Ambulatory Care Ambulatory Care Pharmacology Questions and Answers — Questions and Answers
Question 1: A 65-year-old male, recently started on high-intensity atorvastatin for secondary prevention of ASCVD, calls the clinic complaining of new-onset, bilateral thigh pain that began a week ago. He denies injury, and his creatine kinase (CK) level is within the normal range. What is the most appropriate next step in managing this patient's symptoms?
- Reassure the patient that this is a benign side effect and advise him to continue the medication.
- Hold the atorvastatin for 2-4 weeks and, if symptoms resolve, re-challenge with the same or a lower dose. (Correct answer)
- Immediately switch to a different high-intensity statin, such as rosuvastatin.
- Refer the patient to a rheumatologist for a full workup of myopathy.
Correct answer: Hold the atorvastatin for 2-4 weeks and, if symptoms resolve, re-challenge with the same or a lower dose.
The patient is experiencing statin-associated muscle symptoms (SAMS). The 2018 AHA/ACC cholesterol guidelines recommend a structured approach that includes temporarily stopping the statin to assess if symptoms resolve. If the symptoms resolve, a re-challenge with the same statin (at the same or lower dose) or a different statin can establish causality and help find a tolerable regimen. Simply reassuring the patient dismisses a significant side effect, immediate switching does not confirm the cause, and referral is premature before these initial steps are taken.
Question 2: Which of the following is a key advantage of using a direct oral anticoagulant (DOAC) such as apixaban over warfarin for the treatment of non-valvular atrial fibrillation?
- The availability of a widely used, inexpensive point-of-care test for monitoring.
- A significantly lower risk of major gastrointestinal bleeding.
- The requirement for frequent dose adjustments based on INR monitoring.
- Fewer significant drug-drug and drug-food interactions. (Correct answer)
Correct answer: Fewer significant drug-drug and drug-food interactions.
DOACs have a more predictable pharmacokinetic and pharmacodynamic profile than warfarin, leading to fewer interactions with other drugs and diet (specifically, vitamin K-containing foods). This predictability eliminates the need for routine INR monitoring, which is a major advantage in the ambulatory setting. Warfarin has a point-of-care test (INR), not DOACs. While DOACs often have a better overall bleeding profile, particularly for intracranial hemorrhage, some carry a similar or higher risk of GI bleeding compared to warfarin. The lack of need for frequent monitoring is an advantage of DOACs, not a requirement.
Question 3: In addition to its glucose-lowering effects, which of the following is a well-established benefit of initiating an SGLT2 inhibitor, such as empagliflozin, in a patient with type 2 diabetes and established cardiovascular disease?
- Significant weight gain.
- Increased risk of hypoglycemia when used as monotherapy.
- Reduction in the risk of hospitalizations for heart failure. (Correct answer)
- Improvement in diabetic gastroparesis symptoms.
Correct answer: Reduction in the risk of hospitalizations for heart failure.
Large cardiovascular outcome trials have consistently demonstrated that SGLT2 inhibitors reduce the risk of hospitalization for heart failure in patients with type 2 diabetes and established cardiovascular disease. This benefit is a primary reason for their use in this patient population. SGLT2 inhibitors are associated with modest weight loss, not gain. Their mechanism is insulin-independent, so they carry a low risk of hypoglycemia when used alone. They have no established benefit for gastroparesis.
Question 4: A 55-year-old African American male without other comorbidities is newly diagnosed with Stage 1 hypertension. According to the 2017 ACC/AHA hypertension guidelines, which of the following would be the most appropriate initial monotherapy?
- Lisinopril
- Amlodipine (Correct answer)
- Metoprolol succinate
- Losartan
Correct answer: Amlodipine
The 2017 ACC/AHA guidelines recommend either a thiazide-type diuretic or a calcium channel blocker (CCB) as first-line monotherapy for hypertension in African American adults without heart failure or chronic kidney disease with proteinuria. ACE inhibitors (e.g., lisinopril) and ARBs (e.g., losartan) have been shown to be less effective in lowering blood pressure in this population. Beta-blockers (e.g., metoprolol) are not recommended as first-line agents unless there is a specific compelling indication, such as ischemic heart disease or heart failure.
Question 5: When prescribing opioids for chronic non-cancer pain, which practice is a key component of the CDC Clinical Practice Guideline for Prescribing Opioids for Pain?
- Routinely utilizing state Prescription Drug Monitoring Program (PDMP) data before and during therapy. (Correct answer)
- Prioritizing extended-release/long-acting opioid formulations as initial therapy.
- Co-prescribing a benzodiazepine to manage anxiety often associated with chronic pain.
- Avoiding the use of non-pharmacologic therapies once an opioid has been initiated.
Correct answer: Routinely utilizing state Prescription Drug Monitoring Program (PDMP) data before and during therapy.
The CDC guideline strongly recommends that clinicians review PDMP data before initiating opioid therapy and periodically during treatment to assess for high-risk behaviors, such as receiving prescriptions from multiple providers. The guideline advises using immediate-release opioids first, avoiding co-prescribing with benzodiazepines due to overdose risk, and integrating opioids as part of a multimodal plan that includes non-pharmacologic and non-opioid therapies.
Question 6: Based on the most recent Global Initiative for Asthma (GINA) strategy report, which statement best describes the recommended approach for adult patients with mild asthma?
- Short-acting beta-agonist (SABA) monotherapy as needed is the recommended first-line treatment.
- Daily medium-dose inhaled corticosteroid (ICS) is recommended for all patients.
- As-needed low-dose inhaled corticosteroid (ICS)-formoterol is the preferred reliever therapy. (Correct answer)
- Scheduled, around-the-clock SABA therapy is preferred to prevent inflammation.
Correct answer: As-needed low-dose inhaled corticosteroid (ICS)-formoterol is the preferred reliever therapy.
The GINA guidelines have made a significant shift away from recommending SABA-only treatment for mild asthma (Step 1) due to evidence that it does not address underlying inflammation and may increase the risk of severe exacerbations. The preferred approach for both relief of symptoms and to reduce future risk is as-needed low-dose ICS-formoterol. Daily ICS is for more persistent asthma (Step 2 and higher), and scheduled SABA is not recommended.
