BCPS Therapeutic Decision-Making & Patient Management 2 — Questions and Answers
Question 1: A 68-year-old patient with heart failure (EF 30%) and atrial fibrillation requires anticoagulation. CrCl is 28 mL/min. Which agent is most appropriate?
- Rivaroxaban 20 mg daily
- Apixaban 2.5 mg twice daily (Correct answer)
- Dabigatran 150 mg twice daily
- Edoxaban 60 mg daily
Correct answer: Apixaban 2.5 mg twice daily
Apixaban 2.5 mg twice daily is recommended when ≥2 of these criteria are met: age ≥80, weight ≤60 kg, or SCr ≥1.5 mg/dL; additionally, it has the broadest renal evidence and is preferred in severe renal impairment.
Question 2: A patient on warfarin for mechanical mitral valve replacement presents with an INR of 1.4. What is the most appropriate next step?
- Switch to apixaban 5 mg twice daily
- Increase warfarin dose and bridge with unfractionated heparin (Correct answer)
- Hold warfarin and recheck INR in 1 week
- Administer vitamin K 5 mg orally
Correct answer: Increase warfarin dose and bridge with unfractionated heparin
DOACs are contraindicated in mechanical heart valves; subtherapeutic anticoagulation requires dose adjustment and bridging with UFH to prevent thromboembolism.
Question 3: When initiating beta-blocker therapy in a patient with newly diagnosed acute decompensated heart failure, the MOST appropriate action is to:
- Start carvedilol at target dose immediately
- Start metoprolol succinate at low dose after clinical stability (Correct answer)
- Withhold beta-blockers until EF normalizes
- Initiate bisoprolol during active fluid overload
Correct answer: Start metoprolol succinate at low dose after clinical stability
Beta-blockers should not be initiated during acute decompensation but started at low doses once the patient is clinically stable and euvolemic.
Question 4: A pharmacist reviews a patient's medications and notes methotrexate 15 mg weekly plus trimethoprim-sulfamethoxazole DS twice daily for a UTI. What is the primary concern?
- Increased methotrexate renal clearance
- Additive folate antagonism causing bone marrow suppression (Correct answer)
- Reduced trimethoprim efficacy
- QT prolongation risk
Correct answer: Additive folate antagonism causing bone marrow suppression
Both methotrexate and trimethoprim inhibit dihydrofolate reductase, resulting in additive folate antagonism and potentially severe myelosuppression.
Question 5: A 55-year-old woman with type 2 diabetes and CKD stage 3b (eGFR 38 mL/min/1.73m²) has an A1C of 8.9%. Which agent is CONTRAINDICATED in this patient?
- Empagliflozin
- Liraglutide
- Metformin (Correct answer)
- Sitagliptin (dose-adjusted)
Correct answer: Metformin
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² and should be used with caution (not initiated) at eGFR 30-45; many guidelines recommend avoiding initiation below 45.
Question 6: In the management of septic shock, which vasopressor is recommended as first-line therapy per Surviving Sepsis Campaign guidelines?
- Epinephrine
- Vasopressin
- Norepinephrine (Correct answer)
- Phenylephrine
Correct answer: Norepinephrine
Norepinephrine is the first-line vasopressor for septic shock due to its potent alpha-1 activity with moderate beta-1 effect, maintaining MAP without excessive tachycardia.
Question 7: A patient taking rifampin for tuberculosis is initiated on oral contraceptives. What counseling should the pharmacist provide?
- No interaction exists; continue standard dosing
- Use an additional or alternative contraceptive method (Correct answer)
- Increase estrogen dose to 50 mcg
- Switch to vaginal ring to bypass the interaction
Correct answer: Use an additional or alternative contraceptive method
Rifampin is a potent CYP3A4 and P-glycoprotein inducer that significantly reduces hormonal contraceptive efficacy, requiring additional non-hormonal contraception.
BCPS Therapeutic Decision-Making & Patient Management 2
A 68-year-old patient with heart failure (EF 30%) and atrial fibrillation requires anticoagulation.
CrCl is 28 mL/min.
Which agent is most appropriate?