BCPS Therapeutic Decision-Making & Patient Management 2

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?

Accepted Answer

Apixaban 2.5 mg twice daily

Answer

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?

Accepted Answer

Increase warfarin dose and bridge with unfractionated heparin

Answer

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:

Accepted Answer

Start metoprolol succinate at low dose after clinical stability

Answer

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?

Accepted Answer

Additive folate antagonism causing bone marrow suppression

Answer

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?

Accepted Answer

Metformin

Answer

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.

(BCPS) Board Certified Pharmacotherapy Specialist Practice Test

(BCPS) Board Certified Pharmacotherapy Specialist Practice Test

BCPS Therapeutic Decision-Making & Patient Management 2