NAPLEX QBANK Therapeutic Plan Assessment Questions and Answers 1 — Questions and Answers
Question 1: A 68-year-old male with a history of type 2 diabetes, hypertension, and a previous myocardial infarction presents to the pharmacy with a new prescription for sitagliptin 100 mg daily. His current medication list includes metformin 1000 mg BID, lisinopril 20 mg daily, metoprolol succinate 100 mg daily, aspirin 81 mg daily, and atorvastatin 40 mg daily. His most recent lab results show a SCr of 1.7 mg/dL and an eGFR of 38 mL/min/1.73m². Which of the following represents the most significant drug therapy problem?
- The sitagliptin dose is too high for the patient's renal function. (Correct answer)
- There is a therapeutic duplication with metformin and sitagliptin.
- Atorvastatin is contraindicated in patients with diabetes.
- Metoprolol may mask signs of hypoglycemia.
Correct answer: The sitagliptin dose is too high for the patient's renal function.
The patient's estimated glomerular filtration rate (eGFR) is 38 mL/min/1.73m², indicating moderate chronic kidney disease. The standard dose of sitagliptin is 100 mg daily for patients with an eGFR > 45 mL/min/1.73m². For an eGFR between 30 and 45, the dose should be reduced to 50 mg daily. Therefore, the prescribed dose of 100 mg is inappropriate and poses a safety risk. While metoprolol can mask some signs of hypoglycemia, and metformin/sitagliptin is a common combination, the most immediate and actionable problem is the inappropriate dosing of sitagliptin based on renal function.
Question 2: A pharmacist is conducting a medication therapy review (MTR) for a 75-year-old female patient with osteoporosis, GERD, and insomnia. Her profile includes alendronate 70 mg weekly, calcium/vitamin D supplement daily, omeprazole 20 mg daily, and zolpidem 5 mg at bedtime as needed. The patient reports experiencing increased mid-back pain over the last month. When assessing the therapeutic plan, which is the most critical parameter for the pharmacist to evaluate further?
- Long-term use of a proton pump inhibitor.
- The potential for esophagitis with alendronate.
- The timing of the calcium supplement administration.
- The risk of falls associated with zolpidem use. (Correct answer)
Correct answer: The risk of falls associated with zolpidem use.
While all options are valid considerations in a comprehensive review, the combination of advanced age, a medication known to cause CNS depression and ataxia (zolpidem), and a diagnosis of osteoporosis makes the risk of falls and subsequent fractures the most critical safety concern. A fall in this patient could have devastating consequences. The pharmacist must assess the frequency of zolpidem use, inquire about dizziness or drowsiness, and discuss fall prevention strategies, potentially recommending a safer alternative for insomnia.
Question 3: When assessing a patient's therapeutic plan, which of the following is the primary goal of evaluating the 'effectiveness' of a medication?
- To determine if the medication is causing any adverse effects.
- To verify that the patient is taking the medication as prescribed.
- To ensure the medication has an appropriate indication for the patient's condition.
- To determine if the medication is achieving its desired therapeutic goals. (Correct answer)
Correct answer: To determine if the medication is achieving its desired therapeutic goals.
The assessment of a therapeutic plan involves evaluating four key areas: indication, effectiveness, safety, and adherence. The 'effectiveness' component specifically focuses on whether the drug therapy is producing the desired positive outcomes and meeting the established therapeutic goals for the patient's condition. Safety relates to adverse effects, adherence is about compliance, and indication is about the reason for the therapy.
Question 4: A patient stabilized on warfarin for atrial fibrillation (target INR 2.0-3.0) is prescribed a new medication. Two weeks later, their INR is 1.3. Which of the following newly prescribed medications is the most likely cause of this subtherapeutic INR?
- Amiodarone
- Carbamazepine (Correct answer)
- Metronidazole
- Fluconazole
Correct answer: Carbamazepine
Carbamazepine is a potent inducer of CYP2C9, the primary enzyme responsible for metabolizing the more potent S-enantiomer of warfarin. Induction of this enzyme leads to increased metabolism of warfarin, a lower serum concentration, and a subtherapeutic INR, increasing the risk of thromboembolism. Amiodarone, metronidazole, and fluconazole are all well-known inhibitors of CYP2C9 and would be expected to increase the INR.
Question 5: A pharmacist is developing a therapeutic monitoring plan for a patient starting therapy with lithium for bipolar disorder. In addition to monitoring the lithium serum concentration, which of the following sets of laboratory parameters is MOST important to monitor at baseline and periodically thereafter?
- Complete blood count (CBC) and liver function tests (LFTs)
- Serum electrolytes, lipid panel, and uric acid
- Thyroid function tests (TFTs) and renal function tests (BUN, SCr) (Correct answer)
- Fasting blood glucose and hemoglobin A1c
Correct answer: Thyroid function tests (TFTs) and renal function tests (BUN, SCr)
Lithium is cleared renally and can cause nephrotoxicity; therefore, baseline and periodic monitoring of renal function (BUN, SCr) is essential. Lithium can also cause drug-induced hypothyroidism, so monitoring thyroid function tests (like TSH) is also a standard of care. While other parameters might be monitored based on comorbidities, renal and thyroid function are directly and commonly affected by lithium therapy itself.
Question 6: During a prospective drug utilization review (DUR), a pharmacist notes a prescription for rosuvastatin for a patient currently taking gemfibrozil. Which of the following drug therapy problems should the pharmacist identify?
- Unnecessary drug therapy
- Therapeutic duplication
- A significant drug-drug interaction increasing the risk of myopathy (Correct answer)
- A dose that is too low to be effective
Correct answer: A significant drug-drug interaction increasing the risk of myopathy
The concurrent use of gemfibrozil with statins, particularly rosuvastatin, significantly increases the risk of severe myopathy and rhabdomyolysis. Gemfibrozil inhibits the metabolism of statins, leading to higher systemic concentrations. This combination is generally contraindicated or requires extreme caution with very low statin doses and close monitoring. This represents a critical safety issue that must be addressed before dispensing.
NAPLEX QBANK Therapeutic Plan Assessment Questions and Answers 1
A 68-year-old male with a history of type 2 diabetes, hypertension, and a previous myocardial infarction presents to the pharmacy with a new prescription for sitagliptin 100 mg daily.
His current medication list includes metformin 1000 mg BID, lisinopril 20 mg daily, metoprolol succinate 100 mg daily, aspirin 81 mg daily, and atorvastatin 40 mg daily.
His most recent lab results show a SCr of 1.7 mg/dL and an eGFR of 38 mL/min/1.73m².
Which of the following represents the most significant drug therapy problem?