2011 ACCP Clinical Pharmacy Challenge



2018 ACCP Clinical Pharmacy ChallengeLocal Competition Exam KEY Follow the instructions given by your local faculty member or proctor for each segment of the examination. Do NOT open your examination booklet until instructed to do so. The following examination will consist of three (3) main segments and an optional tie-break section: Trivia/LightningParticipants will have an opportunity to answer up to 15 true-false or multiple-choice questions. Each item answered correctly will be worth 75 points. The subject content for questions in this segment will be selected from the following categories:Pharmacology (including, but not limited to, mechanism of action, adverse effect profiles, drug interactions, dosing, approved indications, and monitoring parameters)Pharmacokinetics/Pharmacodynamics and/or PharmacogenomicsBiostatisticsHealth OutcomesClinical CaseParticipants will be presented with a clinical case vignette (500 words or less) and a series of five one-best-answer questions based on the information in the case text and/or supporting laboratory, physical examination, and/or medical history information contained therein. Point values for each question in this category will be assigned according to difficulty (one 100-point item, two 200-point items, and two 300-point items).Jeopardy-styleParticipants will have an opportunity to answer questions of varying point values (100, 200, or 300 points) in five predetermined categories and may answer as many questions as possible within the allotted time. All items in this segment will be multiple choice. Items in the segment will be selected from five (5) of the following categories:AnticoagulationAsthma/COPDBiostatisticsCardiovascular DisordersClinical Trial DesignCritical CareDermatologyEmergency MedicineEndocrinologyGeriatricsGI/Liver/NutritionHematology/OncologyImmunology/TransplantationInfectious DiseasesMen's HealthNephrologyPain and Palliative CarePediatricsPsychiatry/Central Nervous System DisordersRheumatologyVaccinationsWomen’s HealthCOPD = chronic obstructive pulmonary disease; GI = gastrointestinal.Tie-break OptionTwo fill-in-the blank items are provided. It is recommended that you have each student or team answer the tie-break options and use in grading as needed. In the unusual event that teams would remain tied after using the tie-breaker items, it is recommended that you use the total time completed to take the exam to break the tie (as is done in the online rounds of competition). Note the time when the exams are handed out, and then record the time when the student or team turns in their local exam.0175260Team/Individual ID______________________Total Score ________For Administrative Use Only00Team/Individual ID______________________Total Score ________For Administrative Use Only2018 ACCP Clinical Pharmacy ChallengeLocal Competition Examination KEYTrivia/Lightning SectionThis section consists of 15 items. Each correct answer is worth 75 points. Please circle your answer for each question.Question 1Which lab value would meet criteria to diagnose diabetes?A1C of 6.6% (SI 0.066))Fasting plasma glucose of 120 mg/dL (SI 6.7 mmol/L)2-hour plasma glucose of 175 mg/dL (SI 9.7 mmol/L) during an oral glucose tolerance test Random blood glucose of 187 mg/dL (SI 10.4 mmol/L)Answer: 1.A1C of 6.6% (SI 0.066) Rationale: Diabetes is typically diagnosed based on plasma glucose criteria, either fasting (≥ 126 mg/dL [SI 7.0 mmol/L]) or 2-hr plasma glucose during an oral glucose tolerance test (OGTT) (≥ 200 mg/dL [SI 11.1 mmol/L]), or A1c criteria (≥ 6.5% [SI 48 mmol/mol]). It can also be diagnosed in a patient with symptoms of hyperglycemia and a random plasma glucose of ≥ 200 mg/dL (SI 11.1 mmol/L). Of the lab values above, only the A1C of 6.6% meets these criteria.Citation: American Diabetes Association. Standards of medical care in diabetes – 2016. Diabetes Care 2016;39:Supplement 1. Available at . Accessed November 14, 2016.Question 2The antidepressant effect of which medication is due to inhibition of serotonin reuptake and agonist effects at the 5-HT1A receptor?Bupropion DuloxetineEscitalopramVortioxetine Answer: 4. VortioxetineRationale: Escitalopram is a selective serotonin reuptake inhibitor. Duloxetine is a serotonin-norepinephrine reuptake inhibitor. Bupropion is a norepinephrine and dopamine reuptake inhibitor. Vortioxetine enhances serotonergic activity in the CNS through inhibition of the reuptake of serotonin and 5-HT1A receptor agonism.Citation: Teter CJ, Kando JC, Wells BG. Major depressive disorder. In: DiPiro JT, Talbert TL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 9th ed. New York: McGraw-Hill, 2014: Chapter 51. 9e. Trintellix [package insert]. Deerfield, Il: Takeda Pharmaceuticals America, Inc., 2016.Question 3Which adverse effect is commonly associated with tacrolimus?LeukopeniaMouth ulcersNephrotoxicity ThrombocytopeniaAnswer: 3. NephrotoxicityRationale: Rationale: Nephrotoxicity is a serious and common adverse effect associated with calcineurin inhibitors, such as tacrolimus. Acute nephrotoxicity is due to renal vasoconstriction of the afferent arteriole (option 3 is correct). Mouth ulcers, leukopenia, and thrombocytopenia are associated with mammalian target of rapamycin inhibitors and not calcineurin inhibitors (options 1, 2 and 4 are incorrect).Citation: Citation: Johnson HJ, Schonder KS. Solid-Organ Transplantation. In: DiPiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York: McGraw-Hill, 2017:chap 50.Question 4 Which antibiotic has the greatest potential to cause encephalopathy if not dose adjusted in a patient with acute renal failure?Cefepime CefoxitinCeftarolineCeftriaxoneAnswer: 1. CefepimeRationale: Option A, cefepime, has FDA warnings about nonconvulsive status epilepticus in patients who do not receive adjustment in renal impairment. Data also exists stating cefepime is associated with encephalopathy in patients with existing renal impairment. Option B and C, while capable of seizures do not carry the same risk. Option D does not require renal adjustment.Citation: FDA Drug Safety Communication: Cefepime and risk of seizure in patients not receiving dosage adjustments for kidney impairment. Available at Drugs/DrugSafety/ucm309661.htm. Accessed: December 17th, 2016. Chatellier, D., M. Jourdain, J. Mangalaboyi, F. Ader, C. Chopin, P. Derambure, and F. Fourrier. 2002. Cefepime-induced neurotoxicity: an underestimated complication of antibiotherapy in patients with acute renal failure. Intensive Care Med. 28:214-217.Question 5 Which progestin has the greatest risk of hyperkalemia, especially if used with other medications also linked with hyperkalemia?DienogestDrosperinoneLevonorgestrelNorethindroneAnswer: 2. DrosperinoneRationale: Drosperinone is potassium-sparing progestin unlike the others; concomitant use with other medications that increase potassium will further increase the risk of hyperkalemia. The other progestins have not been linked to hyperkalemia.Citation: Facts & Comparisons eAnswers [Internet database]. Indianapolis, IN: Wolters Kluwer. Updated periodically.Question 6Which is the most appropriate treatment option for a treatment-naive patient with a diagnosis of mild ulcerative proctitis?Intravenous hydrocortisoneIntravenous infliximabOral budesonideMesalamime enema Answer: 4. Mesalamine enemaRationale: Option 4 is the correct answer. Mesalamine suppository is recommended in the treatment of mild ulcerative proctitis. Option 1 is incorrect since intravenous hydrocortisone is recommended in severe or fulminant disease. Option 2 is incorrect since infliximab is a treatment option for patients with moderate to severe active ulcerative colitis and for those patients with UC who are corticosteroid dependent. Option 3 is incorrect since oral budesonide is used in patients with mild to moderate ulcerative colitis.Citation: Hemstreet BA. Inflammatory Bowel Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; 2017. . Accessed January 13,2017 Kornbluth A, Sachar DB; Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010;105:501-23.Question 7 Which agent can cause drug-induced nephrogenic diabetes insipidus in up to 20% to 30% of patients?HydrochlorothiazideFurosemideLithium Valproic acidAnswer: 3. LithiumRationale: This is a well-known side effect of lithium and this is also the most common drug-induced cause of nephrogenic diabetes insipidus. Valproic acid has been associated with nephrogenic diabetes insipidus but the rate is significantly less than that of lithium. Hydrochlorothiazide and furosemide are not associated with nephrogenic diabetes insipidus.Citation: Perazella MA, Shirali A. Kidney Disease Caused by Therapeutic Agents. In: Gilbert SJ, Weiner DE, Gipson DS, et al. eds. National Kidney Foundations’ Primer on Kidney Diseases, 6th ed. Philadelphia: Elsevier Saunders, 2014: 326-336.Question 8Which intravenous hydromorphone regimen should be used in an opioid-na?ve adult patient as needed for pain?0.5 mg every six hours1.5 mg every six hours0.5 mg every three hours1.5 mg every three hoursAnswer: 3. 0.5 mg every three hours.Rationale: The most appropriate dosing interval for intravenous hydromorphone is every 2 to 3 hours. The most appropriate starting dose in an opioid-na?ve patient is 0.2 to 0.6 milligrams. Therefore, the most correct response would be 0.5 milligrams intravenously every three hours as needed for pain.Citation: Baumann TJ, Herndon CM, Strickland JM. Pain management. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw-Hill, 2014.Question 9 Which statistical test is best to determine risk factors that predict poor adherence to secondary prevention medications after acute coronary syndrome?ANOVAChi squareCorrelationRegression Answer: 4. RegressionRationale: Regression analysis examines the ability of one or more variables to predict another variable or construct a predictive model. Correlation examines the strength of association between two variables, but not how they will predict another variable/outcome. ANOVA evaluates continuous data and Chi square evaluates nominal data to find differences between groups, but neither is used solely to predict another variable/outcome.Citation: Sowinski KM. Biostatistics: A refresher. In ACCP Updates in Therapeutics 2015: The Pharmacotherapy Preparatory Review and Certification Course , 2015:1-445 – 1-466.Question 10 A patient has metastatic non-small cell lung cancer. Genetic testing of the tumor reveals an ALK rearrangement. Which agent is indicated?AfatinibCrizotinib ErlotinibNilotinibAnswer: 2. CrizotinibRationale: Crizotinib is indicated for metastatic non-small cell lung cancer (NSCLC) where an ALK rearrangement is detected. When the ALK-rearrangement is detected, it is a first-line recommendation according to national guidelines. Afatinib and erlotinib are indicated for metastatic NSCLC with EGFR mutations. Nilotinib is not used in NSCLC or associated with ALK rearrangements.Citation: National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer, v.3. 2017. . Accessed January 11, 2017. Xalkori [package insert.] New York, NY: Pfizer, 2016.Question 11 A patient is undergoing a non-emergent surgical rectal resection as part of treatment for colon cancer. Along with a mechanical bowel preparation, what would be the best surgical site infection prophylaxis regimen?Intravenous (IV) cefazolinIV ciprofloxacin and IV metronidazoleIV ertapenemOral neomycin, oral erythromycin, and IV ertapenemAnswer: 4. Oral neomycin, oral erythromycin, and IV ertapenemThe combination of oral and IV agents is preferred in colorectal surgeries as this has shown to decrease surgical site infection rates. Oral regimens should include neomycin with either erythromycin or metronidazole in the day prior to surgery if the surgery is not emergent. First generation cephalosporin monotherapy results in high surgical site infection rates due to poor anaerobic coverage. Intravenous ciprofloxacin and metronidazole or IV ertapenem would be reasonable alternative regimens, but do not include the oral regimen.Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283.Question 12 An 80-year-old man with an estimated creatinine clearance of 38 ml/min presents for medication review. Which oral medication exceeds the maximum recommended dose for this patient?Escitalopram 10 mg once daily Gabapentin 800 mg twice dailySpironolactone 25 mg once dailyZolpidem 5 mg once at bedtimeAnswer: 2. Gabapentin 800 mg twice dailyRationale: The maximum recommended dose of escitalopram for older adults is 10 mg/day. Gabapentin’s maximum dose with CrCl = 38 ml/min is 700 mg twice daily. The patient is currently at the recommended maximum dose of spironolactone and zolpidem.Citation: Lexapro[package insert]. St. Louis,MO: Forest Laboratories Inc, 2014.Neurontin [package insert] Parke-Davis Division of Pfizer Inc, NY, NY; 2009Question 13Which is the best oral anticoagulant regimen for a 60-year-old female who weighs 70 kg, is 5 feet 8 inches tall, has a serum creatinine of 1.1 mg/dL (SI 97.24 ?mol/L) and a past medical history of atrial fibrillation, hypertension and peripheral arterial disease?Apixaban 2.5 mg twice dailyDabigatran 75 mg twice dailyEdoxaban 60 mg once daily Rivaroxaban 10 mg once dailyAnswer: 3. Edoxaban 60 mg once daily Rationale: This patients CHADS2-vasc score is 3 (1 point each for female, hypertension, PAD) and is considered at high-risk for stroke requiring anticoagulation to prevent stroke and systemic embolism. Edoxaban 60 mg orally once daily is the appropriate dose for nonvalvular AF (NVAF) when CrCl is 51-95 mL/min. For apixaban dosing for NVAF, the patient does not meet any of the 3 criteria for dose reduction (SCr ≥ 1.5 mg/dL-No, Weight ≤ 60 kg- No, Age ≥ 80 years- No), thus the appropriate dose would be 5 mg orally twice daily rather than 2.5 mg orally twice daily. The patient’s ideal body weight is 63.9 kg. The patient’s actual body weight is 70 kg. It is not necessary to use the IBW in the C-G formula to estimate renal function for dosing DOACs. The estimated CrCl using the Cockroft-Gault formula and actual body weight is 60 mL/min. Dabigatran 150 mg orally twice daily is the appropriate dose for NVAF when CrCl > 50 mL/min rather than 75 mg orally twice daily, which is the dosage adjustment when CrCl < 30 mL/min or when CrCl 30-50 mL/min and receiving concomitant dronedarone or ketoconozole. Rivaroxaban 20 mg orally once daily is the appropriate dose for NVAF when CrCl > 50 mL/min, rather than 10 mg orally once daily, which is the dose for postoperative DVT prophylaxis in hip or knee replacement patients.Citation: LexiComp Online? [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information Inc. Updated periodically. Accessed January 11, 2017.Question 14 A study is designed to compare osteoarthritis hip pain relief on a 0-10 pain scale provided by treatment with naproxen (n=400) or magnesium salicylate (n=400) for 3 weeks followed by a 2 week washout period and then treatment groups will be switched to the other agent. What is the best statistical test for this design?Friedman's testMcNemar's testPaired t-testWilcoxon signed rank Answer: 4. Wilcoxon signed rankRationale: Wilcoxon signed rank is the correct answer because the pain scale is ordinal data with 2 groups that are matched. Friedman’s test would be appropriate if the data were ordinal with 3 or more groups that are matched. McNemar's test would be appropriate if the data were nominal. Paired t-test would be appropriate if the data were continuous.Citation: DeYoung GR. Biostatistics. Pharmacotherapy Webinar Review Course.2010Question 15Which treatment option for migraine headache is best for a pregnant patient regardless of trimester?DihydroergotamineIbuprofenMetoclopramide ProchlorperazineAnswer: 3. MetoclopramideRationale: Little data exists on treatment of migraine in pregnant patients. Acetaminophen, opioids, metoclopramide or corticosteroids can be used. Nonsteroidal anti-inflammatory drugs may be also used until the third trimester. Ergotamines and combination agents with caffeine and isometheptene are contraindicated in pregnant women. Prochlorperazine is not preferred in pregnancy as it may cause jaundice, extrapyramidal symptoms, and could lead to withdrawal symptoms in a newborn.Citation: Harrigan M, Felix AG. Headache. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.66675167005You have reached the end of the Trivia/Lightning Segment. Do Not Proceed until Instructed to do so.00You have reached the end of the Trivia/Lightning Segment. Do Not Proceed until Instructed to do so.right172085Team/Individual ID_______________ Trivia Segment Score ________For Administrative Use Only00Team/Individual ID_______________ Trivia Segment Score ________For Administrative Use Only2018 ACCP Local Competition Exam - Clinical Case SegmentThis segment consists of a case vignette and five items based on the vignette information.Clinical Case Segment History of Present Illness: 65-year-old man is being seen in clinic for chronic lower back pain (LBP). He had worked for the fire department for 30 years, but retired a year ago. He is currently on disability due to the chronic LBP. Current pain level is 8/10.Past Medical History: Diabetes type 2, hypertension, and post-herpetic neuralgiaSocial History: Married, heterosexual male. Does not drink, smoke or use recreational drugsCurrent Medications: Metformin 1000 mg orally twice a day, lisinopril 10mg orally daily, simvastatin 20 mg orally daily, ibuprofen 400 mg orally every 6 hours as needed, lidocaine patch 5% - 3 patches applied daily to his lower back (on for 12 hours and off for 12 hours) daily, Epinephrine pen as needed.Allergies: eggs-anaphylaxis; penicillin-rash; neomycin-anaphylaxis; peanuts-anaphylaxisVital Signs: BP 136/84mmHg; P 76 beats/minute; R 16 breaths/minutes; Pain Scale 8/10Ht 74 in (29cm); Wt 230 lbs (104.5kg)Lab Values: HbA1c 7.6 (SI 0.076); serum chemistries, CBC, liver panel and thyroid panel all within normal limits. Urine drug screen is negativeProcedure Data: not applicableOther Data: not applicableQuestion 1- 100 pointsPatient feels that the lidocaine patches work for his low back pain. What is the maximum number of patches that can be placed on a patient simultaneously?1234Answer: 3. 3 patchesRationale: The maximum number of Lidocaine patches that can be placed on a patient are 3 patches. However, the patches can be cut into smaller sizes if needed.Citation: Lidocaine patch[package insert]. Malvern, PA; Endo Pharmaceutical Inc. 2015.Question 2- 200 pointsThe patient comes to the pharmacy to get his herpes zoster vaccine. He is not having a current zoster outbreak. Which is correct regarding use of the vaccine in this patient?Give ShingrixGive ZostavaxDo not give either vaccine due to egg allergyDo not give either vaccine due to neomycin allergy Answer: 1. Give ShingrixRationale: Shingrix is the preferred herpes zoster vaccine and has no contraindication in patients with egg or neomycin allergy (Answer 1 is correct, answers 2, 3, and 4 are incorrect. Additionally, Zostavax is contraindicated in patients with a history of anaphylactic/anaphylactoid reaction to gelatin, neomycin, or any other component of the vaccine.Citation: Zostavax [package insert]. Whitehouse Station, NJ: Merck & CO. 2016Shingrix [package insert]. Research Triangle Park, NC . GlaxoSmithKline2017Dooling KL, Guo A, Patel M. et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR. January 26, 2018 / 67(3);103–108. Available at . Accessed March 2, 2018.Question 3 – 200 pointsThe patient was taken off of ibuprofen and switched to tramadol immediate-release, 50 mg orally every 6 hours. The switch has controlled the patient’s pain. What is the maximum dose of tramadol per day in this patient if pain control diminishes over time?200 mg300 mg400 mg 500 mgAnswer 3. 400mgRationale: The maximum daily dose for the immediate release formulation is 400mg. For patients >75 years of age, the max dose of immediate release is 300mg/day. The maximum dose of the extended release is 300mg/day. Renal and hepatic dosing exist for the immediate release form, but patient does not need renal or hepatic dosing adjustments.Citation: Tramadol hydrochloride [package insert] Raritan, NJ;ORTHO-McNEIL PHARMACEUTICAL, INC.2008Question 4- 300 points The patient switched providers and was placed on hydrocodone/acetaminophen 10/325 mg by mouth every 4 hours scheduled. He has been on this regimen for 2 months with adequate pain relief. His insurance requires him to switch him to morphine sulfate extended release as they won't cover his short acting treatment any longer. Assuming zero cross tolerance, what is the appropriate morphine dose?15 mg orally twice a day30 mg orally twice a day 45 mg orally twice a day60 mg orally twice a dayAnswer: 2. 30 mg twice dailyRationale: Patient is getting 60 mg of hydrocodone daily which is equivalent to 60 mg morphine daily per morphine equivalent dosing charts Assuming zero cross tolerance this would equate to a dose of morphine sulfate 30mg twice daily..Citation: Morphine Sulfate extended-release tablets [Package Insert]. Stamford, CT: Purdue. 2016Question 5- 300 pointsFive years later the patient has end-stage metastatic colon cancer and is having continued significant pain despite regular use of 100 mg of long-acting morphine sulfate every 12 hours. What is the maximum 24-hour dose of morphine sulfate that you may safely titrate up to in order to relieve this patient’s pain?360 mg480 mg600 mgNo limit, titrate to analgesia and tolerable side effects Answer: 4. No limit, titrate to analgesia and tolerable side effectsRationale: Because there is no therapeutic ceiling for morphine, extremely large dosages can be used safely and effectively if the drug is titrated properly.Citation: Morphine Sulfate extended-release tablets [Package Insert]. Stamford, CT: Purdue. 2016-60071099695Team/Individual ID_____________________________ Case Segment Score ________For Administrative Use Only00Team/Individual ID_____________________________ Case Segment Score ________For Administrative Use Only2018 Local Competition Exam - Jeopardy SegmentThis segment will consist of 15 items in five predetermined categories. Point values for each item are indicated below. Please circle your answer for each item.Cardiovascular DisordersQuestion 1- 100 points A 49-year-old man presents to the emergency department with significant swelling of the cheeks and lips. His tongue is enlarged and his respirations are increasing. The team is considering the use of icatibant. Which best describes its pharmacologic action?Antagonizes angiotensin receptorsAntagonizes bradykinin receptors Stimulates formation of C1-esterase inhibitorStimulates formation of ACEAnswer: 2. Antagonizes bradykinin receptorsRationale” Icatibant is a bradykinin B2 receptor blocker that has been used for hereditary angioedema and recently studied for ACE inhibitor inducted angioedema. Bradykinin is thought to play a role in the development of angioedema. The other choices do not describe mechanism that would block the actions of or reduce bradykinin.Micromedex? Healthcare Series [Internet database]. Greenwood Village, CO: Thomson Reuters (Healthcare). Updated periodically.Question 2- 200 points Which initial antiplatelet regimen is recommended for patients presenting with a non-ST segment myocardial infarction for whom an initial invasive or ischemia guided strategy is intended?Aspirin 81 mg and prasugrel 60 mgAspirin 81 mg and clopidogrel 300 mgAspirin 325 mg and ticagrelor 90 mgAspirin 325 mg and clopidogrel 600 mgAnswer: 4. Aspirin 325mg and clopidogrel 600 mgRationale: An initial aspirin dose of 162-325mg is recommended for all patients (Options 1 and 2 are incorrect). Because prasugrel is only indicated for patients who undergo primary PCI, its use in patients who may have a medical management strategy is not recommended (Option 1 is incorrect). The dose of ticagrelor is a treatment dose, dose a loading dose. (Option 3 is incorrect). Option 4 is the preferred therapy.Amsterdam, Ezra A., et al. "2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 64.24 (2014): e139-e228.Question 3 -300 points A 53-year-old woman (5'6", 75 kg) with NYHA class I heart failure with reduced ejection fraction is currently on furosemide 40 mg orally twice daily, ramipril 10 mg orally once daily, carvedilol 25 mg orally twice daily, digoxin 0.125 mg orally once daily, and spironolactone 12.5 mg orally once daily. She has been stable on this regimen for the past 4 months. Today her vitals are: BP 125/78 mmHg, HR 70 bpm, K 4.6 mEq/L (4.6 mmol/L), creatinine 1.5 mg/dL (SI 132.6 ?mol/L) today and 1.1 mg/dL (SI 97.2 ?mol/L) one month ago, and digoxin 1.2 ng/mL (SI 1.5 nmol/L). What intervention, if any, should be made?No changes are neededDecrease carvedilol to 12.5 mg twice dailyDecrease digoxin to 0.125 mg every other dayIncrease ramipril to 20 mg dailyAnswer: 3. Decrease digoxin to 0.125mg every other dayRationale: Option 3, decrease digoxin to 0.125 mg orally every other day is the correct answer. This patient's digoxin concentration is supratherapeutic and should be between 0.5-1.0 ng/mL. Levels greater than 1.0 ng/mL have been associated with an increase in mortality in patients with HFrEF. Therefore, the dose of digoxin should be decreased by 50%. Option 4 is incorrect because the ramipril is already at the target dose of 10 mg/day. No additional survival benefit would be obtained by further increasing the dose of ramipril. Option 2 is incorrect because this patient is not bradycardic or experiencing any signs/symptoms of worsening HF. Option 1 is incorrect because of the supratherapeutic digoxin level. If the level had been normal, one could make the argument to do nothing at this timeCitation: Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:e240-327.EndocrinologyQuestion 1- 100 points A female patient presents with proximal myopathy, spontaneous bruising, and menstrual irregularity. On physical examination, central obesity and hirsutism is noted by the medical provider. The patient’s presentation is most consistent with which of the following?Addison's diseaseAdrenal hyperandrogenismCushing's syndrome Primary hyperaldosteronismAnswer: 3. Cushing’s syndromeRationale: These clinical features are suggestive of Cushing's syndrome. While menstrual irregularity and hirsutism may overlap with other conditions (i.e., adrenal hyperandrogenism), central obesity is a distinguishing feature of Cushing's syndrome, compared to the other listed disease states.Citation: Arnaldi G, Angeli A, Atkinson AB, et al: Diagnosis and complications of Cushing’s syndrome: A consensus statement. J Clin Endocrinol Metab 2003;88:5593-5602.Question 2- 200 points A patient with an estimated glomerular filtration rate of 38 mL/min is on metformin for the treatment of type 2 diabetes. If the patient's renal function remains stable, what is the maximum oral dose of metformin?500 mg twice daily 850 mg twice daily1000 mg in the morning, 500 mg in the evening1000 mg twice dailyAnswer: 1.500 mg twice dailyRationale: Based on recent clinical trials and updates to the prescribing information, there have been changes to the metformin dosing in patients with mild-to-moderate renal insufficiency. Metformin in contraindicated in patients with a GFR< 30mL/min; It should not be initiated in patients with a GFR of 30-45mL/min, however, if a patient has been receiving metformin previously, and presents with a GFR of 30-45mL/min, then the patient can still receive metformin but at half the maximal dose. The maximum effective dose for metformin is 2000 mg/day for normal renal function; therefore, 500 mg orally twice daily would be the maximum dose of metformin for this patient. The other doses would be too high.Citation: Lipska KJ, Baily CJ, Inzucchi SE. Use of metformin in the setting of mild-to-moderate renal insufficiency. Diabetes Care 2011;34:1431-7.Question 3- 300 points A 70 kg, 55-year-old female is newly diagnosed with hypothyroidism. She does not have any cardiovascular disease. The most appropriate initial dose for full replacement of levothyroxine would be:75 mcg100 mcg112 mcg125 mcgAnswer: 112 mcgThe full replacement dose of levothyroxine is 1.6 mcg/kg/day. Based on the patient's history, full replacement dosing would be acceptable. Based on 70 kg, the exact amount of levothyroxine is 112 mcg. The other dosages listed are below or above the full replacement dose for this patient. Garber JR, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012 Nov-Dec;18(6):988-1028; Synthroid (levothyroxine) [prescribing information]. North Chicago, Il: Abbott Laboratories; June 2011.Infectious DiseasesQuestion 1- 100 points A patient comes to your urgent care clinic with a moderately severe, purulent leg cellulitis. The patient is on warfarin for stroke prevention secondary to a mitral valve replacement. The physician drains the abscess and would like to send the patient home with an antibiotic. You would suggest:Cephalexin twice daily for 7 daysDoxycycline twice daily for 5 days Oritavancin once over three hoursTrimethoprim-sulfamethoxazole twice daily for 7 daysAnswer: 2.Doxycycline twice daily for 5 daysRationale: Because this is a purulent skin infection, the most important aspect of care is incision and drainage of the abscess. However, in moderate to severe cases, empiric coverage of community-acquired methicillin-resistant S. aureus (CA-MRSA) is recommended. Cephalxin does not provide MRSA coverage. While oritavancin may be administered in the urgent care clinic, it may falsely elevate the PT/INR, confounding management of the patient’s warfarin. Trimethoprim-sulfamethoxazole represents a severe drug interaction with the patient’s warfarin which reliably and severely increases the INR via CYP2C9 inhibition. Doxycycline would likely provide coverage of CA-MRSA and rarely interacts with warfarin.Citations: 1) Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10-e52. 2) Micromedex? Solutions [Internet database]. Greenwood Village, CO: Truven Health Analytics, Inc. Updated periodically.Question 2 – 200 points A 35-year-old homeless female presents to the ED with vomiting in the morning for the fourth day in a row. Lab tests show that she is 4 weeks pregnant. A further work-up shows an elevated RPR ratio, leading to an additional diagnosis of syphilis that is assumed to be late latent. What treatment should be used for her syphilis?Aqueous crystalline penicillin G 3 MU intravenously every 4 hours for 10 daysBenzathine penicillin 2.4 MU intramuscularly (IM) onceBenzathine penicillin 2.4 MU IM weekly x 3 dosesProcaine penicillin 2.4 MU IM with oral probenecid, once daily for 10 daysAnswer: 3.Benzathine penicillin 2.4 MU IM, weekly x 3 dosesRationale: Pregnant patients are treated the same as non-pregnant patients for late latent syphilis. Benzathine PCN 2.4MU IM weekly x3 is recommended for late-latent syphilis. The once time treatment is reserved for primary and secondary syphilis. The aqueous and procaine PCN are reserved for neurosyphilis.Citation: STD Guidelines, MMWR / June 5, 2015 / Vol. 64 / No. 3, Pages 39, 40, 44Question 3- 300 points A 48-year-old man with a 20-year history of HIV has been on and off treatment for various reasons. He is known to be fully resistant to emtricitabine due to the M184V mutation. To which other antiretroviral agent is he also completely resistant?Lamivudine StavudineTenofovirZidovudineAnswer: 1. Lamivudine Rationale: The M184V mutation is known to cause complete resistance to emtricitabine and lamivudine. None of the other three medications listed are adversely affected by this resistance mutation.Citation: Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, DHHS Guidelines, July 2016, H-18 ()PediatricsQuestion 1- 100 points Which is the preferred first-line treatment approach for uncomplicated infant gastroesophageal reflux disease (GERD)?AntacidsHistamine-2 receptor antagonistProton pump inhibitorNon-pharmacologic/lifestyle changesAnswer: 4.Non-pharmacologic/lifestyle changesRationale: For uncomplicated disease, only lifestyle modifications including parental education, changes to feeding composition, frequency, and volume are considered necessary for management according to the NASPGHAN guidelines.Citation: Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49(4):498-547.Question 2- 200 points Which is the preferred antimicrobial therapy for eradication of initial Pseudomonas aeruginosa growth from an airway culture in a 4-year-old female with cystic fibrosis?Nebulized aztreonam three times daily for 28 daysNebulized colistin twice daily for 21 daysNebulized tobramycin twice daily for 28 days Oral ciprofloxacin twice daily for 21 daysAnswer: 3.Nebulized tobramycin twice daily for 28 daysRationale: Tobramycin inhaled twice daily for 28 days is the preferred regimen for treatment of initial or new growth of P. aeruginosa from airway cultures in patients with CF. Tobramycin was selected as first-line therapy based on available literature, as well as practical considerations, since colistin is not currently formulated for use as an inhaled therapy and has a higher potential toxicity profile. Inhaled antibiotic therapy is preferred for treatment of initial or new growth of P. aeruginosa from airway cultures in patients with CF. The addition of oral ciprofloxacin to inhaled therapies does not appear to provide additional benefit, and monotherapy with oral agents is not currently recommended. Given tobramycin has long standing experience and data in the pediatric population and especially those under age 7 years, aztreonam is not first-choice.Citation: Mogayzel PJ Jr, Naureckas ET, Robinson KA et al.; Cystic Fibrosis Foundation Pulmonary Clinical Practice Guidelines Committee. Cystic Fibrosis Foundation pulmonary guideline. pharmacologic approaches to prevention and eradication of initial Pseudomonas aeruginosa infection. Ann Am Thorac Soc. 2014;11(10):1640-50.Question 3- 300 points A 7-year-old male presents in the ED with shortness of breath, wheezing, RR 32 breaths/min, HR 130 beats/min, and O2 sat 85%. The patient receives albuterol and ipratropium nebulized treatments x 3, is started on intravenous methylprednisolone and oxygen supplementation, but remains symptomatic with little improvement. Which is the next step in managing this patient’s asthma exacerbation?Intravenous magnesium sulfate Intravenous terbutalineNebulized levalbuterolSubcutaneous epinephrineAnswer: 1.Intravenous magnesium sulfateRationale: Magnesium sulfate may be considered for patients with severe exacerbations not responding to initial therapies. Levalbuterol and albuterol are both short-acting bronchodilators. Initiating levalbuterol would be a duplication of therapy. Epinephrine is indicated in addition to standard therapy when the exacerbation is associated with anaphylaxis and angioedema. It is not routinely recommended for other asthma exacerbations. Terbutaline may be considered for asthma exacerbations in children ages 5 and younger, when bronchodilators cannot be given by inhalation or in cases where patients fail to clinically improve on other first line therapies (i.e., albuterol, ipratropium, systemic steroid, magnesium sulfate) and usually used in the critical care setting.Citation: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Accessed 19 Jan 2017 at: .RheumatologyQuestion 1-100 points A 46-year-old female with new onset joint pain and arthritis symptoms presents to her primary care provider for evaluation. During the patient visit, the provider is determining if the patient has osteoarthritis or rheumatoid arthritis. Which of the following is true?Morning stiffness associated with osteoarthritis lasts more than 60 minutes.Patients with osteoarthritis usually present with symmetrical joint involvement Obesity is a common risk factor for osteoarthritis. The peak age of onset in rheumatoid arthritis is > 65 years old.Answer: 3.Obesity is a common risk factor for osteoarthritis.Rationale: Obesity is a common risk factor for osteoarthritis (OA) due to the load bearing increases on the hips and knees. The peak age of onset for rheumatoid arthritis (RA)is 35-50 years old and over 50 for OA. Morning stiffness associated with OA usually lasts for less than 30 minutes and greater than 60 minutes for RA. Patients with RA usually present with symmetrical joint patterns of involvement. Patients with OA may present with symmetric or asymmetric patterns of joint involvement.Citations: 1) Bruce SP. Rheumatoid Arthritis. In: Chisholm-Burns MA, Schwinghammer TL, Wells BG, Malone PM, Kolesar JM, DiPiro JT, eds. Pharmacotherapy Principles & Practice, 4e. New York, NY: McGraw Hill, 2016. 2). Carris N, Smith SM, Gums JG. Osteoarthritis. In: Chisholm-Burns MA, Schwinghammer TL, Wells BG, Malone PM, Kolesar JM, DiPiro JT, eds. Pharmacotherapy Principles & Practice, 4e. New York, NY: McGraw Hill, 2016.Question 2- 200 points A 76-year-old male with chronic tophaceous gouty arthropathy presents for evaluation. Upon physical exam, he has multiple tophi. His serum uric acid is 10 mg/dL (SI 595 mmol/L), creatinine clearance is 30 mL/min, and blood pressure is 126/76 mmHg. Current medications include losartan 50 mg daily and allopurinol 200 mg daily. Which is the best therapeutic option?Discontinue allopurinol and initiate febuxostat 40 mg daily Increase allopurinol to 300 mg dailyIncrease losartan to 100 mg dailyInitiate pegloticase 8 mg every 2 weeksAnswer: 1.Discontinue allopurinol and initiate febuxostat 40 mg dailyRationale: The goal with this patient is to lower uric acid below 6 mg/dL (SI 357micromoles/L). The dose of allopurinol cannot be increased because of the patient’s renal function. The dose of losartan should not be increased because of his blood pressure. Pegloticase may be considered after maximizing therapy with xanthine oxidase inhibitors and uricosurics. Since the xanthine oxidase inhibitor therapy is not yet maximized, the best option is to discontinue the allopurinol and initiate febuxostat.Citation: Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res 2012;64:1431-46.Question 3- 300 points A 56-year-old female presents with rheumatoid factor negative rheumatoid arthritis (10 years, moderate severity), dyslipidemia and hypertension (5 years each). She is a nonsmoker. Current medications are methotrexate 15 mg once weekly, folic acid 1 mg daily, hydrochlorothiazide 25 mg daily, ibuprofen 800 mg 3 times daily as needed (used ~ once monthly), and prednisone 7.5 mg daily prn. She reports increasing symptoms over the last 2 months. Which of the following should be added?Abatacept 750 mg at 0, 2 and 4 weeks then every 4 weeksInfliximab 3 mg/kg at 0, 2 and 6 weeks, then every 8 weeks Rituximab 1000 mg x 2 doses given one month apartTocilizumab 8 mg/kg every 4 weeksAnswer: 2.Infliximab 3 mg/kg at 0, 2 and 6 weeks, then every 8 weeksRationale: If disease activity remains after methotrexate monotherapy, combination disease modifying therapy should be initiated. TNF inhibitors are typically the first class of biologics considered in RA. Rituximab is unlikely to be effective in this patient since she is rheumatoid factor negative; additionally, the dosage regimen is incorrect. There is less evidence to support use of tocilizumab ahead of the other disease modifying agents. Abatacept may be considered if she does not respond to the TNF inhibitor.Citation: Singh JA, Saag KG, Bridges L, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res 2016;68:1-26.00You have reached the end of the Jeopardy Segment. Do Not Proceed until Instructed to do so.You have reached the end of the Jeopardy Segment. Do Not Proceed until Instructed to do so.00Team/Individual ID_______________ Jeopardy Segment Score ________For Administrative Use OnlyTeam/Individual ID_______________ Jeopardy Segment Score ________For Administrative Use OnlyTie Break Round (Fill in the blank)Item 1A 32-year-old man was recently given a diagnosis of acute nonlymphocytic leukemia. His WBC is 48 x 103 cells/mm3 (SI 48 x 109/L), and he is initiated on high-dose chemotherapy and aggressive hydration with normal saline and allopurinol. Several days later, the patient’s uric acid concentration is 14 g/dL (SI 0.83 mmol/L). Which agent should be added to decrease this patient’s uric acid concentration (drug name only)?Answer: Rasburicase (Elitek)Rationale: This patient has tumor lysis syndrome from high-dose chemotherapy, despite aggressive hydration and allopurinol prophylaxis. The patient’s uric acid concentration is now extremely high, and he is at high risk of additional complications, including renal failure. Rasburicase, a recombinant product, may be used to catalyze the conversion of uric acid to allantoin, which is more soluble than uric acid and better for urinary excretion.Citation: Elitek [package insert]. New York: Sanofi-Aventis, 2003.Item 2A 54-year-old man presents to the clinic with complaints of erectile dysfunction. His medical history includes benign prostatic hypertrophy, hypertension, hyperlipidemia, hypothyroidism, and chronic kidney disease (stage 3). He has purchased yohimbine and asks if it is safe to use. Which two factors in his medical history preclude the use of yohimbine?Answer: Hypertension and chronic kidney diseaseRationale: Increased blood pressure is associated with yohimbine; therefore, this agent should not be used in this patient because of his underlying hypertension. In addition, yohimbine is not recommended in patients with underlying renal dysfunction because its use may worsen the underlying disease.Citation: American Urological Association (AUA). Guideline on the Management of Erectile Dysfunction. Available at education/guidelines/erectile-dysfunction.cfm. Accessed January 16, 2014.You have reached the conclusion of the 2018 ACCP Clinical Pharmacy Challenge Local Exam. Please follow the instructions of your faculty member or proctor.-247650179070Team/Individual ID_______________ Total Exam Score ________Tie Break Score (if needed) ________For Administrative Use Only00Team/Individual ID_______________ Total Exam Score ________Tie Break Score (if needed) ________For Administrative Use Only ................
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