AANP Chronic Disease Management 2 — Questions and Answers
Question 1: A patient with rheumatoid arthritis has inadequate response after 3 months of methotrexate monotherapy. She has no comorbidities. What is the most appropriate next step per current guidelines?
- Add a TNF inhibitor or other biologic DMARD (Correct answer)
- Switch to hydroxychloroquine monotherapy
- Add prednisone 20 mg daily indefinitely
- Increase methotrexate to maximum dose before adding another agent
Correct answer: Add a TNF inhibitor or other biologic DMARD
ACR guidelines recommend adding a biologic or targeted synthetic DMARD (such as a TNF inhibitor) after 3 months of inadequate response to methotrexate monotherapy.
Question 2: A patient with stable angina is found to have an LDL of 98 mg/dL on high-intensity statin therapy. His 10-year ASCVD risk is 28%. What is the most appropriate next step?
- Add ezetimibe to further reduce LDL (Correct answer)
- Switch to a moderate-intensity statin
- Add niacin for additional LDL lowering
- No additional intervention is needed
Correct answer: Add ezetimibe to further reduce LDL
In very high-risk ASCVD patients with LDL ≥70 mg/dL despite maximally tolerated statin, adding ezetimibe is the recommended next step to further reduce cardiovascular risk.
Question 3: A 68-year-old patient with atrial fibrillation and a CHA₂DS₂-VASc score of 4 is not on anticoagulation. He has no contraindications. What is the appropriate management?
- Initiate oral anticoagulation with a DOAC (Correct answer)
- Prescribe aspirin 325 mg daily
- Observe and reassess in 6 months
- Initiate rate control only
Correct answer: Initiate oral anticoagulation with a DOAC
A CHA₂DS₂-VASc score ≥2 in males indicates high stroke risk, and oral anticoagulation with a DOAC is recommended over aspirin, which is no longer guideline-supported for AF stroke prevention.
Question 4: A patient with a 40-pack-year smoking history, age 58, is seen for an annual visit. He currently smokes 1 PPD. Which lung cancer screening recommendation applies?
- Annual low-dose CT scan of the chest (Correct answer)
- Annual chest X-ray
- Sputum cytology every 6 months
- No screening is indicated until symptoms develop
Correct answer: Annual low-dose CT scan of the chest
USPSTF recommends annual low-dose CT (LDCT) for adults aged 50–80 with a 20+ pack-year history who currently smoke or quit within the past 15 years.
Question 5: A 48-year-old patient with type 2 diabetes has an eGFR of 68 and urine albumin-to-creatinine ratio (UACR) of 180 mg/g. He is on metformin and linagliptin. Which medication should be added for renoprotection?
- An SGLT-2 inhibitor (Correct answer)
- A GLP-1 receptor agonist
- A loop diuretic
- A calcium channel blocker
Correct answer: An SGLT-2 inhibitor
SGLT-2 inhibitors (e.g., empagliflozin, dapagliflozin) have demonstrated significant renoprotective benefits in diabetic kidney disease with albuminuria, reducing CKD progression and cardiovascular events.
Question 6: A patient with inflammatory bowel disease (Crohn's disease) on long-term corticosteroids presents for a routine visit. Which monitoring intervention is most important?
- Bone density scan (DEXA) (Correct answer)
- Pulmonary function testing
- Serum ferritin only
- Colonoscopy every 6 months
Correct answer: Bone density scan (DEXA)
Long-term corticosteroid use significantly increases osteoporosis risk; DEXA scan is recommended for patients on chronic steroid therapy to assess bone density and guide preventive treatment.
Question 7: A patient with poorly controlled hypertension (BP 162/96) is on lisinopril 20 mg. He has no edema, normal renal function, and no diabetes. What is the best addition to his regimen?
- Chlorthalidone (thiazide-type diuretic) (Correct answer)
- Clonidine
- Doxazosin
- Hydralazine
Correct answer: Chlorthalidone (thiazide-type diuretic)
Thiazide-type diuretics such as chlorthalidone are the preferred second agent added to an ACE inhibitor for hypertension management per JNC and AHA/ACC guidelines.
AANP Chronic Disease Management 2
A patient with rheumatoid arthritis has inadequate response after 3 months of methotrexate monotherapy.
She has no comorbidities.
What is the most appropriate next step per current guidelines?