AANP Chronic Disease Management 1 — Questions and Answers
Question 1: A 58-year-old patient with type 2 diabetes has an HbA1c of 8.9%. Current treatment is metformin 1000 mg twice daily. Which is the most appropriate next step?
- Add a GLP-1 receptor agonist (Correct answer)
- Switch to insulin glargine monotherapy
- Reduce metformin dose and recheck in 6 months
- Refer to endocrinology before any change
Correct answer: Add a GLP-1 receptor agonist
Adding a GLP-1 receptor agonist to metformin is guideline-recommended when HbA1c remains above goal; it provides cardiovascular and weight benefits with low hypoglycemia risk.
Question 2: A patient with stage 3 chronic kidney disease (eGFR 42 mL/min) and type 2 diabetes asks about medication adjustments. Which agent requires dose reduction or avoidance at this eGFR?
- Metformin (Correct answer)
- Sitagliptin
- Glipizide
- Dulaglutide
Correct answer: Metformin
Metformin is contraindicated when eGFR falls below 30 and requires caution/dose reduction between 30–45 mL/min due to risk of lactic acidosis.
Question 3: A 65-year-old with COPD is on a short-acting bronchodilator PRN. Spirometry shows FEV1/FVC < 0.70 and FEV1 55% predicted. He reports two exacerbations in the past year. What is the most appropriate maintenance therapy?
- Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) (Correct answer)
- Inhaled corticosteroid (ICS) monotherapy
- Oral theophylline
- Short-acting beta-agonist scheduled four times daily
Correct answer: Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA)
GOLD guidelines recommend dual bronchodilation with LAMA+LABA for COPD group E patients (high symptom burden and ≥2 exacerbations), with ICS added only if eosinophils are elevated.
Question 4: A patient with heart failure with reduced ejection fraction (HFrEF, EF 35%) is already on an ACE inhibitor and beta-blocker at target doses. Which additional medication has been shown to reduce mortality in this patient?
- Spironolactone (Correct answer)
- Amlodipine
- Digoxin
- Hydralazine alone
Correct answer: Spironolactone
Aldosterone antagonists such as spironolactone reduce mortality in HFrEF when added to ACE inhibitor and beta-blocker therapy, per the RALES trial.
Question 5: A 72-year-old patient with hypertension and stage 3a CKD has a blood pressure of 148/88 mmHg on amlodipine 10 mg. Which antihypertensive class should be added first?
- ACE inhibitor or ARB (Correct answer)
- Thiazide diuretic
- Beta-blocker
- Alpha-1 blocker
Correct answer: ACE inhibitor or ARB
ACE inhibitors and ARBs are preferred add-on agents in CKD with hypertension because they reduce proteinuria and slow progression of kidney disease.
Question 6: A patient with osteoporosis has a T-score of -2.6 at the lumbar spine. She is already taking calcium and vitamin D. What is the first-line pharmacologic treatment?
- Alendronate (Correct answer)
- Raloxifene
- Calcitonin nasal spray
- Denosumab
Correct answer: Alendronate
Bisphosphonates such as alendronate are first-line pharmacologic therapy for osteoporosis due to their proven efficacy in reducing vertebral and hip fractures.
Question 7: A 55-year-old male with hyperlipidemia has an LDL of 145 mg/dL. He has a 10-year ASCVD risk of 12% calculated by the Pooled Cohort Equations. Which intervention is indicated?
- Moderate-intensity statin therapy (Correct answer)
- High-intensity statin therapy
- Lifestyle modification alone for 6 months
- Ezetimibe monotherapy
Correct answer: Moderate-intensity statin therapy
ACC/AHA guidelines recommend moderate-intensity statin therapy for intermediate-risk patients (10-year ASCVD risk 7.5–20%) to lower LDL by 30–49%.
AANP Chronic Disease Management 1
A 58-year-old patient with type 2 diabetes has an HbA1c of 8.9%.
Current treatment is metformin 1000 mg twice daily.
Which is the most appropriate next step?