Clinical Pharmacy Flashcards

A patient with CKD stage 4 is prescribed metformin. What is the most appropriate action?

Answer: Discontinue metformin

Metformin is contraindicated in CKD stage 4 (eGFR <30 mL/min/1.73m²) due to risk of lactic acidosis.

Which parameter is most important to monitor in a patient receiving vancomycin for MRSA bacteremia?

Answer: AUC/MIC ratio

Current ASHP/IDSA guidelines recommend AUC/MIC-guided monitoring (target AUC 400–600 mg·h/L) for vancomycin efficacy and nephrotoxicity avoidance.

A 68-year-old patient on warfarin for atrial fibrillation develops a UTI and is prescribed trimethoprim-sulfamethoxazole. What is the expected INR effect?

Answer: INR will increase

TMP-SMX inhibits CYP2C9, reducing warfarin metabolism and raising the INR.

A patient presents with symptoms of serotonin syndrome. Which combination is the most likely cause?

Answer: Linezolid + sertraline

Linezolid has MAO-inhibitor activity; combining it with an SSRI like sertraline can precipitate serotonin syndrome.

Which diuretic is most appropriate for a patient with heart failure and a serum potassium of 3.1 mEq/L?

Answer: Spironolactone

Spironolactone is a potassium-sparing diuretic that also reduces morbidity and mortality in heart failure.

A patient taking phenytoin for seizures is started on fluconazole. What is the expected outcome?

Answer: Phenytoin levels increase due to inhibition

Fluconazole inhibits CYP2C9, decreasing phenytoin metabolism and increasing its serum levels.

When counseling a patient on sublingual nitroglycerin for angina, what is the maximum number of doses to take before calling emergency services?

Answer: 3 doses

Patients should take up to 3 sublingual nitroglycerin doses 5 minutes apart; if pain is unrelieved after the third dose, call 911.