Clinical Pharmacy and Therapeutics Flashcards

A patient with type 2 diabetes has HbA1c of 9.5% and is on maximum dose metformin. What is the most appropriate next step?

Answer: Add a second agent — SGLT2 inhibitor or GLP-1 agonist preferred if cardiovascular disease present

Current diabetes guidelines recommend step-up therapy when glycemic targets are not met. If cardiovascular disease (CVD) or CKD is present, SGLT2 inhibitors (e.g., empagliflozin) or GLP-1 receptor agonists (e.g., semaglutide) have proven cardiovascular/renal benefits beyond glucose lowering.

A patient with newly diagnosed atrial fibrillation (AF) requires anticoagulation. Which direct oral anticoagulant (DOAC) is the preferred choice over warfarin?

Answer: DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred due to predictable pharmacokinetics and no routine monitoring

DOACs are preferred over warfarin for non-valvular AF due to predictable pharmacokinetics (no routine INR monitoring), fewer drug interactions, no dietary restrictions, and superior or equivalent efficacy with lower intracranial hemorrhage risk. Warfarin is still used in mechanical heart valves and significant renal failure.

A pharmacist counsels a patient starting a statin for the first time. Which side effect should the patient be specifically instructed to report?

Answer: Muscle pain, weakness, or dark urine — possible myopathy or rhabdomyolysis

Statins can cause myopathy (muscle pain, weakness, elevated CK) and, rarely, rhabdomyolysis (muscle breakdown causing dark urine from myoglobinuria and potentially acute renal failure). Patients should report these symptoms promptly. Risk increases with concurrent CYP3A4 inhibitors and high-dose statins.

Which agent is preferred for acute treatment of status epilepticus in an adult?

Answer: IV lorazepam or IV diazepam (benzodiazepine first-line)

Status epilepticus is a medical emergency. IV benzodiazepines (lorazepam 4 mg or diazepam 10 mg IV) are first-line treatment, acting rapidly by enhancing GABA at the GABA-A receptor. If benzodiazepines fail, IV fosphenytoin, levetiracetam, or valproate are second-line options.

A patient is on long-term proton pump inhibitor (PPI) therapy. Which complication should the pharmacist monitor for?

Answer: Hypomagnesemia, vitamin B12 deficiency, and increased risk of Clostridioides difficile infection

Long-term PPI use is associated with: hypomagnesemia (impaired intestinal Mg absorption), vitamin B12 deficiency (requires acidic environment for absorption), increased C. diff infection risk (reduced gastric acid barrier), and possible increased fracture risk. Annual review of PPI necessity is recommended.

Which therapeutic drug monitoring (TDM) parameter is most important for aminoglycoside dosing to prevent nephrotoxicity?

Answer: Trough level (pre-dose concentration) — trough >2 mg/L increases nephrotoxicity risk with multiple daily dosing

For traditional multiple-daily dosing aminoglycoside regimens, trough levels (<2 mg/L for gentamicin) are monitored to prevent nephrotoxicity (renal cortical accumulation) and ototoxicity. Peak levels predict efficacy. For once-daily dosing, AUC/MIC and the Hartfeller protocol are used.