Treatment Planning Flashcards

A 68-year-old patient with stage 3 CKD (eGFR 32 mL/min/1.73m²), type 2 diabetes, and newly diagnosed heart failure with reduced ejection fraction (HFrEF, LVEF 35%) is referred for medication optimization. Which of the following treatment plan decisions is MOST appropriate?

Answer: Initiate sacubitril/valsartan and empagliflozin 10 mg daily, monitoring potassium and renal function closely

Empagliflozin is approved for HFrEF with cardiovascular benefit regardless of diabetes status and can be used down to eGFR ≥20. Sacubitril/valsartan is the preferred RAAS agent in HFrEF over ACE inhibitors. Both can be used with eGFR 32 with careful monitoring of potassium and renal function. Withholding RAAS therapy is incorrect — the benefit in HFrEF persists even in moderate CKD. Hydralazine/nitrate is reserved for patients who cannot tolerate RAAS therapy (e.g., due to angioedema or persistent hyperkalemia). Metformin is actually contraindicated in eGFR <30 and should not be initiated here.

A 54-year-old woman is being treated for recurrent Clostridioides difficile infection (CDI) — her third episode within 6 months. She has no significant comorbidities and her last episode was treated with a standard vancomycin taper. Which treatment plan is MOST appropriate for this recurrence?

Answer: Fecal microbiota transplantation (FMT) after an initial course of vancomycin to reduce CDI burden

For a third CDI recurrence, current IDSA/SHEA guidelines strongly recommend fecal microbiota transplantation (FMT) as it addresses the underlying dysbiosis and has the highest efficacy (>85%) for preventing further recurrence. A preceding antibiotic course (vancomycin) is used to reduce bacterial burden before FMT. Fidaxomicin is preferred over vancomycin for the first or second recurrence but is less effective than FMT for a third episode. Repeating vancomycin taper is less effective at this stage. Oral metronidazole is no longer recommended for CDI by IDSA/SHEA guidelines due to inferior cure rates.

A 72-year-old man with atrial fibrillation and a CHA₂DS₂-VASc score of 5 is on warfarin (INR target 2–3). His time in therapeutic range (TTR) over the past 12 months is 58%. He has no history of mechanical heart valves or significant renal/hepatic impairment. What is the MOST appropriate modification to his anticoagulation plan?

Answer: Switch to apixaban 5 mg BID, as DOACs are preferred over warfarin when TTR is consistently below 70%

A TTR below 65–70% indicates poor warfarin control, and CCS/ACC/ESC guidelines recommend switching to a DOAC in this scenario for non-valvular AF. Apixaban is preferred in elderly patients due to its favorable bleeding profile. Simply increasing monitoring frequency rarely achieves meaningful TTR improvement if the underlying variability is pharmacogenomic or dietary. LMWH is not an appropriate long-term oral anticoagulation strategy for AF. Aspirin is not an acceptable substitute for anticoagulation in AF — it does not significantly reduce stroke risk and is not recommended by current guidelines for this indication.

A 44-year-old woman with treatment-resistant major depressive disorder (MDD) has failed two adequate trials of SSRIs and one trial of SNRIs at therapeutic doses. She has no history of bipolar disorder, psychosis, or substance use disorder. Which next-step pharmacotherapy is MOST aligned with Canadian evidence-based treatment guidelines for treatment-resistant depression?

Answer: Add aripiprazole augmentation to her current antidepressant given its approval as adjunctive therapy

For treatment-resistant MDD after ≥2 antidepressant failures, CANMAT guidelines recommend augmentation strategies. Atypical antipsychotic augmentation (aripiprazole, quetiapine, olanzapine) has the strongest Level 1 evidence for adjunctive use in MDD. Lithium augmentation is also evidence-based but is a second-line augmentation due to monitoring burden and tolerability. Switching to bupropion as monotherapy does not address treatment resistance at this stage — the patient has already failed two different mechanistic classes. Intranasal esketamine is indicated as an adjunct (not monotherapy) and is specifically approved for treatment-resistant depression, but augmenting the existing antidepressant with an atypical antipsychotic is the more standard next guideline step before escalating to esketamine.

A 61-year-old male with COPD (post-bronchodilator FEV₁/FVC = 0.62, FEV₁ 48% predicted) reports 3 exacerbations in the past year (2 required oral corticosteroids, 1 required hospitalization) and persistent dyspnea despite LAMA monotherapy. His blood eosinophil count is 380 cells/µL. What is the MOST appropriate treatment plan optimization?

Answer: Escalate to triple therapy (LABA/LAMA/ICS) given frequent exacerbations and high eosinophil count

GOLD guidelines recommend escalation to triple therapy (LABA/LAMA/ICS) for patients with frequent exacerbations (≥2 moderate or ≥1 severe per year) already on dual bronchodilator therapy or LAMA monotherapy. An eosinophil count ≥300 cells/µL further supports adding ICS, as these patients demonstrate the greatest ICS-related exacerbation reduction. LAMA/ICS dual therapy (without LABA) is not a preferred combination — LABA/LAMA is the standard dual bronchodilator approach. Switching away from LAMA to LABA/ICS would remove an established bronchodilator. Roflumilast is indicated as an add-on in chronic bronchitis with frequent exacerbations and FEV₁ <50%, but only after optimizing bronchodilator and ICS therapy — it is not the next priority here.

A 38-year-old pregnant woman (28 weeks gestation) with a new diagnosis of deep vein thrombosis (DVT) requires anticoagulation therapy. She has no history of heparin-induced thrombocytopenia (HIT) and normal renal function. Which treatment plan is MOST appropriate?

Answer: Initiate therapeutic-dose low-molecular-weight heparin (LMWH) and continue throughout pregnancy and for at least 6 weeks postpartum

LMWH (e.g., dalteparin, enoxaparin) is the anticoagulant of choice for VTE during pregnancy. It does not cross the placenta, has a predictable pharmacokinetic profile, and is safe for the fetus. Therapy should continue throughout pregnancy and for a minimum of 6 weeks postpartum (total duration ≥3 months). Warfarin crosses the placenta and is teratogenic — it is contraindicated in the first trimester and associated with embryopathy and fetal bleeding. DOACs (rivaroxaban, apixaban) are contraindicated in pregnancy as they cross the placenta and have no established safety data. UFH is used in special circumstances (e.g., near delivery or with mechanical heart valves) but is not preferred over LMWH for outpatient DVT management in pregnancy due to its IV route and HIT risk.