Ambulatory Care Ambulatory Care Pharmacology Questions and Answers

Question 1

A 65-year-old male, recently started on high-intensity atorvastatin for secondary prevention of ASCVD, calls the clinic complaining of new-onset, bilateral thigh pain that began a week ago. He denies injury, and his creatine kinase (CK) level is within the normal range. What is the most appropriate next step in managing this patient's symptoms?

Accepted Answer

Hold the atorvastatin for 2-4 weeks and, if symptoms resolve, re-challenge with the same or a lower dose.

Answer

The patient is experiencing statin-associated muscle symptoms (SAMS). The 2018 AHA/ACC cholesterol guidelines recommend a structured approach that includes temporarily stopping the statin to assess if symptoms resolve. If the symptoms resolve, a re-challenge with the same statin (at the same or lower dose) or a different statin can establish causality and help find a tolerable regimen. Simply reassuring the patient dismisses a significant side effect, immediate switching does not confirm the cause, and referral is premature before these initial steps are taken.

Question 2

Which of the following is a key advantage of using a direct oral anticoagulant (DOAC) such as apixaban over warfarin for the treatment of non-valvular atrial fibrillation?

Accepted Answer

Fewer significant drug-drug and drug-food interactions.

Answer

DOACs have a more predictable pharmacokinetic and pharmacodynamic profile than warfarin, leading to fewer interactions with other drugs and diet (specifically, vitamin K-containing foods). This predictability eliminates the need for routine INR monitoring, which is a major advantage in the ambulatory setting. Warfarin has a point-of-care test (INR), not DOACs. While DOACs often have a better overall bleeding profile, particularly for intracranial hemorrhage, some carry a similar or higher risk of GI bleeding compared to warfarin. The lack of need for frequent monitoring is an advantage of DOACs, not a requirement.

Question 3

In addition to its glucose-lowering effects, which of the following is a well-established benefit of initiating an SGLT2 inhibitor, such as empagliflozin, in a patient with type 2 diabetes and established cardiovascular disease?

Accepted Answer

Reduction in the risk of hospitalizations for heart failure.

Answer

Large cardiovascular outcome trials have consistently demonstrated that SGLT2 inhibitors reduce the risk of hospitalization for heart failure in patients with type 2 diabetes and established cardiovascular disease. This benefit is a primary reason for their use in this patient population. SGLT2 inhibitors are associated with modest weight loss, not gain. Their mechanism is insulin-independent, so they carry a low risk of hypoglycemia when used alone. They have no established benefit for gastroparesis.

Question 4

A 55-year-old African American male without other comorbidities is newly diagnosed with Stage 1 hypertension. According to the 2017 ACC/AHA hypertension guidelines, which of the following would be the most appropriate initial monotherapy?

Accepted Answer

Amlodipine

Answer

The 2017 ACC/AHA guidelines recommend either a thiazide-type diuretic or a calcium channel blocker (CCB) as first-line monotherapy for hypertension in African American adults without heart failure or chronic kidney disease with proteinuria. ACE inhibitors (e.g., lisinopril) and ARBs (e.g., losartan) have been shown to be less effective in lowering blood pressure in this population. Beta-blockers (e.g., metoprolol) are not recommended as first-line agents unless there is a specific compelling indication, such as ischemic heart disease or heart failure.

Question 5

When prescribing opioids for chronic non-cancer pain, which practice is a key component of the CDC Clinical Practice Guideline for Prescribing Opioids for Pain?

Accepted Answer

Routinely utilizing state Prescription Drug Monitoring Program (PDMP) data before and during therapy.

Answer

The CDC guideline strongly recommends that clinicians review PDMP data before initiating opioid therapy and periodically during treatment to assess for high-risk behaviors, such as receiving prescriptions from multiple providers. The guideline advises using immediate-release opioids first, avoiding co-prescribing with benzodiazepines due to overdose risk, and integrating opioids as part of a multimodal plan that includes non-pharmacologic and non-opioid therapies.

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Ambulatory Care Ambulatory Care Pharmacology Questions and Answers