PEBC Treatment Planning 3 — Questions and Answers
Question 1: A 30-year-old woman with epilepsy on valproic acid 1000 mg/day is planning a pregnancy. What is the pharmacist's MOST important recommendation?
- Switch to levetiracetam before conception and start high-dose folic acid 5 mg/day (Correct answer)
- Continue valproic acid and take standard folic acid 0.4 mg/day
- Discontinue all antiepileptic therapy before attempting conception
- Switch to carbamazepine and take folic acid 1 mg/day
Correct answer: Switch to levetiracetam before conception and start high-dose folic acid 5 mg/day
Valproic acid carries the highest teratogenic risk among antiepileptics; pre-conception transition to a safer agent plus high-dose folic acid (5 mg/day) is strongly recommended.
Question 2: A patient with community-acquired pneumonia (CAP) and no comorbidities is treated in an outpatient setting. Per Canadian guidelines, what is the preferred first-line treatment?
- Amoxicillin-clavulanate 875/125 mg BID for 7 days
- Azithromycin 500 mg day 1, then 250 mg days 2–5
- Doxycycline 100 mg BID for 5–7 days or amoxicillin 1 g TID (Correct answer)
- Levofloxacin 750 mg daily for 5 days
Correct answer: Doxycycline 100 mg BID for 5–7 days or amoxicillin 1 g TID
Canadian guidelines recommend amoxicillin or doxycycline as first-line for outpatient CAP in otherwise healthy patients without recent antibiotic use.
Question 3: A pharmacist identifies that a patient on lithium for bipolar disorder has started ibuprofen regularly for arthritis pain. What is the primary concern?
- Ibuprofen reduces lithium absorption from the GI tract
- NSAIDs decrease renal clearance of lithium, raising serum levels toward toxicity (Correct answer)
- Ibuprofen accelerates lithium metabolism via CYP450 induction
- This combination has no significant clinical interaction
Correct answer: NSAIDs decrease renal clearance of lithium, raising serum levels toward toxicity
NSAIDs inhibit prostaglandin-mediated renal blood flow, reducing lithium clearance and potentially causing lithium toxicity.
Question 4: A 72-year-old patient is prescribed temazepam for insomnia. What Beers Criteria concern should the pharmacist raise?
- Temazepam is contraindicated in patients over 65 due to hepatic metabolism
- Benzodiazepines increase risk of cognitive impairment, falls, and motor vehicle accidents in older adults (Correct answer)
- Temazepam causes clinically significant QTc prolongation in elderly patients
- There is no special concern; temazepam is preferred for elderly insomnia
Correct answer: Benzodiazepines increase risk of cognitive impairment, falls, and motor vehicle accidents in older adults
The Beers Criteria lists benzodiazepines as potentially inappropriate in older adults due to increased sensitivity and risks of falls, fractures, and cognitive impairment.
Question 5: A patient with active tuberculosis is started on standard RIPE therapy. Which combination of adverse effects should the pharmacist monitor for with rifampin?
- Peripheral neuropathy and optic neuritis
- Orange discoloration of body fluids and drug-drug interactions via CYP450 induction (Correct answer)
- Hyperuricemia and hepatotoxicity
- Ototoxicity and nephrotoxicity
Correct answer: Orange discoloration of body fluids and drug-drug interactions via CYP450 induction
Rifampin is a potent CYP450 inducer causing numerous drug interactions, and it characteristically turns urine, tears, and sweat orange.
Question 6: A patient with COPD (FEV1 45% predicted) has increasing exacerbations despite LAMA monotherapy. What is the most evidence-based next step?
- Add inhaled corticosteroid (ICS) monotherapy
- Add a long-acting beta-2 agonist (LABA) to form LAMA/LABA combination (Correct answer)
- Switch to short-acting bronchodilators only
- Initiate oral corticosteroids indefinitely
Correct answer: Add a long-acting beta-2 agonist (LABA) to form LAMA/LABA combination
GOLD guidelines recommend escalation to LAMA/LABA dual bronchodilation for COPD patients with persistent symptoms or exacerbations on monotherapy before adding ICS.
Question 7: Which pharmacist action BEST demonstrates collaborative practice in developing a treatment plan for a patient with uncontrolled hypertension?
- Independently prescribe a new antihypertensive without contacting the physician
- Provide the patient with lifestyle pamphlets only and refer to their doctor
- Document a SOAP note with a therapeutic recommendation and communicate it directly to the prescriber (Correct answer)
- Dispense the current prescription and make no changes
Correct answer: Document a SOAP note with a therapeutic recommendation and communicate it directly to the prescriber
Documenting a structured pharmacist assessment with a specific therapeutic recommendation and communicating it to the prescriber exemplifies collaborative pharmaceutical care.
PEBC Treatment Planning 3
A 30-year-old woman with epilepsy on valproic acid 1000 mg/day is planning a pregnancy.
What is the pharmacist's MOST important recommendation?