 [nl 136-145]; K 6.0 [nl 3.5-5]; Cl 100 [nl 3.5-5]; BUN 44 [nl 10-20]; Creatinine 2.0 (Pt’s baseline 1.5) [nl <1.5]; eGFR 27 [nl > 90]

Which intervention is MOST appropriate?

Hold spironolactone (Aldactone) and discontinue naproxen (Naprosyn / Aleve)
Replace sacubitril/valsartan (Entresto) with valsartan (Diovan) Only
Increase furosemide (Lasix) to enhance potassium excretion
Begin patiromer (Veltassa) and continue all medications

Question 19

Elise, a 67 yo woman presents with pain in her left thigh muscle, duplex ultrasonography indicates the presence of DVT in the affected limb. The decision was made to start heparin. During the next few days, the patient was also started on warfarin (Coumadin) and heparin was discontinued after attaining an INR of 2.2. Two months later, she returned after a severe nose bleed. INR was 9.1. To prevent severe hemorrhage, warfarin (Coumadin) should be held and patient treated with which of the following?

Phytonadione (Vitamin k) (Mephyton)
Aminocaproic acid (Amicar)
Protamine
Desmopressin (DDAVP)

Question 20

A 68-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic with persistent symptoms despite being on dual inhaled therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA). He reports frequent exacerbations, including episodes of increased dyspnea, cough, and sputum production, which require systemic corticosteroid treatment. His blood eosinophil count is 120 cells/μL. Based on current guidelines, what is the most appropriate next step in the management of this patient’s COPD?

Escalate therapy to triple inhaled therapy with LAMA/LABA/ICS
Initiate treatment with azithromycin (Zithromax)
Continue dual inhaled therapy with LAMA/LABA
Switch current therapy of long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA) to oral roflumilast (Daliresp) only

Question 21

Larry is a 60 year old male with symptomatic BPH, hypertension and moderately severe allergic rhinitis. His biggest complaint are nasal symptoms unrelieved by fexofenadine (Allegra), which he purchased over the counter.

Current medications:

Finasteride (Proscar) 5mg QD for benign prostatic hyperplasia (BPH)
Prazosin (Minipress) 1mg HS for benign prostatic hyperplasia (BPH)
Losartan (Cozaar) 50mg QD for hypertension Advanced Pharmacology

Which of the following choices would be the BEST approach for controlling Larry’s symptoms?

Oral diphenhydramine (Benadryl)
Oral pseudoephedrine (Sudafed)
Intranasal tetrahydrozoline (Afrin)
Fluticasone (Flonase) nasal spray

Question 22

PMH: Heart failure with reduced ejection fraction (class III, stage C) HTN, arthritis.
Physical exam: Edema of her feet and ankles (2+) with some crackles noted in the lungs on inspiration
Medications: HCTZ (Hydrodiuril) 12.5mg daily, and ibuprofen (Advil / Motrin) 200mg BID for arthritis in knee.
Vitals: height 5’2″, 63kg, BP 134/84, HR 78, EF 35% per echocardiogram.

Which of the following is/are accurate regarding the use of a beta-blocker (BB) in Josina?

A beta blocker, specifically metoprolol succinate, bisoprolol or carvedilol, should be initiated in Josina when she is clinically stable and euvolemic
All of the answers listed are correct
Josina’s symptoms may temporarily worsen when starting or increasing the dose of a beta-blocker
Beta blockers, specifically metoprolol succinate, bisoprolol or carvedilol, may reduce all-cause mortality regardless of age or gender in patients with heart failure with reduced ejection fraction Advanced Pharmacology

Question 23

Andrea, a 27 y/o F with a history of asthma, has followed your prescribed asthma treatment plan and is doing much better (she is well controlled). Concerned about using the lowest effective dose of medications and still maintaining control of the asthma, you decide to step down therapy. The current guidelines suggest this is possible because Andrea has been well controlled for at least how long?

Three weeks
One month
One Week
Three months

Question 24

Which of the following statements regarding warfarin (Coumadin) is correct?

Dose adjustments are made based on the INR and are calculated by increasing or decreasing the previous days dose by 5-20 %
Dose changes are usually evident in about 24 hours.
The target INR is 2-3 for most indications
In the elderly, those with CHF, who are debilitated, malnourished, or with elevated bleeding risk, the initial dose of warfarin should be 5-10mg for 1 or 2 days, then adjusted based on INR

Question 25

Michelle, a 35 y/o woman, is hospitalized for evaluation of severe chest pain, which occurs almost daily at about 5 AM. Michelle rates the pain as about a 7 /10. It is associated with diaphoresis and is not relieved by change in position or rest. She has no cardiovascular risk factors, her hobbies include triathlon competition and rock climbing, neither of which cause chest pain. She follows a strict vegetarian diet. Michelle is diagnosed with variant (Prinzmetal’s) angina. The next day Michelle is abruptly awakened by severe chest pain, which was relieved within 60 seconds by one 0.4mg SL NTG.

Which of the following agents would be appropriate to prevent her (now daily) symptoms?

Aspirin (St. Joseph’s Baby Aspirin)
Ramipril (Altace)
Diltiazem extended release (Cardizem CD)
Atenolol (Tenormin)

Question 26

Anthony is a 70yo male who presents with complaints of substernal chest pain (he ranked as a 5 out of 10) that occurred while doing yard work. His pain resolved after he rested. He feels frustrated because this problem is limiting him from getting exercise. His PMH includes hypertension for which he takes metoprolol (Lopressor) 12.5 mg BID. He takes no other medications and does not smoke. Vitals: BP 140/70, HR 72, RR 20, and EKG is normal sinus rhythm (NSR). Now with the diagnosis of angina, which is (are) the most appropriate recommendation(s) for Anthony at this time?

Add SL nitroglycerin (Nitrostat) ‘PRN’
All of the options listed are appropriate
Add aspirin 81mg daily
Add atorvastatin (Lipitor)
Increase metoprolol (Lopressor) to 25mg BID

Question 27

Edward is a 65 yo male with chronic kidney disease (CKD) and hypertension. Based on the 2017 ACC/AHA guidelines, which of the following is Edward’s BP goal?

< 140/90
< 120/80
< 130/80
< 150/90

Question 30

The use of metoprolol (Lopressor / Toprol XL), a cardioselective (also known as β1 selective) beta blocker, is absolutely contraindicated in patients with COPD (or asthma) despite any possible compelling indications (e.g. stable heart failure or IHD).

True
False

Question 31

Jonathan is a 72yo Caucasian male with a history of hypertension and stable angina. His home medications include chlorthalidone (Hygroton) 12.5mg daily, lisinopril (Zestril) 10mg daily, and amlodipine (Norvasc) 5mg once daily. His father died at age 50 of a heart attack. Recently he experienced episodes of chest pain so he was scheduled for an exercise stress test which supported a diagnosis of coronary artery disease (CAD). At his follow-up appointment, Jonathan’s BP is his normal of 130/68 but he has continued to experience chest pain during exertion. The pain resolves when he sits down.

He is very compliant with his heart healthy diet and exercise routine, but is concerned that this angina limits his ability to exercise and he started smoking 10 years ago after his sister died of pancreatic cancer, but is trying to quit. Jonathan weighs 165 lbs and is 5’9″ tall. Fasting labs include total cholesterol 155 [<200], HDL 50 [low-<40, high > 60], LDL 126 [<100], Triglycerides 168 [<160], BG 93 [75-115]. Other labs are all normal including LFT and CK. Which of the following recommendations are appropriate for Jonathan?

All of the answers listed are correct
Start atorvastatin (Lipitor) 40mg daily
Add aspirin 81mg daily
Add nitroglycerin SL (Nitrostat) PRN chest pain

Question 32

Tyson is a 50 yo black male with a past medical history significant for hypertension and a heart attack (resulting in reduced LVEF) one year ago. He is currently taking lisinopril (Zestril) and a higher dose of amlodipine (Norvasc). He says he is having ankle edema over the past couple months since amlodipine (Norvasc) was started. His kidney function is normal, and he has no other signs/symptoms of fluid accumulation (e.g. pulmonary congestion, weight gain). Tyson’s BP is 138/70, and HR 72. His laboratory values are normal. Considering not only hypertension, but his past medical history (prior MI / stable HFrEF) and most recent complaint (ankle edema), which of the following recommendations is most appropriate for Tyson to correct the edema and optimize heart failure therapy?

Add digoxin (Lanoxin)
D/C amlodipine (Norvasc); start metoprolol succinate (Toprol XL)
No changes are needed, Tyson’s therapy is already optimal
D/C lisinopril (Zestril); start candesartan (Atacand)

Question 33

A 45-year-old female presents to the clinic with complaints of persistent cough, wheezing, and shortness of breath. She has a history of asthma and reports that her symptoms have been worsening over the past few weeks despite using her albuterol inhaler as needed. The nurse practitioner decides to initiate inhaled corticosteroid (ICS) therapy to better control her asthma symptoms. Which of the following interventions is most effective in reducing the incidence of local adverse effects associated with ICS therapy?

Using the ICS without a spacer
Having the patient rinse the mouth with water and expectorate after using the ICS
Administering the ICS in high doses
Instructing the patient to swallow immediately after inhaling the medication

Question 36

Peter is a 48 year old man with hypertension, COPD, erectile dysfunction and stable but moderately intense angina with physical exertion. He typically fails to keep appointments and declines invasive diagnostic and therapeutic interventions. His hypertension has been poorly controlled until recently. His current medications include metoprolol (Toprol), ramipril (Altace), amlodipine (Norvasc), atorvastatin (Lipitor) and a nitroglycerin patch (Nitro-Dur) worn from 10AM to 10PM. He recently received tadalafil tablets (Cialis) for erectile dysfunction from a questionable internet pharmacy and wants to know how to use them safely. Which statement is true about the use of tadalafil (Cialis) in Peter? (Note: tadalafil inhibits phosphodiesterase for 36-48 hours)

Tadalafil (Cialis) is safe to use during the nitrate free window from 10PM to 10AM
Tadalafil (Cialis) is safe to use if Peter does not apply his nitroglycerin patch on the day of sexual activity
Tadalafil (Cialis) is unsafe and contraindicated due its long duration of action and Peter’s existing nitrate requirement for moderate ischemic disease. Combining therapies may result in severe and potentially life-threatening hypotension.
Tadalafil (Cialis) is unsafe and contraindicated because of bronchoconstriction from the nitrate & phosphodiesterase inhibitor combination

Question 37

Angela is a 79yo Caucasian female with a history of heart failure with reduced ejection fraction (HFrEF) and hypertension. Her BP is 142/76 and heart rate is 73 bpm. Medications include carvedilol (Coreg) 25mg twice daily, lisinopril (Zestril) 40 mg daily, Empagliflozin (Jardiance) 10mg daily and furosemide (Lasix) 40 mg daily. She has been fairly compliant with the recommended lifestyle modifications. Angela returns to your clinic 2 months later with a new complaint of a dry cough. Her lungs are clear, weight and labs are unchanged, and she has no other symptoms. Which of the following is most appropriate?

Increase furosemide (Lasix) to 60mg daily.
Switch carvedilol (Coreg) to Propranolol (Inderal) 10mg four times a day
Add dextromethorphan (Delsym / Robitussin DM) (cough suppressant) 10-20mg every 4 hours.
Switch lisinopril (Zestril) to losartan (Cozaar) 50mg daily.

Question 38

TS is a 63-year-old woman with a past medical history of hypertension, diabetes, dyslipidemia and chronic stable angina treated with aspirin 81 mg PO once daily, metoprolol succinate (Toprol xl) 100 mg PO once daily, rosuvastatin (Crestor) 40 mg PO once daily, sublingual nitroglycerin (Nitrostat) as needed and metformin (Glucophage) 500mg BID. Her angina symptoms are currently well controlled (ie. no limitations to activities of daily living) as is her diabetes (ie A1c. 6.8%). Her blood pressure is 148/90 mm Hg, and her pulse is 55 beats/min. Based on GDMT (guideline directed medical therapy), what is the most appropriate addition to therapy to optimize TS’s regimen?

Add ramipril (Altace)
Add verapamil SR (Calan SR)
Add isosorbide mononitrate SR (Imdur)
No changes are needed. Therapy is optimized

Question 39

Minnie is a 72yo Caucasian woman who presents for a follow-up appointment. Her past medical history includes ischemic stroke. Medication use at home only includes aspirin 81mg daily. Her BP at the last visit and today averages 168/98 mmHg (Stage II hypertension) with a heart rate of 58 bpm. Minnie lives alone, but walks most days of the week for about 30 minutes. She eats eggs with bacon for breakfast and mostly pre-packaged frozen food for lunch and dinner and will eat a sandwich at Long John Silvers usually 1-2 times weekly. She smokes 1 ppd, and denies alcohol use. Which of the following recommendations is most appropriate for Minnie?

Initiate lifestyle modifications without drug therapy for 6 months, then reassess.
Start lisinopril (Zestril) and hydrochlorothiazide (Hydrodiuril).
Start lisinopril (Zestril) and clonidine (Catapres).
Start chlorthalidone (Hygroton) and hydrochlorothiazide (Hydrodiuril).

Question 41

A high-intensity statin regimen is capable of lowering LDL cholesterol by how much on average?

Greater than or equal to 30%
Greater than or equal to 20%
Greater than or equal to 70%
Greater than or equal to 50%

Question 42

Emily is an 76 yo female who was recently discharged from the hospital for an exacerbation of heart failure (HFrEF). She was discharged 4 weeks ago with the following medications: enalapril (Vasotec) 10 mg BID, furosemide (Lasix) 40 mg BID and spironolactone (Aldactone) 25 mg daily. Her PMH includes heart attack and heart failure (LVEF < 35%). Her current BP is 134/84 mmHg and heart rate is 89 bpm. She is currently stable with no additional symptoms and daily weights remain unchanged. What is your recommendation to optimize therapy?

Add valsartan (Diovan) 80mg once daily.
No changes are needed.
Add bisoprolol (Zebeta) 2.5mg and hydrochlorothiazide 6.25mg (Ziac) once daily.
Add carvedilol (Coreg) 3.125mg BID (and titrate, as tolerated, to target dose)

Question 43

All of the following statements are correct except?

ACE inhibitors (or ARBs or ARNIs) may be associated with a “first dose phenomenon” (i.e. Orthostasis)
ACE inhibitors are indicated in NYHA class I and II HF only
ACE inhibitors (or ARBs or ARNIs) are titrated to target or maximally tolerated doses in HFrEF
Monitoring of ACE inhibitor therapy (or ARBs or ARNIs) should include BUN, SCr and potassium

Question 44

Andrea, a 27 y/o female with a history of asthma, presents with worsening of symptoms. After a review of symptoms (ROS), you find the symptoms have been present on a daily basis, they are causing nocturnal awakening about twice a week, and SABA is being used multiple times a day, but no additional therapies are being used. How should Andrea be managed after the resolution of this “flare”?

Continue monotherapy with Albuterol (Proventil / Ventolin) as needed. No other changes are necessary.
Regular use of intranasal corticosteroid (INCS) + leukotriene receptor antagonist (LTRA)
Low dose ICS-formoterol maintenance and reliever therapy (SMART)
Salmeterol + theophylline

Question 45

Lynette is a 68 yo female who presents to your clinic for a follow up appointment after her recent heart failure diagnosis. She complains of weakness, loss of appetite, and she is seeing a blue/green halo. Her daughter comments that she has appeared confused over the past day or so. Which medication may be causing these side effects?

Ramipril (Altace)
Verapamil (Calan / Verelan)
Digoxin (Lanoxin)
Carvedilol (Coreg)

Question 46

Tess is a 55yo African American female with a PMH of HTN, DM and hyperlipidemia. She weighs 175 lbs and is 5’4″ and sometimes eats processed foods and admits to having trouble with portion control. Tess does not exercise regularly and she does not smoke. Her mother had a MI at the age of 70. Her fasting lipid profile shows TC 200 [<200], LDL 134 [<100], HDL 42 [low<40, high >60], TG 180 [<160]. All other labs are normal. Her physician started her on simvastatin (Zocor) 20mg daily. After 1 week, her legs started to ache. Which of the following labs would you want to run to investigate the severity of her muscle aches and rule out rhabdomyolysis?

C-reactive protein (CRP)
Liver function tests (LFTs)
Serum Potassium
Creatine kinase (CK)

Question 47

Which medication has demonstrated an increased risk of severe asthma exacerbations and asthma-related death when administered as monotherapy in asthma?

Salmeterol (Serevent)
Fluticasone (Flovent)
Fexofenadine (Allegra)
Albuterol (Proventil / ProAir) MDI

Question 48

A 67 yo woman presents with pain in her left thigh muscle, duplex ultrasonography indicates the presence of DVT in the affected limb. The decision was made to start enoxaparin (Lovenox). Relative to unfractionated heparin, enoxaparin (Lovenox)…

Is more likely to cause thrombosis and thrombocytopenia
Is associated with teratogenicity
Is more likely to be given intravenously (IV)
Can be used without monitoring of the patients aPTT

Question 49

Louise is an older, but active 79yo African American woman who presents to the clinic with intermittent chest pain. The stabbing pain occurs with activity, but quickly subsides with rest. She ranks the pain as a 4 out of 10. She would like to be able to continue her activity without experiencing chest pain. Louise sticks to a healthy diet and exercises regularly and is a lifetime nonsmoker. Her cardiologist has recommended medical therapy for her angina. Her PMH includes hypertension and hyperlipidemia. Medications include ramipril (Altace) 5mg daily, aspirin 81mg daily, atorvastatin (Lipitor) 10mg daily, bisoprolol (Zebeta) 5mg daily and SL nitroglycerin (Nitrostat) PRN. Her BP is 140/88 (consistent over the last 2 visits), HR 74 bpm and EKG shows a normal sinus rhythm. Pertinent labs include total cholesterol 142 [<200], TG 145 [<160], HDL 45 [low<40, high>60], LDL 68 [<100]. Which of the following is the best recommendation regarding Louise’s dyslipidemia management?

Start fenofibrate (Antara / Tricor) 43mg once daily for triglyceride lowering
No changes are needed
Discontinue atorvastatin (Lipitor)
Add ezetimibe (Zetia) 10mg daily for additional LDL lowering

Question 50

A 71-year-old woman comes into the ED complaining of exertional chest pain. She currently takes atenolol (Tenormin) 50 mg PO daily, amlodipine (Norvasc) 5 mg PO daily, ramipril (Altace) 10 mg PO daily, aspirin (Bayer Baby Aspirin) 81 mg PO daily, and rosuvastatin (Creastor) 10 mg PO daily. Which monitoring parameters are needed for you to make a recommendation to relieve her angina symptoms?

Heart rate and potassium
Blood pressure and renal function
Heart rate and renal function
Blood pressure and heart rate

Advanced Pharmacology, Pharmacology

Isaura K

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