CCMA Pharmacology and Medications 2 — Questions and Answers
Question 1: Which of the following is a side effect commonly associated with ACE inhibitors?
- Dry, persistent cough (Correct answer)
- Hyperkalemia only at high doses
- Weight gain and edema
- Photosensitivity rash
Correct answer: Dry, persistent cough
ACE inhibitors (e.g., lisinopril, enalapril) commonly cause a dry, persistent, non-productive cough due to accumulation of bradykinin in the airways.
ACE inhibitors block angiotensin-converting enzyme, preventing conversion of angiotensin I to angiotensin II. This reduces vasoconstriction and aldosterone secretion, lowering blood pressure. Common side effects: dry cough (caused by bradykinin accumulation, occurs in 10–20% of patients — most common reason for discontinuation), hyperkalemia, first-dose hypotension. Contraindicated in pregnancy (teratogenic). If cough is intolerable, ARBs (angiotensin receptor blockers — e.g., losartan) are substituted as they do not affect bradykinin and do not cause cough.
Question 2: A patient is prescribed warfarin (Coumadin). Which dietary instruction is most important?
- Increase consumption of leafy green vegetables to improve bone health
- Maintain consistent intake of vitamin K-rich foods and avoid sudden dietary changes (Correct answer)
- Avoid all sources of vitamin K completely
- Increase sodium intake to counteract fluid retention
Correct answer: Maintain consistent intake of vitamin K-rich foods and avoid sudden dietary changes
Warfarin's anticoagulant effect is sensitive to vitamin K intake. Consistent (not eliminated) vitamin K consumption is essential to maintain stable INR levels.
Warfarin is a vitamin K antagonist anticoagulant used for atrial fibrillation, DVT/PE treatment and prevention, and mechanical heart valves. Vitamin K (found in leafy greens: spinach, kale, broccoli) competes with warfarin's mechanism. Patients should NOT eliminate vitamin K but maintain consistent intake — sudden increases raise vitamin K, reduce warfarin effect (increase clotting risk); sudden decreases lower vitamin K, enhance warfarin effect (increase bleeding risk). INR is monitored regularly (target 2–3 for most indications). Drugs, alcohol, and many foods also interact with warfarin.
Question 3: Which medication class works by inhibiting the proton pump in the stomach lining to reduce acid production?
- H2 receptor antagonists
- Antacids
- Proton pump inhibitors (PPIs) (Correct answer)
- Anticholinergics
Correct answer: Proton pump inhibitors (PPIs)
Proton pump inhibitors (PPIs) such as omeprazole and pantoprazole irreversibly inhibit the H+/K+-ATPase enzyme (proton pump) in gastric parietal cells, producing the most potent acid suppression available.
Gastric acid-reducing medications: PPIs (omeprazole, pantoprazole, esomeprazole) — irreversibly block the H+/K+-ATPase (proton) pump; most effective acid suppression; used for GERD, H. pylori eradication, peptic ulcers, Zollinger-Ellison syndrome. H2 blockers (famotidine, ranitidine) — block histamine H2 receptors on parietal cells; less effective than PPIs. Antacids (calcium carbonate, aluminum/magnesium hydroxide) — neutralize existing acid; provide immediate but short-lived relief. PPIs should be taken 30–60 minutes before the first meal of the day for optimal efficacy.
Question 4: Insulin glargine (Lantus) is classified as which type of insulin?
- Rapid-acting insulin
- Short-acting insulin
- Intermediate-acting insulin
- Long-acting (basal) insulin (Correct answer)
Correct answer: Long-acting (basal) insulin
Insulin glargine is a long-acting (basal) insulin analog with a duration of approximately 24 hours and no pronounced peak, providing steady background insulin coverage.
Insulin types by duration: Rapid-acting (lispro, aspart, glulisine): onset 15 min, peak 1–2 hr, duration 3–5 hr — given with meals. Short-acting (regular): onset 30 min, peak 2–4 hr, duration 5–8 hr — given 30 min before meals. Intermediate-acting (NPH): onset 1–4 hr, peak 6–10 hr, duration 12–18 hr. Long-acting (glargine/Lantus, detemir/Levemir): onset 1–2 hr, no pronounced peak, duration 20–24 hr (glargine) — basal coverage. Ultra-long-acting (degludec/Tresiba): duration >42 hours. Glargine must NEVER be mixed with other insulins and should be injected subcutaneously at the same time each day.
Question 5: When teaching a patient about their new statin medication (atorvastatin), which symptom should prompt immediate reporting to the physician?
- Mild constipation in the first week
- Muscle pain, weakness, or dark-colored urine (Correct answer)
- Increased appetite
- Mild headache on the first day
Correct answer: Muscle pain, weakness, or dark-colored urine
Muscle pain and weakness with dark urine may indicate rhabdomyolysis (severe muscle breakdown), a rare but serious life-threatening adverse effect of statins.
Statins (HMG-CoA reductase inhibitors: atorvastatin, simvastatin, rosuvastatin) reduce LDL cholesterol and cardiovascular risk. Most common side effects: myalgia (muscle aches, 5–10% of patients), mild GI upset, elevated liver enzymes. Serious side effects: Myopathy (muscle weakness + elevated CK); Rhabdomyolysis (severe muscle breakdown, myoglobinuria causing dark/tea-colored urine, acute kidney injury — rare but life-threatening) — requires immediate statin discontinuation. Risk increases with concurrent use of fibrates, niacin, certain antibiotics (clarithromycin), and grapefruit juice (inhibits statin metabolism). Routine CK monitoring is not required unless symptoms develop.
Question 6: A patient is taking a beta-blocker medication. Which vital sign must be assessed before administering each dose?
- Blood pressure and respiratory rate
- Heart rate (pulse) and blood pressure (Correct answer)
- Temperature and oxygen saturation
- Blood glucose level
Correct answer: Heart rate (pulse) and blood pressure
Beta-blockers reduce heart rate and blood pressure; pulse and blood pressure must be assessed before each dose and the drug withheld if heart rate is below 60 bpm or BP is low per physician parameters.
Beta-blockers (metoprolol, atenolol, carvedilol, propranolol) block beta-adrenergic receptors, reducing heart rate, contractility, and blood pressure. Pre-administration assessment: apical pulse for 1 full minute — hold if HR <60 bpm (or per physician parameter) and notify the physician; blood pressure — hold if systolic <90 mmHg. Beta-blockers must NEVER be abruptly discontinued (rebound tachycardia, hypertension, angina, myocardial infarction risk). They also mask hypoglycemia symptoms in diabetic patients (especially propranolol, non-selective). Document and report any parameters outside the physician-specified range.
CCMA Pharmacology and Medications 2
Which of the following is a side effect commonly associated with ACE inhibitors?