Wikes University NSG 533. Advanced Pharmacology

Question 2

Wikes University NSG 533. Advanced Pharmacology. A 50-year-old man with a history of hypertension and long-standing uncontrolled type 2 diabetes comes to establish care. One year ago, he had a myocardial infarction (MI) and now has a left ventricular ejection fraction of 45%. He is currently taking the following medications:

• Metformin (Glucophage*)
• Aspirin 81 mg daily (Ecotrin*)
• Rosuvastatin (Crestor*)
• Metoprolol Succinate (Toprol Xl*)
• Quinapril (Accupril*)

Which of the following is the most appropriate medication to add to his current regimen to improve glycemic control and reduce cardiovascular risk?

• An SGLT2 inhibitor (e.g., empagliflozin) or a GLP-1 receptor agonist (e.g., liraglutide)
• A sulfonylurea (e.g., glipizide)
• A DPP-4 inhibitor (e.g., saxagliptin)
• A thiazolidinedione (e.g., pioglitazone)

Question 3

Case Study Exam Question:

James, a 58-year-old male with a 10-year history of type 2 diabetes, presents to the clinic for routine follow-up. He has a history of hypertension and chronic kidney disease. Recent laboratory results indicate the presence of albuminuria. His current blood pressure reading is 145/92 mm Hg. His 10-year ASCVD risk score is calculated at 18%.

Which of the following is the most appropriate blood pressure goal and initial antihypertensive therapy for James?

• Blood pressure goal < 130/80 mm Hg; initial therapy with an ACE inhibitor (or ARB)
• Blood pressure goal < 140/90 mm Hg; initial therapy with a calcium channel blocker
• Blood pressure goal < 130/80 mm Hg; initial therapy with a beta-blocker
• Blood pressure goal < 140/90 mm Hg; initial therapy with a thiazide diuretic

Question 4

SD is a 20 year old girl who has finally sought treatment for depression which she has had for several years. She started on fluoxetine (Prozac) two weeks ago, and is calling your office with extreme anxiety because she spent the day in tears and feeling worthless. What actions should you consider for SD today?

• Stop the antidepressant today
• Switch the antidepressant today
• Continue the antidepressant for several more weeks, consider a short term benzodiazepine
• Stop the antidepressant and consider a short term benzodiazepine

Question 5

Case: JH is a 67 year old man whom you see as a new patient in your ambulatory care clinic for persistent Afib, HTN, and type 2 DM. He has recently been exploring the possibility of ablation for his Afib as he is tired of taking medication for it, including amiodarone (Cordarone) and warfarin (Coumadin). He also feels fat, tired, and frustrated with the low salt diet the doctor put him on. His wife is complaining because he has outgrown his shirts and neckties. He just doesn’t feel like himself and wants you to figure out what is wrong with him.

What is the likely explanation for JH’s symptoms of lethargy and weight gain as it related to his medications?

• Drug induced hypothyroidism
• Thyrotoxicosis
• Parathyroid disease
• A drug allergy

Question 6

KF is a 68 year old white female who is newly diagnosed with DM 2. She is not currently on any medications, and she has an appointment with the nutritionist today. Her clinical information is as follows: height: 165cm, weight: 78kg, BP 142/88 (goal < 130/80), HR 76 (nl 60-100 bpm), Fasting Glucose: 189 mg/dl (nl <99 mg/dl), BUN: 18 mg/dl (nl 6-24 mg/dl), Creatinine: 1.1 mg/dl (nl 0.6-1.3), K: 4.1 mg/dl (nl 3.5-5 mg/dl), HgbA1C: 8.7 (goal < 7), TG: 260 mg/dl (<150 mg/dl), LDL: 196 mg/dl (nl 100-129 mg/dl). Her 10 year ASCVD risk is estimated to be ~ 39%. She has no concern for any bleeding risk.

After a comprehensive discussion with the patient of the benefits vs. risks, what medication(s) would you start at this patient’s visit today to manage the diabetes and prevent long term complications such as micro- and macro- vascular disease?

• Metformin (Glucophage)
• Metformin (Glucophage), lisinopril (Zestril), aspirin (St. Joseph’s Baby Aspirin), atorvastatin (Lipitor).
• Insulin and metformin (Glucophage)
• Sitagliptin (Januvia), because it produces weight loss

Question 7

HD is a 56 year old female who has been taking metformin (Glucophage*) 1000mg BID for 2 years for a “prediabetic state”. She has a history of pancreatitis and family history of medullary thyroid carcinoma. Despite this therapy, at her last clinic visit her fasting BS is found to be 189 mg/dl and her HgbA1C is found to be 9.2% and asymptomatic. Considering the patient is unwilling to use insulin (or other injectable medications) and her other risk factors, what would be the best change to make to her medication therapy?

• Stop metformin and start acarbose (Precose) 25mg TID with meals
• Continue metformin and add glipizide (Glucotrol XL ) 5mg once daily
• Stop metformin and start sitagliptin (Januvia) 50mg daily
• Continue metformin and add exenatide (Byetta) mcg SQ BID within 1 hr of AM and PM meal

Question 9

CASE: GK is 28 yo female who has been diagnosed with general anxiety disorder and depression. She is currently reporting excess fatigue, lack of appetite, worry, and anxiety x 4 months. She had initially been prescribed Alprazolam (Xanax) 0.5 mg QID PRN anxiety. She reports this helps a little but the symptoms reoccur and are affecting her social life.

QUESTION: GK visits her physician and begins taking citalopram. When can GK expect to feel the full effects of her new anxiety medication?

• 1-2 days
• 1-2 weeks
• 4-6 weeks
• 4-6 months

Question 10

Patient Background: Linda, a 35-year-old female, presents to the clinic with a 6-month history of persistent heartburn and regurgitation that worsens after meals and when lying down. She describes a burning sensation behind her breastbone, extending up towards her throat. Linda has tried using over-the-counter antacids and a two week course of therapy with on-demand famotidine (Pepcid OTC) with minimal relief. She has no significant past medical history but has a family history of gastrointestinal disorders.

Linda is interested in starting a more effective medication regimen to manage her symptoms and prevent further complications.

Question: Considering the effectiveness of various pharmacologic therapies for GERD, which of the following treatment options should be recommended next for Linda?

• Begin an antiemetic regimen.
• Continue with higher doses of antacids.
• Start a proton pump inhibitor (PPI).
• Continue treatment with a histamine-2 receptor antagonist (H2RA) like famotidine (Pepcid OTC)

Question 11

Sarah, a 35-year-old woman, presents to her primary care provider with symptoms of low mood, loss of interest in activities, fatigue, and difficulty concentrating for the past several weeks. She reports experiencing these symptoms nearly every day, and they have significantly impacted her ability to function at work and enjoy time with her family. Sarah denies any thoughts of self-harm or suicide. Upon assessment, her provider suspects she may be suffering from depression.

Question: Based on the provided information, what is the recommended first-line treatment for Sarah’s depression according to the guidelines?

• Tricyclic antidepressants
• Benzodiazepines
• Atypical antipsychotics
• Selective serotonin reuptake inhibitors (SSRIs)

Question 12

Patient Background: Mary, a 50-year-old woman, presents to the clinic with complaints of fatigue, weight gain, and cold intolerance. She reports feeling sluggish and has noticed dry skin and hair loss. Mary’s family history is significant for thyroid disorders, with her mother having been diagnosed with hypothyroidism.

Medical History:

• No known drug allergies
• Family history of thyroid disorders
• Otherwise healthy with no significant medical history

Mary undergoes thyroid function testing, which reveals elevated thyroid-stimulating hormone (TSH) levels and low free thyroxine (T4) levels, consistent with hypothyroidism.

Question: Considering the treatment options for hypothyroidism, which thyroid hormone product is the treatment of choice for almost all patients, mimicking the normal physiology of the thyroid gland?

• Synthetic levothyroxine (LT4)
• Synthetic triiodothyronine (T3)
• Desiccated thyroid extract (DTE)
• Liothyronine sodium (L-T3)

Question 13

In the treatment of patients with Major Depressive Disorder (MDD), the primary goal is solely the resolution of depressive symptoms and return to euthymia, with prevention of suicide and suicide attempts being of secondary importance.

• True
• False

Question 14

Case: JK is a 51-year-old woman experiencing severe vasomotor symptoms (hot flashes, night sweats, flushes), pain during intercourse, and mood swings that disrupt her work and relationship. Her medical history is significant for controlled HTN. She has no surgical history (intact uterus).

Question: What is the best course of action to follow for JK?

• Begin estrogen-only systemic hormone replacement for JK
• Begin combined estrogen/progesterone systemic hormone replacement for JK
• Begin topical estrogen vaginal cream (non-systemic) for JK
• Do not begin any new therapy for JK

Question 15

Case: FE is a 74-year-old man with erectile dysfunction (ED). His medical history includes HTN, CAD, status-post MI, and BPH. Current medications are Metoprolol succinate 100mg PO daily, Aspirin 81mg PO daily, and Dutasteride 0.5mg PO once daily.

Question: What is a reasonable change to make to FE’s medications given his new complaint of ED and assuming the prostate size is < 30g?

• Discontinue the Metoprolol succinate (Toprol XL)
• Stop dutasteride (Avodart) and begin tadalafil (Cialis) 5mg once daily
• Discontinue the Aspirin 81mg and begin clopidogrel (Plavix) 75mg daily
• Begin clonidine (Catapress) 0.1mg PO twice daily

Rationale: Dutasteride is a 5-alpha reductase inhibitor (5-ARI) used for BPH management but is frequently associated with sexual side effects, including ED. Since the patient’s prostate size is small (< 30g), a 5-ARI is less beneficial. Discontinuing dutasteride and initiating low-dose daily tadalafil (Cialis) 5mg is a logical approach, as daily tadalafil is FDA-approved to treat both ED and lower urinary tract symptoms secondary to BPH simultaneously.

Question 16

Question: Which one of the following statements is TRUE regarding ramelteon (Rozerem)?

• Ramelteon is a histamine antagonist
• Ramelteon has a cross-tolerance with alcohol
• Ramelteon causes significant next-day sedation and psychomotor impairment.
• Ramelteon is a melatonin agonist

Question 17

Question: All of the following are universal treatment goals in the management of diarrhea EXCEPT?

• Identify cause of diarrhea
• Maintain hydration
• Prevent electrolyte disturbances
• Stop diarrhea as soon as possible

Question 18

Question: On your way to this examination, you experience the vulnerable feeling that an attack of acute diarrhea is imminent! If you stop at a drug store, which of the following anti-diarrheal drugs could you buy without a prescription even though it is chemically related to the strong opioid analgesic meperidine (but acts only on the peripheral opioid receptor)?

• Loperamide (Imodium)
• Magnesium hydroxide (Milk of Magnesia)
• Bismuth Subsalicylate (Pepto-Bismol)
• Docusate sodium (Colace)

Question 19

Case: DD is a 67-year-old man with a long-standing history of Type 2 Diabetes (T2DM). His current regimen consists of maximum oral therapy: Metformin 2000mg daily, glyburide 10mg once daily, and sitagliptin 100mg daily. His current $HbA_{1c}$ is highly elevated at 11.2%, and lifestyle modification attempts have failed.

Question: What is the logical next step in his therapy?

• Add exenatide (Byetta)
• Stop the medications except for metformin and begin insulin glargine (Lantus) and insulin lispro (Humalog) as a basal-bolus regimen
• Add pramlintide (Symlin)
• Continue all medications and add insulin lispro (Humalog)

Question 21

Question: Which of the following is not a side effect associated with with anticholinergic medications such as tricyclic antidepressants?

• Dry mouth
• Urinary retention
• Diarrhea
• Blurred vision / Dry eyes

Question 22

Case: JO is a 30-year-old female with a history of Graves’ disease who has decided to undergo a total thyroidectomy because she would like to become pregnant in the next year.

Question: What, if any, thyroid drug therapy should she be maintained on after her surgery?

• Levothyroxine (Synthroid), and her dose during pregnancy is likely to be HIGHER than her eventual chronic dosing needs
• Levothyroxine (Synthroid), and her dose during pregnancy is likely to be LOWER than her eventual chronic dosing needs
• Liothyronine (Cytomel), because T3 is more effective than T4 replacement for

Question 23

Case: Carlos, a 50-year-old male, has nonerosive GERD. An endoscopy showed no signs of erosion. He has just completed an 8-week trial of a scheduled proton pump inhibitor (PPI) regimen and is now reporting significant improvement, with only occasional mild symptoms remaining. He is concerned about long-term use of medications.

Question: Based on Carlos’s positive response to the PPI trial for his GERD, what is the next best step in managing his condition for the long term?

• Switch to sucralfate (Carafate) four times a day before meals and at bedtime.
• Step down to the lowest effective dose of the PPI for maintenance therapy.
• Continue the current PPI at the same (high) dosage indefinitely.
• Discontinue the PPI and continue with lifestyle modifications only.

Question 24

Case: MD is a 26-year-old woman who is 6 weeks post-partum and is currently being maintained on Phenytoin 100 mg PO three times daily following an eclamptic seizure risk. She is also taking Amoxicillin for a sinus infection. She wishes to restart oral contraceptives using Ortho Tri-Cyclin Lo (25mcg ethinyl estradiol / 1mg norgestimate).

Question: What considerations do you have at today’s visit?

• She should be started on the lowest estrogen dose oral contraceptive available, as it will provide her with the best efficacy for birth control
• She should be informed of the potentially serious health problems associated with oral contraceptive use in women over the age of 25 and the Ortho-Tri_cyclen Lo should not be prescribed
• She should be cautioned about reduced effectiveness of the oral contraceptives because she is lactating, thus a second method of contraceptive should be used during this period
• She should be cautioned about reduced effectiveness of the BCPs due to the phenytoin and antibiotic, and should utilize >1 other methods of birth control concurrently until the medications are completed / discontinued

Question 25

Case: Mary, a 50-year-old woman with type 2 diabetes managed with diet, exercise, and metformin, presents with symptoms of hypoglycemia (shakiness, profuse sweating, confusion).

Question: Considering the typical symptoms and management of hypoglycemia, what is the appropriate initial step for Mary to take in managing her symptoms?

• Check blood glucose level, consume 15 grams of carbohydrate, wait 15 minutes, and retest.
• Administer an intramuscular injection of glucagon to rapidly raise blood sugar levels.
• Consume a high-protein snack to stabilize blood sugar levels.
• Wait for the symptoms to resolve on their own without intervention.

Question 26

Case: A 52-year-old postmenopausal woman presents with moderate-to-severe vasomotor symptoms (VMS) and genitourinary symptoms (vaginal dryness and discomfort). Her medical history is significant for hypertension and breast cancer.

Question: Which of the following treatment options would be most appropriate for managing her symptoms?

• Initiate paroxetine (Paxil, Brisdelle) and Over-The-Counter (OTC) vaginal lubricants
• Initiate replacement therapy with systemic estrogen alone
• Initiate combined estrogen-progestin hormone replacement therapy
• Prescribe low-dose vaginal estrogen cream alone Wikes University NSG 533. Advanced Pharmacology

Question 27

Question: Which of the following statements is true regarding the use of SGLT2 inhibitors in this patient’s treatment plan?

• SGLT2 inhibitors are only effective as monotherapy and should not be combined with metformin.
• SGLT2 inhibitors primarily work by increasing insulin secretion from pancreatic beta cells.
• SGLT2 inhibitors can be used as an add-on to metformin to help reduce A1c by 0.5% to 1%.
• SGLT2 inhibitors should not be used in patients with a history of hypertension and overweight due to increased risk of cardiovascular events.

Question 28

Question: Which of the following statements correctly describes the pharmacologic differences between uroselective and non-selective alpha-1 blockers in the treatment of BPH?

• Non-selective alpha-1 blockers (e.g., doxazosin [Cardura*], terazosin [Hytrin*]) block alpha-receptors in the prostate only.
• Non-selective alpha-1 blockers (e.g., doxazosin [Cardura*], terazosin [Hytrin*]) are preferred over uroselective agents as they are not likely to increase the risk of falls, syncope, and injury.
• Uroselective alpha-1 blockers (e.g., tamsulosin [Flomax*]) primarily target alpha-1A receptors in the prostate and bladder neck, minimizing effects on vascular smooth muscle.
• Uroselective alpha-1A blockers (e.g., tamsulosin [Flomax*]) cause significant blood pressure reduction.

Question 29

Question: Considering James’s need for aspirin, NSAID therapy and his history of gastric ulcers, which prophylactic treatment should be recommended to minimize his risk of NSAID-induced peptic ulcer disease (PUD)?

• Start an H2 receptor antagonist for gastric protection.
• Begin treatment with aggressive antacid therapy such as with Magnesium Hydroxide (Milk of Magnesia*).
• Begin treatment with a proton pump inhibitor (PPI) at standard doses.
• Prescribe a COX-2 selective inhibitor (e.g., Celebrex*) instead of traditional NSAIDs despite the associated cardiovascular risk.

Question 30

Question: What initial change do you want to make to her DM medications in light of worsening heart failure?

• Stop the repaglinide (Prandin).
• Start Metformin (Glucophage).
• Stop pioglitazone (Actos).
• Add bromocriptine.

Question 31

Considering the principles of insulin therapy for T1DM, which statement accurately describes the basal-bolus insulin approach?

• Basal-bolus insulin therapy replicates basal insulin response with intermediate- or long-acting insulin and bolus release of insulin with short- or rapid-acting insulin around meals.
• Basal-bolus insulin therapy aims to reproduce basal insulin response using short- or rapid-acting insulin and bolus release of insulin using intermediate- or long-acting insulin.
• Basal-bolus insulin therapy provides a fixed total daily dose of insulin without considering individualized patient factors.
• Basal-bolus insulin therapy involves using short-acting insulin for basal insulin requirements and long-acting insulin for bolus doses around meals. Wikes University NSG 533. Advanced Pharmacology

Question 32

Question: Which of the following medications would be considered the most effective initial treatment for her GERD?

• Omeprazole (Prilosec)
• Pantoprazole (Protonix)
• Dexlansoprazole (Dexilant)
• Any proton pump inhibitor (PPI) given at appropriate (standard) dose

Question 33

Question: Which of the following stimulant laxatives works by selectively acting on the nerve plexus of intestinal smooth muscle to enhance colonic motility?

• Polyethylene glycol (PEG)(Miralax*)
• Senna (Senokot*)
• Docusate sodium (Colace*)
• Bismuth Subsalicylate (Pepto-Bismol)

Question 34

Question: Considering the characteristics and preferences for antidepressants in treating anxiety, which class of antidepressants is generally preferred due to safety and tolerability?

• Tricyclic antidepressants (TCAs)
• Monoamine oxidase inhibitors (MAOIs)
• Selective serotonin reuptake inhibitors (SSRIs)

Question 35

Question: Which one of the following medications is the best treatment for ongoing (long term) therapy of GK?

• Sertraline (Zoloft*)
• Amitriptyline (Elavil)
• Bupropion (Wellbutrin)
• Lorazepam (Ativan)

Question 36

Statement: Bismuth subsalicylate (BSS) is thought to have antisecretory and antimicrobial effects and used to treat acute diarrhea. Although it passes largely unchanged through the GI tract, the salicylate portion is absorbed in the stomach and small intestine. For this reason, BSS should not be given to people who are allergic to salicylates, including aspirin. Patients taking BSS should be informed that their stool will turn black.

• True
• False

Question 37

Question: Which of the following is the most accurate counseling point?

• Ulipristal acetate (Ella*) is contraindicated in women with higher BMI because it is less effective than levonorgestrel (Plan B*) in this population.
• EC works by preventing implantation of a fertilized egg and should always be given, even if she is already pregnant.
• Missing pills in week 3 increases ovulation risk, so EC may be considered. Because of her BMI, ulipristal acetate (Ella*) would be preferred over levonorgestrel (Plan B*).
• Levonorgestrel EC (Plan B*) is equally effective in women of all body weights and is available only by prescription.

James, a 60-year-old man, presents to the clinic with complaints of chronic constipation. He reports infrequent and difficult bowel movements, often accompanied by straining and discomfort. James has tried increasing his dietary fiber intake and drinking more water without significant improvement. He is seeking guidance on managing his symptoms.

Medical History:

• No known drug allergies
• History of hypertension, well controlled with medication
• Sedentary lifestyle with minimal physical activity

James is interested in exploring different treatment options to alleviate his constipation.

Considering the properties and characteristics of stool softeners (e.g. Docusate sodium (Colace*), what is an important consideration regarding their effectiveness?

• Stool softeners have a rapid onset of action, typically within 12-24 hours.
• Stool softeners are best suited for the prevention and management of mild constipation because the onset of action is longer than with most stimulants laxatives, often taking up to 72 hours.
• Stool softeners are most effective in treating severe or chronic constipation of long duration.
• Stool softeners should be taken with a meal to enhance their effectiveness.

Question 39

Patient Background: Sophia, a 28-year-old woman, presents to the clinic with complaints of chronic anxiety. She reports feeling constantly on edge, experiencing difficulty concentrating, and having trouble falling asleep due to worrying thoughts. Sophia mentions that her symptoms have been ongoing for several months and are now significantly impacting her daily functioning.

Medical History:

• No known drug allergies
• No significant medical history
• Non-smoker, minimal alcohol consumption

After discussing long-term treatment options, the provider prescribes sertraline (Zoloft*) 50 mg daily. However, Sophia expresses concern about waiting several weeks for symptom relief and requests something to help with her anxiety in the meantime.

Which of the following is the most appropriate short-term treatment to manage Sophia’s acute anxiety symptoms while waiting for the SSRI to take effect?

• The antihistamine cetirizine (Zyrtec*)
• The anxiolytic Buspirone (Buspar*)
• The benzodiazepine Lorazepam (Ativan*)
• The SSRI Fluoxetine (Prozac*)

Question 40

A 62-year-old male presents to your clinic with complaints of frequent urination, nocturia, hesitancy, and weak urinary stream for the past 6 months. He denies any hematuria, dysuria, or urinary retention. On digital rectal examination, you note a moderate to severely enlarged prostate (55g). Based on the symptoms and the degree of prostatic enlargement, what is the most appropriate initial pharmacological management for this patient?

• Prescribe a combination of $\alpha$1-adrenergic antagonist and $5\alpha$-reductase inhibitor
• Initiate treatment with a $5\alpha$-reductase inhibitor alone
• Start treatment with an $\alpha$1-adrenergic antagonist alone
• Refer the patient for surgical intervention Wikes University NSG 533. Advanced Pharmacology

Question 41

Please choose the best definition for drugs which are considered pregnancy category “X” by the FDA

• Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, but there may be certain situations where benefit might outweigh the risk (life threatening or serious diseases where other drugs are ineffective or carry a greater risk).
• Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women or animal studies have indicated fetal risk, but controlled studies in pregnant women failed to demonstrate a risk
• Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters) and the possibility of fetal harm appears remote
• Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
• There is definite fetal risk based on studies in animals or humans or based on human experience and the risk clearly outweighs any benefit in pregnant women
  

Question 42

Miss Hartburnd is a 67 yo female who presents with a 2 month history of substernal burning and “sour taste” occurring 4-5 days/week mainly after a large or “spicy” meal. Her PMH is significant for hiatal hernia. Her home medications include a daily multiple vitamin and lorazepam (Ativan) for sleep. She has no medication allergies. She smokes cigarettes 1 ppd and drinks 2 glasses of wine with dinner.

What interventions would you want to make at today’s visit for Miss Hartburnd?

• Increase the lorazepam (Ativan) dosage
• Add Ibuprofen (Motrin) 800mg PO three times daily
• Add after dinner mints to each meal to reduce the bitterness of the reflux
• Stop the alcoholic drinks and ask the patient to stop smoking. Re-evaluate at subsequent visit.

Question 45

Sarah, a 40-year-old woman, presents to the clinic with complaints of chronic constipation. She reports infrequent bowel movements, difficult defecation, and a sensation of incomplete evacuation. Sarah has tried over-the-counter laxatives without significant relief and is seeking guidance on managing her symptoms.

Medical History:

• No known drug allergies
• Otherwise healthy with no significant medical history
• Sedentary lifestyle with minimal physical activity

Sarah is interested in exploring different treatment options to alleviate her constipation.

Considering the properties and potential adverse effects of bulk-forming laxatives, what is an essential precaution for patients taking these agents to avoid complications?

• Take bulk-forming laxatives with a meal to enhance their effectiveness.
• Use bulk-forming laxatives only in combination with other laxatives for maximum effect.
• Avoid consuming fluids while taking bulk-forming laxatives to prevent bloating.
• Consume sufficient fluid while supplementing with bulk-forming agents to prevent esophageal obstruction.

Question 46

Patient Background: John, a 58-year-old male, has just been diagnosed with type 2 diabetes mellitus (T2DM). His medical history includes chronic kidney disease (CKD), and a recent diagnosis of heart failure with reduced ejection fraction (HFrEF). His home medications include lisinopril (Zestril*) and furosemide (Lasix*). John reports that he leads a moderately active lifestyle.

Clinical Information: John’s lab results indicate an HbA1c of 7.8%. His blood pressure is well controlled, and his lipid profile is within normal limits, though his renal function is impaired.

Based on the current guidelines, which of the following treatment options is most appropriate for John as an initial therapy for his type 2 diabetes?

• Start metformin (Glucophage*) alone, as it is always considered initial therapy for type 2 diabetes due to its neutral effects on weight and cardiovascular profile.
• Initiate an SGLT2 inhibitor, considering his CKD and heart failure with reduced ejection fraction.
• Initiate a sulfonylurea to effectively reduce his HbA1c level.