BCPS Therapeutic Decision-Making & Patient Management 3 — Questions and Answers
Question 1: A 72-year-old male with a history of stroke 3 months ago is started on dual antiplatelet therapy (aspirin + clopidogrel). He is a CYP2C19 poor metabolizer. What is the BEST therapeutic recommendation?
- Continue clopidogrel at double dose
- Switch clopidogrel to ticagrelor or prasugrel (Correct answer)
- Add a PPI to enhance clopidogrel absorption
- Continue current regimen without changes
Correct answer: Switch clopidogrel to ticagrelor or prasugrel
CYP2C19 poor metabolizers cannot adequately convert clopidogrel to its active metabolite; ticagrelor or prasugrel are preferred alternatives for adequate P2Y12 inhibition.
Question 2: When counseling a patient starting clozapine therapy, which monitoring parameter is MOST critical to establish at baseline and continue regularly?
- Liver function tests weekly
- Absolute neutrophil count (ANC) (Correct answer)
- QTc interval monthly
- Fasting lipids quarterly
Correct answer: Absolute neutrophil count (ANC)
Clozapine carries a black box warning for agranulocytosis; ANC must be monitored weekly for 6 months, then every 2 weeks for 6 months, then monthly thereafter.
Question 3: A patient with COPD (GOLD Group D) is currently on LABA/LAMA. Their exacerbation rate remains high. What is the most appropriate intensification strategy?
- Add inhaled corticosteroid (ICS) to the regimen (Correct answer)
- Switch to tiotropium monotherapy
- Add theophylline
- Add a short-acting beta-agonist only
Correct answer: Add inhaled corticosteroid (ICS) to the regimen
For GOLD Group D patients with persistent exacerbations on LABA/LAMA, adding ICS (triple therapy) reduces exacerbation frequency, especially if eosinophils ≥300 cells/µL.
Question 4: An elderly patient with benign prostatic hyperplasia (BPH) requires antihistamine therapy for seasonal allergies. Which agent is MOST appropriate?
- Diphenhydramine 25 mg at bedtime
- Hydroxyzine 25 mg three times daily
- Cetirizine 10 mg daily (Correct answer)
- Chlorpheniramine 4 mg every 6 hours
Correct answer: Cetirizine 10 mg daily
Cetirizine is a second-generation antihistamine with minimal anticholinergic activity, reducing the risk of urinary retention in patients with BPH.
Question 5: A 45-year-old HIV-positive patient on dolutegravir/abacavir/lamivudine is started on rifampin for TB. What adjustment is required?
- No adjustment needed
- Double the dolutegravir dose to 50 mg twice daily (Correct answer)
- Switch to a boosted PI-based regimen
- Discontinue abacavir and add tenofovir
Correct answer: Double the dolutegravir dose to 50 mg twice daily
Rifampin induces UGT1A1 and reduces dolutegravir AUC by ~54%; doubling the dolutegravir dose to 50 mg BID compensates for this induction.
Question 6: Which pharmacokinetic parameter BEST predicts the efficacy of concentration-dependent antibiotics such as aminoglycosides?
- Time above MIC (T>MIC)
- AUC/MIC ratio
- Peak/MIC ratio (Correct answer)
- Trough concentration
Correct answer: Peak/MIC ratio
Aminoglycosides exhibit concentration-dependent killing, where the Peak/MIC ratio (target ≥10) best predicts bactericidal activity and clinical efficacy.
Question 7: A patient with gout and a serum urate of 9.8 mg/dL requires urate-lowering therapy. He has a history of nephrolithiasis (uric acid stones) and eGFR of 55 mL/min. Which agent is PREFERRED?
- Probenecid 500 mg twice daily
- Allopurinol 100 mg daily, titrating up (Correct answer)
- Febuxostat 80 mg daily
- Pegloticase IV every 2 weeks
Correct answer: Allopurinol 100 mg daily, titrating up
Allopurinol is preferred over probenecid (contraindicated with nephrolithiasis and reduced renal clearance) and is first-line per ACR guidelines, titrated to a target serum urate <6 mg/dL.
BCPS Therapeutic Decision-Making & Patient Management 3
A 72-year-old male with a history of stroke 3 months ago is started on dual antiplatelet therapy (aspirin + clopidogrel).
He is a CYP2C19 poor metabolizer.
What is the BEST therapeutic recommendation?