Clinical Pharmacy and Therapeutics Flashcards

A pharmacist is advising on antibiotic stewardship. Which practice is the most important principle of antibiotic stewardship?

Answer: Using the narrowest-spectrum antibiotic for the shortest effective duration based on culture/sensitivity

Antibiotic stewardship aims to optimize antibiotic use to minimize resistance and adverse effects. Core principles: right drug, right dose, right duration, narrowest effective spectrum. De-escalation (switching to narrower spectrum once results available) and minimizing duration reduce resistance and C. diff rates.

A patient develops hypertensive crisis (BP 220/120 mmHg) with encephalopathy. What is the pharmacist's recommendation for immediate management?

Answer: IV labetalol or IV nicardipine — reduce BP by 20–25% in first hour (not to normal immediately)

Hypertensive emergency requires IV antihypertensives (labetalol, nicardipine, clevidipine) with a controlled reduction of 20–25% in the first hour (rapid normalization can cause ischemic stroke, MI). Sublingual nifedipine is no longer recommended due to unpredictable rapid falls causing ischemia.

A patient with osteoporosis is prescribed alendronate. Which counseling point is most important?

Answer: Take on an empty stomach with a full glass of water, remain upright for 30 minutes after taking

Bisphosphonates (especially alendronate) have poor oral absorption (<1%) and must be taken fasting with plain water. Remaining upright for 30 minutes prevents esophageal reflux and esophagitis/ulceration — the most clinically significant side effect of oral bisphosphonates.

A patient with rheumatoid arthritis is being started on methotrexate (MTX). Which monitoring is required at baseline and during therapy?

Answer: CBC, liver function tests, renal function, and chest X-ray — hepatotoxicity, myelosuppression, pulmonary toxicity

Methotrexate causes hepatotoxicity (fibrosis/cirrhosis with long-term use), myelosuppression (bone marrow suppression), and pulmonary toxicity (MTX pneumonitis). Baseline and regular CBC, LFTs, and renal function are mandatory. Folic acid 5 mg once weekly (not on MTX day) reduces mucositis and GI side effects.

A pharmacist is performing medication reconciliation for a newly admitted patient. Which is the most important purpose of medication reconciliation?

Answer: Identifying discrepancies (omissions, duplications, interactions) between home medications and hospital orders to prevent medication errors

Medication reconciliation compares the patient's complete home medication list with hospital orders at every transition of care (admission, transfer, discharge). Its primary purpose is identifying and resolving discrepancies — unintentional omissions, duplications, wrong doses, or interactions — that commonly cause adverse drug events.

A patient with systolic heart failure (HFrEF) is on ramipril and carvedilol. The pharmacist notes their serum potassium is 5.6 mEq/L. What adjustment is most appropriate?

Answer: Hold or reduce the dose of spironolactone/eplerenone if prescribed; evaluate ACE inhibitor dose; dietary potassium restriction

Hyperkalemia (K+ >5.5 mEq/L) in heart failure is commonly caused by ACE inhibitors (reduce aldosterone, retain K+) and MRAs (spironolactone). Management includes reviewing and potentially reducing/holding potassium-retaining drugs, dietary counseling, and loop diuretics if needed. Carvedilol does not significantly affect potassium.