BCPS Therapeutic Decision-Making & Patient Management 5 — Questions and Answers
Question 1: A patient with moderate persistent asthma is inadequately controlled on low-dose ICS. According to GINA guidelines, what is the preferred step-up therapy?
- Add montelukast to low-dose ICS
- Add a long-acting beta-agonist (LABA) to low-dose ICS (Correct answer)
- Switch to high-dose ICS monotherapy
- Add tiotropium to low-dose ICS
Correct answer: Add a long-acting beta-agonist (LABA) to low-dose ICS
GINA Step 3 recommends adding a LABA to low-dose ICS as the preferred step-up for uncontrolled moderate persistent asthma, providing superior outcomes versus increasing ICS dose.
Question 2: A 70-year-old patient with CKD (eGFR 22 mL/min) and hyperkalemia (K+ 5.9 mEq/L) is on lisinopril for diabetic nephropathy. What is the MOST appropriate intervention?
- Discontinue lisinopril immediately and switch to amlodipine
- Add patiromer and continue lisinopril with close monitoring (Correct answer)
- Add sodium polystyrene sulfonate daily and continue lisinopril
- Add spironolactone to manage potassium
Correct answer: Add patiromer and continue lisinopril with close monitoring
Patiromer is a GI potassium binder that allows continuation of ACE inhibitor therapy (which provides critical renoprotection in diabetic CKD) by managing hyperkalemia without the risks of sodium polystyrene sulfonate.
Question 3: An oncology patient receiving cisplatin-based chemotherapy develops acute kidney injury (SCr doubles from baseline). Which antiemetic should be AVOIDED due to its renal elimination?
- Ondansetron (Correct answer)
- Granisetron
- Metoclopramide
- Prochlorperazine
Correct answer: Ondansetron
Ondansetron undergoes significant renal elimination; its clearance is reduced in severe renal impairment, necessitating dose adjustment or use of hepatically cleared alternatives.
Question 4: A patient with treatment-resistant depression has failed two adequate trials of SSRIs. What pharmacogenomic factor most commonly explains SSRI non-response?
- CYP2D6 ultrarapid metabolizer status (Correct answer)
- HLA-B*5701 carrier status
- TPMT deficiency
- G6PD deficiency
Correct answer: CYP2D6 ultrarapid metabolizer status
CYP2D6 ultrarapid metabolizers rapidly metabolize many SSRIs, leading to subtherapeutic drug levels and apparent treatment failure, making pharmacogenomic testing clinically actionable.
Question 5: In the management of status epilepticus refractory to benzodiazepines, which second-line agent is preferred based on efficacy and safety evidence from the ESETT trial?
- Phenobarbital 20 mg/kg IV
- Levetiracetam 4500 mg IV
- Valproate 40 mg/kg IV
- All three showed similar efficacy and safety in ESETT (Correct answer)
Correct answer: All three showed similar efficacy and safety in ESETT
The ESETT trial found no significant difference in efficacy or safety among levetiracetam, fosphenytoin, and valproate for benzodiazepine-refractory status epilepticus, making agent selection patient-specific.
Question 6: A patient with chronic hepatitis C genotype 1a and compensated cirrhosis (Child-Pugh A) is being considered for direct-acting antiviral (DAA) therapy. Which regimen is most appropriate?
- Elbasvir/grazoprevir for 12 weeks without ribavirin
- Sofosbuvir/velpatasvir for 12 weeks (Correct answer)
- Glecaprevir/pibrentasvir for 8 weeks
- Ledipasvir/sofosbuvir for 12 weeks without ribavirin
Correct answer: Sofosbuvir/velpatasvir for 12 weeks
Sofosbuvir/velpatasvir for 12 weeks is a pangenotypic regimen with high SVR rates in compensated cirrhosis and does not require genotypic resistance testing for NS5A.
Question 7: A 52-year-old male with schizophrenia is switching from oral risperidone to a long-acting injectable (LAI). He had an adequate response to oral risperidone 4 mg/day. What is the BEST approach for initiating the LAI?
- Stop oral risperidone immediately and give first LAI dose
- Initiate LAI and overlap with oral risperidone for 3 weeks (Correct answer)
- Wait 2 weeks after stopping oral before starting LAI
- Start LAI at half the equivalent dose for 1 month
Correct answer: Initiate LAI and overlap with oral risperidone for 3 weeks
When initiating risperidone LAI, a 3-week oral overlap is required because the injection depot takes approximately 3 weeks to reach therapeutic plasma levels.
BCPS Therapeutic Decision-Making & Patient Management 5
A patient with moderate persistent asthma is inadequately controlled on low-dose ICS.
According to GINA guidelines, what is the preferred step-up therapy?