CCP Drug Therapy Management 3 — Questions and Answers
Question 1: A patient on chronic opioid therapy for pain management develops opioid-induced constipation unresponsive to stimulant laxatives. Which agent is specifically indicated for this condition?
- Methylnaltrexone (Correct answer)
- Docusate sodium
- Lactulose
- Bisacodyl
Correct answer: Methylnaltrexone
Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist specifically approved for opioid-induced constipation that does not respond to laxatives.
Question 2: When reviewing a patient's medication regimen, a consultant pharmacist identifies that an ACE inhibitor and an angiotensin receptor blocker are prescribed together. This combination is generally considered:
- Potentially harmful and should be avoided due to increased risk of hyperkalemia and renal failure (Correct answer)
- Beneficial for patients with heart failure with reduced ejection fraction
- Standard of care for hypertension management
- Acceptable only in patients with diabetic nephropathy
Correct answer: Potentially harmful and should be avoided due to increased risk of hyperkalemia and renal failure
Dual renin-angiotensin-aldosterone system blockade with ACE inhibitors and ARBs together is not recommended as it increases risk of hyperkalemia, hypotension, and acute kidney injury.
Question 3: A resident with Parkinson's disease is admitted with worsening motor symptoms. The nursing staff administered metoclopramide for nausea. What is the primary concern?
- Metoclopramide is a dopamine antagonist that can worsen Parkinson's symptoms (Correct answer)
- Metoclopramide interacts with levodopa to cause hypertensive crisis
- Metoclopramide decreases carbidopa absorption significantly
- Metoclopramide has no significant effect on Parkinson's disease
Correct answer: Metoclopramide is a dopamine antagonist that can worsen Parkinson's symptoms
Metoclopramide blocks dopamine receptors centrally, directly antagonizing the dopaminergic therapy used in Parkinson's disease and worsening motor symptoms.
Question 4: Which Beers Criteria medication should be avoided in older adults due to its high anticholinergic burden and risk of cognitive impairment?
- Diphenhydramine (Correct answer)
- Loratadine
- Cetirizine
- Fexofenadine
Correct answer: Diphenhydramine
Diphenhydramine has significant anticholinergic effects and is listed in the Beers Criteria as potentially inappropriate in older adults due to increased risk of delirium and cognitive decline.
Question 5: A patient with chronic kidney disease (eGFR 25 mL/min) is prescribed metformin for type 2 diabetes. What is the most appropriate recommendation?
- Discontinue metformin due to risk of lactic acidosis at this level of renal impairment (Correct answer)
- Reduce metformin dose by half and continue
- Switch to a higher dose of metformin for better glucose control
- Metformin is safe and no changes are needed
Correct answer: Discontinue metformin due to risk of lactic acidosis at this level of renal impairment
Metformin is contraindicated when eGFR falls below 30 mL/min due to accumulation and increased risk of lactic acidosis.
Question 6: A consultant pharmacist is reviewing pain management in a hospice patient. Which principle is most important when titrating opioids for end-of-life pain control?
- Dose to effect, titrating based on patient's comfort and response (Correct answer)
- Always use the lowest effective dose to prevent addiction
- Avoid around-the-clock dosing to minimize tolerance
- Limit total daily opioid dose to prevent respiratory depression
Correct answer: Dose to effect, titrating based on patient's comfort and response
In hospice and palliative care, the goal is patient comfort, and opioids should be titrated to achieve adequate pain control without arbitrary dose limits.
Question 7: Which drug interaction is most clinically significant and requires dose adjustment when clopidogrel is co-administered with omeprazole?
- Omeprazole inhibits CYP2C19, reducing conversion of clopidogrel to its active metabolite (Correct answer)
- Omeprazole increases clopidogrel absorption by raising gastric pH
- Omeprazole accelerates clopidogrel metabolism via CYP3A4 induction
- Omeprazole has no clinically meaningful interaction with clopidogrel
Correct answer: Omeprazole inhibits CYP2C19, reducing conversion of clopidogrel to its active metabolite
Omeprazole inhibits CYP2C19, which is required to convert clopidogrel (a prodrug) to its active antiplatelet metabolite, potentially reducing its efficacy.
CCP Drug Therapy Management 3
A patient on chronic opioid therapy for pain management develops opioid-induced constipation unresponsive to stimulant laxatives.
Which agent is specifically indicated for this condition?