Treatment Planning Flashcards

A 68-year-old male with CKD stage 3b (eGFR 32 mL/min/1.73m²), type 2 diabetes, and heart failure (EF 35%) presents with a new HbA1c of 9.2%. He is currently on metformin 500 mg BID and ramipril 10 mg daily. Which treatment planning decision is MOST appropriate?

Answer: Discontinue metformin and initiate empagliflozin 10 mg daily

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² and should be used with caution below 45. At eGFR 32, it should be discontinued. Empagliflozin has Health Canada approval for heart failure with reduced ejection fraction and provides CV/renal benefits, but its glucose-lowering is less effective below eGFR 45 — however its HF indication persists. Sitagliptin requires dose reduction and doesn't address HF. Semaglutide lacks a dedicated HF-rEF mortality benefit indication. Continuing metformin at eGFR 32 poses lactic acidosis risk and is the primary error to avoid.

A 45-year-old woman with recurrent major depressive disorder has failed two adequate SSRI trials (sertraline and escitalopram at therapeutic doses for ≥8 weeks each). She has no history of mania, currently has moderate depression (PHQ-9 = 16), and is 12 weeks pregnant. Which augmentation or switch strategy is MOST appropriate?

Answer: Initiate venlafaxine 75 mg daily, titrating to 150 mg

After two SSRI failures, switching to an SNRI (venlafaxine) is a guideline-supported next step for treatment-resistant depression. Bupropion is a reasonable option in non-pregnant patients but carries teratogenicity uncertainty and is generally avoided in pregnancy, particularly in the first trimester. Lithium crosses the placenta and carries risk of Ebstein's anomaly and neonatal toxicity — it is not a first-line augmentation choice in pregnancy. Quetiapine use in pregnancy is associated with neonatal adaptation syndrome and metabolic concerns; it is not preferred in a 12-week pregnancy without bipolar indication. Venlafaxine has the most evidence for treatment-resistant MDD as a next-line switch and is categorized as relatively acceptable in pregnancy when benefit outweighs risk.

A 72-year-old man on warfarin for atrial fibrillation (CHA₂DS₂-VASc = 5) requires a total knee replacement. His INR is 2.4. The surgeon requests bridging anticoagulation. Which statement BEST reflects current evidence-based treatment planning for perioperative anticoagulation in this patient?

Answer: Bridging with low-molecular-weight heparin is NOT indicated; warfarin should be held and restarted post-operatively without bridging

The BRIDGE trial demonstrated that in patients with atrial fibrillation on warfarin undergoing elective surgery, forgoing bridging anticoagulation was non-inferior for thromboembolism prevention and was associated with significantly less major bleeding. This finding applies even at moderate-to-high CHA₂DS₂-VASc scores for elective procedures. Bridging with UFH is not preferred over LMWH and adds complexity. Maintaining INR at 1.5–2.0 intraoperatively increases surgical bleeding risk. Switching to a DOAC pre-operatively is not standard practice and introduces its own perioperative management challenges.

A pharmacist reviews a treatment plan for a 55-year-old man with gout and stage 3a CKD (eGFR 48 mL/min/1.73m²). He has had three flares in the past year. He is currently on hydrochlorothiazide 25 mg for hypertension and his serum urate is 580 µmol/L. Which intervention represents the MOST comprehensive, guideline-aligned treatment plan?

Answer: Switch hydrochlorothiazide to losartan, initiate allopurinol 100 mg daily with planned uptitration, and provide colchicine 0.6 mg daily as flare prophylaxis during uptitration

Losartan has uricosuric properties and is the preferred antihypertensive in gout patients, replacing thiazide diuretics which raise serum urate. Allopurinol must be started at low doses (≤100 mg/day) in CKD and uptitrated slowly to reduce risk of allopurinol hypersensitivity syndrome. Colchicine 0.6 mg daily (dose-adjusted in CKD) is guideline-recommended for flare prophylaxis during the first 3–6 months of ULT initiation, as urate-lowering can mobilize crystals and precipitate flares. Febuxostat at 80 mg without switching the thiazide misses a modifiable contributing factor; additionally, febuxostat carries a CV safety signal. Allopurinol 300 mg immediately in CKD is inappropriate. Diet alone is insufficient with three flares and a urate of 580 µmol/L.

A 28-year-old woman with epilepsy controlled on valproic acid 1500 mg/day wishes to become pregnant. Her neurologist asks for pharmacy input on the treatment plan. She has been seizure-free for 3 years. Which recommendation is MOST appropriate?

Answer: Discuss transitioning to lamotrigine monotherapy before conception, with a slow valproic acid taper supervised by neurology

Valproic acid is a high-risk teratogen (neural tube defects, fetal valproate syndrome, cognitive impairment in offspring) and is contraindicated in pregnancy when alternatives exist — Health Canada and international guidelines (EURAP, NICE) strongly recommend avoiding it in women of childbearing potential. Lamotrigine is among the preferred AEDs in pregnancy with the most favorable teratogenicity profile. The transition should occur before conception and be done with a slow, supervised taper to avoid breakthrough seizures. High-dose folic acid does not mitigate valproate's major teratogenic risks. Abruptly switching to levetiracetam without tapering valproate risks seizure breakthrough. Continuing valproate without reconsideration is not aligned with current standards of care.

A 60-year-old man with COPD (GOLD Group E, post-bronchodilator FEV₁/FVC 0.62, FEV₁ 42% predicted) is on tiotropium 18 mcg daily and has had two moderate exacerbations in the past year. His blood eosinophil count is 420 cells/µL. Which treatment plan modification provides the STRONGEST evidence-based benefit for exacerbation reduction?

Answer: Add an inhaled corticosteroid/long-acting beta-agonist combination to tiotropium (triple therapy)

The IMPACT trial demonstrated that triple therapy (ICS/LABA/LAMA) significantly reduced exacerbations compared to dual bronchodilation or ICS/LABA alone in patients with GOLD Group E COPD. An eosinophil count ≥300 cells/µL is a strong predictor of ICS response and is a key biomarker used to guide ICS addition in COPD guidelines (GOLD 2024). This patient's eosinophil count of 420 cells/µL strongly supports ICS addition. Switching to LABA/LAMA alone misses the ICS benefit indicated by high eosinophils. Roflumilast is indicated in chronic bronchitis with FEV₁ <50% but the eosinophil count makes ICS the priority. Azithromycin prophylaxis is an option but is a second-line measure with hearing/resistance concerns and less impact than triple therapy at this eosinophil level.