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Answer: (c and d). The active ingredient founds in Paxlovid are Nirmatrelvir and Ritonavir. Nirmatrelvir is a SARS-CoV-2 main protease (Mpro) inhibitor, and Ritonavir is an HIV-1 protease inhibitor and CYP3A inhibitor. Nirmatrelvir is available as immediate-release, film-coated tablets. Each tablet contains 150 mg Nirmatrelvir. Ritonavir is available as film-coated tablets. Each tablet contains 100 mg Ritonavir. The U.S. Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for the emergency use of the unapproved product Paxlovid for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral testing, and who are at high risk1 for progression to severe COVID-19, including hospitalization or death. Paxlovid may only be prescribed for an individual patient by physicians, advanced practice registered nurses, a licensed pharmacist and physician assistants that are licensed or authorized under state law to prescribe drugs in the therapeutic class to which Paxlovid belongs (i.e., ant infectives). Nirmatrelvir must be co-administered with ritonavir. Failure to correctly co-administer Nirmatrelvir with ritonavir may result in plasma levels of Nirmatrelvir that are insufficient to achieve the desired therapeutic effect. The dosage for Paxlovid is 300 mg Nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) with all three tablets taken together orally twice daily for 5 days. Prescriptions should specify the numeric dose of each active ingredient within Paxlovid. Completion of the full 5-day treatment course and continued isolation in accordance with public health recommendations are important to maximize viral clearance and minimize transmission of SARS-CoV-2. The 5-day treatment course of Paxlovid should be initiated as soon as possible after a diagnosis of COVID-19 has been made, and within 5 days of symptom onset. Should a patient require hospitalization due to severe or critical COVID-19 after starting treatment with Paxlovid, the patient should complete the full 5-day treatment course per the healthcare provider's discretion. Paxlovid (both Nirmatrelvir and Ritonavir tablets) can be taken with or without food. Dysgeusia, diarrhea, hypertension, and myalgia are reported side effects of Paxlovid.

137

Multiple options

c and d

What is the active ingredient found in Paxlovid?

Answer: (b). The SARS-CoV-2 RNA codes for a pair of protease enzymes that are essential to production of viable virions upon release. Since protease inhibitors have been highly effective for treating patients with infections of human immunodeficiency virus and hepatitis C virus, that is the best choice. Use of neuraminidase inhibitors (e.g., oseltamivir, peramivir, zanamivir) is not logical, since coronaviruses do not have a gene for neuraminidase. Nucleoside analogues (e.g., acyclovir, ganciclovir, ribavirin) would be expected to exert effects only at high levels since the coronavirus has an exonuclease that would recognize and remove the analogues when incorporated into the viral genome. It is currently unknown as to whether angiotensin converting enzyme (ACE) inhibitors or angiotensin-2 receptor blockers (ARBs) are beneficial or harmful based on changes in the ACE2 protein involved in viral entry in lung tissue.

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b

Based on the genetic make-up of SARS-CoV-2, which of the following drug classes is most likely to prove effective?

Answer: (a). The active ingredient found in Olumiant is Baricitinib. It is a Janus kinase (JAK) inhibitor indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies. 1. The recommended dose of Olumiant (Baricitinib) in patients taking strong Organic Anion Transporter 3 (OAT3) inhibitors (e.g., probenecid) is 1 mg once daily. 2. The recommended dose of Olumiant (Baricitinib) in patients with moderate renal impairment is 1 mg once daily. 3. Olumiant (Baricitinib) is not recommended in patients with severe renal impairment. 4. Olumiant (Baricitinib) is not recommended in patients with severe hepatic impairment.

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None

a

The recommended dose of Olumiant in patients taking strong Organic Anion Transporter 3 (OAT3) inhibitors is _____________.

Answer: b The active ingredient found in Olumiant is Baricitinib. It is a Janus kinase (JAK) inhibitor indicated for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies. The recommended dose of Olumiant is 2 mg once daily. Upper respiratory tract infections, nausea, herpes simplex, and herpes zoster are commonly reported side effects of the drug. The drug also has shown promising result for the treatment of Covid-19 infection when administered simultaneously with Remdesivir.Olumiant (Baricitinib) in combination with Veklury (Remdesivir) cuts the median recovery time by about a day, compared to patients treated with Remdesivir alone.

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b

Which of the following statements would indicate that a patient understands why he is taking Olumiant?

Answer: (a). The active ingredient found in Veklury is Remdesivir. Veklury (Remdesivir) is authorized for use under an Emergency Use Authorization (EUA) only for the treatment of adult and pediatric patients hospitalized with suspected or laboratory-confirmed COVID-19, and for whom use of an intravenous (IV) agent is clinically appropriate. Veklury must be administered via IV infusion. It is only administered intravenously in a hospital setting under the care of a physician. Remdesivir is an adenosine nucleotide prodrug that distributes into cells where it is metabolized to form the pharmacologically active nucleoside triphosphate metabolite. Metabolism of Remdesivir to Remdesivir triphosphate has been demonstrated in multiple cell types. Remdesivir triphosphate acts as an analog of adenosine triphosphate (ATP) and competes with the natural ATP substrate for incorporation into nascent RNA chains by the SARS-CoV-2 RNA-dependent RNA polymerase, which results in delayed chain termination during replication of the viral RNA. Remdesivir triphosphate is a weak inhibitor of mammalian DNA and RNA polymerases with low potential for mitochondrial toxicity.

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a

Veklury must be administered:

Answer: (a,b,c,e) The COVID-19 often begins with malaise, dry cough, dyspnea, fatigue, and feeling of fever. It progresses over an 11- to 14-day period. It has incubation period of 2- to 14-day. Some patients have had nausea, vomiting, and diarrhea. In contrast to the sudden onset people report with influenza, progression of symptoms with SARS-CoV-2 have a slower onset. During early phases of viral spread, symptoms began an average of 3.5 days (not 7 days) before patients sought medical or emergent care. Fever occurs in almost all symptomatic patients (89%), cough is very common (68%), and some patients have fatigue (38%), sputum production (33%), shortness of breath (19%), sore throat (14%), and headache (14%).

132

Multiple options

a,b,c,e

Which of the following statements is/are TRUR ABOUT Covid-19?

Answer: (a,b,c,e) The COVID-19 often begins with malaise, dry cough, dyspnea, fatigue, and feeling of fever. It progresses over an 11- to 14-day period. It has incubation period of 2- to 14-day. Some patients have had nausea, vomiting, and diarrhea. In contrast to the sudden onset people report with influenza, progression of symptoms with SARS-CoV-2 have a slower onset. During early phases of viral spread, symptoms began an average of 3.5 days (not 7 days) before patients sought medical or emergent care. Fever occurs in almost all symptomatic patients (89%), cough is very common (68%), and some patients have fatigue (38%), sputum production (33%), shortness of breath (19%), sore throat (14%), and headache (14%).

131

Multiple options

a,b,c,e

Which of the following statements is/are TRUR ABOUT Covid-19?

Answer:(d). About 5% of patients with COVID-19 (one-fourth of those needing hospitalization) present with advanced symptoms or become critically ill as viral damage in the lungs results in acute respiratory distress syndrome. Multi-organ failure occurs later in the disease course; changes in smell and taste and nonproductive cough are early symptoms of COVID-19.

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None

d

The transition from mild/moderate symptoms to more severe stages of COVID-19 is marked by the onset of:

Answer: (d). Liver toxicity with acetaminophen may occur and is a serious, dose-dependent effect. The maximum recommended dosage is 75 mg/kg/day (adults not to exceed 4 g/d), and products carry warnings about exceeding this dose. Signs associated with acetaminophen toxicity can mimic influenza symptoms and may include nausea, vomiting, diarrhea, and excessive sweating. This may lead parents and caregivers to administer more medication to the child. Care should be taken not to exceed this threshold by administering higher doses more frequently than recommended. In 2011 and 2012, the manufacturer of brand-name Tylenol products voluntarily reduced the maximum daily dosage to 3000 mg (6 tablets), with the dosing interval changed from 2 tablets every 4 to 6 hours to 2 tablets every 6 hours; the maximum daily dosage for Regular Strength Tylenol has been reduced to 3250 mg. However, generic manufacturers may still have a maximum dose of 4000 mg on the product label.

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d

Liver toxicity with acetaminophen may occur and is a serious, dose-dependent effect. The maximum recommended dosage is:

Answer: (c) The active ingredient found in Xofluza (Baloxavir marboxil) is Baloxavir marboxil. Xofluza (Baloxavir marboxil) is a polymerase acidic (PA) endonuclease inhibitor. Baloxavir marboxil is a prodrug that is converted by hydrolysis to baloxavir, the active form that exerts anti-influenza virus activity. Baloxavir inhibits the endonuclease activity of the polymerase acidic (PA) protein, an influenza virus-specific enzyme in the viral RNA polymerase complex required for viral gene transcription, resulting in inhibition of influenza virus replication.

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c

The probable mechanism of action of Baloxavir Marboxil?

Answer: (b). Prescription antiviral medications with influenza virus activity may be useful adjuncts in influenza prevention and treatment and are most effective when administered within 48 hours of symptom onset.

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b

Prescription antiviral medications with influenza virus activity may be useful adjuncts in influenza prevention and treatment and are most effective when administered within _______ of symptom onset.

Answer: (c) Influenza is named according to the type, the location of initial isolation, the strain designation, and the year of isolation. For example, A/Texas/50/2012 (H3N2), or H3N2, is influenza type A with origin in Texas, with strain No. 50, isolated in 2012 and of the H3N2 subtype.

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c

What is a strain number of influenza virus in A/Texas/50/2012 (H3N2)?

Answer (b,c): Salicylates, like NSAIDs, work by inhibiting prostaglandin synthesis by inhibiting both COX-1 and COX-2 enzymes; however, salicylates do so in an irreversible manner, while NSAIDs do so reversibly. Absorption in the gut is affected by the dosage form, gastric pH, gastric emptying time, dissolution rate, and food/antacids. Aspirin is widely bioavailable with an onset of analgesia within 30 minutes and lasting 4 to 6 hours. FDA-approved uses for salicylates include treatment of symptoms for osteoarthritis, rheumatoid arthritis, and other rheumatologic diseases, as well as temporary relief of minor aches and pains associated with backache or muscle aches. High-dose aspirin (900-1000 mg) has been established as an effective treatment option for acute migraine. Aspirin causes dyspepsia and GI irritation even more frequently than OTC NSAIDs.

125

Multiple options

b,c

In which aspect, Salicylate is different from NSAIDs?

The active ingredient found in Botox is OnabotulinumtoxinA. It is an acetylcholine release inhibitor and a neuromuscular blocking agent. Botox (OnabotulinumtoxinA) blocks neuromuscular transmission by binding to acceptor sites on motor or autonomic nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. This inhibition occurs as the neurotoxin cleaves SNAP-25, a protein integral to the successful docking and release of acetylcholine from vesicles situated within nerve endings. When injected intramuscularly at therapeutic doses, Botox (OnabotulinumtoxinA) produces partial chemical denervation of the muscle resulting in a localized reduction in muscle activity. In addition, the muscle may atrophy, axonal sprouting may occur, and extrajunctional acetylcholine receptors may develop. There is evidence that reinnervation of the muscle may occur, thus slowly reversing muscle denervation produced by Botox (OnabotulinumtoxinA). When injected intradermally, Botox (OnabotulinumtoxinA) produces temporary chemical denervation of the sweat gland resulting in local reduction in sweating. Following intradetrusor injection, Botox (OnabotulinumtoxinA) affects the efferent pathways of detrusor activity via inhibition of acetylcholine release.

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None

c

Botox (OnabotulinumtoxinA) inhibits the release which of the following?

Answer: (d,e). Acetaminophen has been shown in studies to reduce pain, as well as improve photophobia and phonophobia in individuals with migraine and tension-type headache. They have not been shown to improve symptoms of nausea, vomiting, or blurry vision with migraine.

123

Multiple options

d,e

At 1000 mg dose, Acetaminophen is usually effective treating which of the following Migraine related symptoms? [Select ALL THAT APPLY]

Answer: (a,c,d) 1. Tension-type headaches often are caused by stress, depression, anxiety, emotional conflicts, or other stimuli. 2. They are sometimes called stress headaches and may result from pericranial muscle contraction. 3. Patients experience bilateral symptoms that may be over the top of the head to the neck and vary from diffuse ache to tight, pressing, and constricting pain. 4. They have gradual onset and may last minutes to days. 5. They are not accompanied by nausea or vomiting but may have either mild photophobia or phonophobia. 6. Routine physical activity such as walking or climbing stairs does not aggravate the headache. 7. Tension-type headaches may be episodic or chronic. Episodic headaches occur less than 15 days per month. Chronic headaches occur 15 or more days per month for at least 3 months.

122

Multiple options

a,c,d

Which of the following statements is NOT TRUE about the tension-type headaches?

Answer (b): Headaches are classified as primary or secondary according to the International Classification of Headache Disorders (ICHD) 2018. Primary headaches are not caused by underlying illness. ICHD further classifies primary headaches as tension-type headache, migraine, trigeminal autonomic cephalalgias, or other primary headache disorders. Secondary headaches are associated with an underlying condition (e.g., head injury or trauma, infection, stroke, substance withdrawal, or facial or cranial disorders). Medication-overuse headaches are considered secondary by ICHD although they are not caused by an underlying disease (but are attributed to the withdrawal effect of analgesic medication).

121

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b

Medication-overuse headache is generally classified as a:

Answer: (c). The active ingredient found in Qdolo is Tramadol hydrochloride. It is available as an oral solution. It is a schedule IV controlled substance. The simultaneous administration of Ultram (Tramadol) with Qdolo (Tramadol) is considered duplication of therapy; concurrent use should be avoided. Qdolo is an opioid agonist indicated in adults for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. Start at 25 mg/day and titrate in 25 mg increments as separate doses every 3 days to reach 100 mg/day (25 mg four times a day). Thereafter the total daily dose may be increased by 50 mg as tolerated every 3 days to reach 200 mg /day (50 mg four times a day). After titration, Qdolo 50 mg to 100 mg can be administered as needed for pain relief every 4 to 6 hours not to exceed 400 mg/day. Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for use in patients for whom alternative treatment options are inadequate; limit dosages and durations to the minimum required; and follow patients for signs and symptoms of respiratory depression and sedation. Monitor patients closely for respiratory depression, especially within the first 24–72 hours of initiating therapy and following dosage increases with Qdolo and adjust the dosage accordingly. The most common incidence of treatment-emergent adverse events in patients from clinical trials were dizziness/vertigo, nausea, constipation, headache, somnolence, vomiting and pruritus.

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c

The simultaneous administration of which of the following with Qdolo is considered as a duplication of therapy?

Answer: (a,d,e) The active ingredient found in Spravato is Esketamine. It is available in a nasal spray. It is a schedule III controlled substance. Spravato is a non-competitive N-methyl D-aspartate (NMDA) receptor antagonist indicated, in conjunction with an oral antidepressant, for the treatment of: 1. Treatment-resistant depression (TRD) in adults. 2. Depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior. Spravato is administered intranasally under the supervision of a healthcare provider. The recommended dosage of Spravato (Esketamine) for the treatment of depressive symptoms in adults with MDD with acute suicidal ideation or behavior is 84 mg twice per week for 4 weeks. Dosage may be reduced to 56 mg twice per week based on tolerability. Spravato (Esketamine) is for nasal use only. The nasal spray device delivers a total of 28 mg of Esketamine. To prevent loss of medication, do not prime the device before use. Use 2 devices (for a 56 mg dose) or 3 devices (for an 84 mg dose), with a 5-minute rest between use of each device. Dissociation, dizziness, nausea, sedation, vertigo, hypoesthesia, anxiety, lethargy, blood pressure increased, vomiting, and feeling drunk are commonly reported side effects of Spravato. Because of the risks for sedation, dissociation, and abuse and misuse, Spravato (Esketamine) is only available through a restricted program called the Spravato (Esketamine) Risk Evaluation and Mitigation Strategy (REMS) Program. Spravato (Esketamine) can only be administered at healthcare settings certified in the Spravato (Esketamine) REMS Program and to patients enrolled in the program.

119

Multiple options

a,d,e

Which of the following statements is/are TRUE ABOUT Spravato? .

Answer (c) The active ingredient found in Kesimpta is Ofatumumab. It is available in a single-dose prefilled syringe. Kesimpta (Ofatumumab) is a CD20-directed cytolytic antibody indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. The precise mechanism by which Ofatumumab exerts its therapeutic effects in multiple sclerosis is unknown, but is presumed to involve binding to CD20, a cell surface antigen present on pre-B and mature B lymphocytes. Following cell surface binding to B lymphocytes, ofatumumab results in antibody-dependent cellular cytolysis and complement-mediated lysis. Hepatitis B virus (HBV) and quantitative serum immunoglobulins screening are required before the first dose. Initial Dosing: 20 mg subcutaneously administered at Week 0, 1, and 2. Subsequent Dosing: 20 mg subcutaneously administered monthly starting at Week 4. Respiratory tract infection, headache, injection-related reactions, and local injection site reactions are reported side effects of drug.

118

None

c

Kesimpta (Ofatumumab) is indicated for the treatment of:

Answer (b,c)

117

Multiple options

b,c

Which of the following glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is administered subcutaneously once daily? .

Answer: (a,c). The active ingredient found in Winlevi is Clascoterone. It is available as cream. Each gram of Winlevi cream contains 10 mg of Clascoterone. It is an androgen receptor inhibitor indicated for the topical treatment of acne vulgaris in patients 12 years of age and older. Erythema/reddening, pruritus, scaling/dryness, edema, stinging, and burning are commonly reported side effects of Winlevi. Clascoterone is first-in-class topical androgen receptor inhibitor that tackles the androgen hormone component of acne in both males and females. Androgen receptor inhibitors act by limiting the effects of these hormones on increasing sebum production and inflammation. Acne is a multifactorial skin condition, affected by four distinct pathways: excess oil (sebum) production, clogged pores (hyperkeratinization), bacteria growth (C. acnes), and inflammation. Topical treatment options that target androgens, which largely drive sebum production and inflammation, presented a significant unmet need in the acne treatment market until now. Elevated potassium levels (Hyperkalemia) were observed in some patients during the clinical trials.

116

Multiple options

a,c

Which of the following statements is/are TRUE ABOUT Winlevi? .

Answer: (a,b,c) The active ingredient found in Rybelsus is Semaglutide. It is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: 1. an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Rybelsus should be taken: 1. Take on an empty stomach when you first wake up. 2. Take with no more than 4 ounces of plain water. 3. Wait at least 30 minutes before eating, drinking, or taking other oral medications. Instruct patients to take Rybelsus (Semaglutide) at least 30 minutes before the first food, beverage, or other oral medications of the day with no more than 4 ounces of plain water only. Waiting less than 30 minutes, or taking with food, beverages (other than plain water) or other oral medications will lessen the effect of Rybelsus (Semaglutide). Waiting more than 30 minutes to eat may increase the absorption of Rybelsus (Semaglutide). Swallow tablets whole. Do not cut, crush, or chew tablets. Start Rybelsus (Semaglutide) with 3 mg once daily for 30 days. After 30 days on the 3 mg dose, increase the dose to 7 mg once daily. Dose may be increased to 14 mg once daily if additional glycemic control is needed after at least 30 days on the 7 mg dose.

115

Multiple options

a,b,c

How one should take Rybelsus? [Select All That Apply]

Answer: (b) I and II only. Ozempic (Semaglutide) is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: 1. an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. 2. to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease. It is available as 0.5 or 1 mg subcutaneous injection. It is not indicated for use in type 1 diabetes mellitus or treatment of diabetic ketoacidosis. The recommended starting dose is 0.25 mg once weekly. After 4 weeks, increase the dose to 0.5 mg once weekly. If after at least 4 weeks additional glycemic control is needed, increase to 1 mg once weekly. It can be administered once weekly at any time of day, with or without meals. The oral dosage form of this drug is available under the brand name of Rybelsus. It is available in 7 mg or 14 mg tablets. The tablet dosage form is indicated as: 1. an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. The most common adverse reactions, reported in greater than 5% of patients treated with Ozempic (Semaglutide) are: nausea, vomiting, diarrhea, abdominal pain and constipation.

114

None

b

Ozempic (Semaglutide) is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: I. an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. II. to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease. III. an adjunct to diet and exercise to improve glycemic control in adults with type 1 diabetes mellitus.

Answer: (a, d, c and e). Epidiolex (Cannabidiol) is a prescription medicine that is used to treat seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older. It is not known if Epidiolex (Cannabidiol) is safe and effective in children under 2 years of age. The active ingredient found in Epidiolex (Cannabidiol) is Cannabidiol. It is the first and Only FDA-Approved Prescription Cannabidiol (CBD). It is classified as a schedule V controlled drug. The recommended starting dosage is 2.5 mg/kg (Not 20 mg/kg) taken twice daily (5 mg/kg/day). After one week, the dosage can be increased to a maintenance dosage of 5 mg/kg twice daily (10 mg/kg/day). Epidiolex (Cannabidiol) can cause transaminase elevations. Concomitant use of valproate and higher doses of Epidiolex (Cannabidiol) increase the risk of transaminase elevations. The therapy should be monitored by regularly checking serum transaminases (ALT and AST) and total bilirubin levels. The most common side effects of Epidiolex (Cannabidiol) include sleepiness, decreased appetite, diarrhea, increase in liver enzymes, feeling very tired and weak, rash, sleep problems, and infections.

113

Multiple options

a, d, c and e

Which of the following information is/are TRUE about Epidiolex? [Select All That Apply]

Answer: (d) All. Preeclampsia is a condition during pregnancy where there is a sudden rise in blood pressure and swelling, mostly in the face, hands, and feet. Signs and symptoms associated with preeclampsia: 1. a headache that persists 2. swelling of the face or hands 3. changes in eyesight 4. sudden weight gain 5. shoulder pain 6. nausea and vomiting

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None

d

What are signs and symptoms of preeclampsia? I. a persistent headache II. swelling of the face or hands III. shoulder pain

Answer: (a, d and e). A menstrual migraine headache may occur before, during, or after a period whereas premenstrual syndrome (PMS) headaches typically occur before a period begins. Acute migraine headaches are normally reported when the level of estrogen in the body drops (not rises) significantly. Around 60% (not 10%) of females who experience migraine report that menstruation is a trigger for these headaches. Other symptoms of a menstrual migraine headache tend to include: 1. sensitivity to bright lights 2. sensitivity to noise 3. throbbing pain on one side of the head 4. nausea 5. vomiting

111

Multiple options

a, d and e

Which of the following information is/are TRUE ABOUT headaches during menstrual period? [Select All That Apply]

Answer: (a, b, d and e). Oscillopsia is the sensation that the surrounding environment is constantly in motion when it is, in fact, stationary. It usually occurs as a result of conditions that affect eye movement or alter how parts of the eye, inner ear, and brain stabilize images and maintain balance. The American Psychological Association describe oscillopsia as "the sensation of perceiving oscillating movement of the environment." It often links to types of nystagmus (not ataxia), which is a condition that causes abnormal or involuntary eye movement. Some of the most common conditions that experts have associated with oscillopsia include: 1. neurological conditions, such as seizures, multiple sclerosis, and superior oblique myokymia 2. brain or head injuries, especially bilateral vestibular cerebellar injuries 3. conditions, such as stroke, that affect the eye muscles or muscles around the eyes 4. conditions that affect or damage the inner ear, including Meniere's disease 5. conditions that cause brain inflammation, such as tumors or meningitis

110

Multiple options

a, b, d and e

Which of the following information is/are TRUE ABOUT Oscillopsia? [Select All That Apply]

Answer: (e). Valtoco (diazepam nasal spray) is indicated for the acute treatment of intermittent, stereotypic episodes of frequent seizure activity (ie, seizure clusters, acute repetitive seizures) that are distinct from a patient’s usual seizure pattern in patients with epilepsy 6 years of age and older. Valtoco is a proprietary formulation of diazepam incorporating the Science of Intravail. Intravail transmucosal absorption enhancement technology enables the non-invasive delivery of a broad range of protein, peptide and small molecule drugs.

109

None

e

The FDA has recently approved Valtoco (Diazepam). How is it administered to a patient?

Answer: (b,c and d). According to the National Institute of Mental Health, about 0.6% of adults in the United States experienced anorexia between 2001 and 2003, compared to 0.3% who experienced bulimia. There are essential differences between anorexia and bulimia, and it is possible for a person to have both at the same time. People with anorexia and bulimia may fixate on weight and appearance, and they may have a distorted body image. Both conditions result in a person trying to lose weight using unhealthy strategies. There are key differences between anorexia and bulimia. People with anorexia tend to adopt extreme diets. They may restrict their food intake to a degree that can lead to malnourishment and even death. Some people with anorexia exercise to excess. If a person is already malnourished, this amount of exercise may cause them to faint or experience other potentially severe adverse effects. Also, a person with anorexia may vomit or take laxatives to lose weight. The primary characteristic of bulimia is episodes of binge eating followed by 'purging.' An episode may involve overeating and later vomiting, using laxatives, or administering enemas to get rid of the calories consumed. The primary symptom of anorexia is restricting food intake with extreme dieting. The main symptom of bulimia is compensating for episodes of overeating by trying to purge the food. Anorexia can cause a person to: lose weight rapidly avoid meals eat very little at meals try to hide how much they eat have brittle hair and nails fixate on their weight develop anemia have constipation experience weakness experience fainting and fatigue stop menstruating, which doctors call amenorrhea develop infertility experience organ failure Some signs and symptoms of bulimia include: frequent overeating eating in secret disappearing after meals having a swollen throat or neck developing acid reflux having oral health problems, such as tooth loss or broken teeth experiencing severe dehydration having electrolyte imbalances, which can cause health problems

108

Multiple options

b,c and d

What is the primary sign or symptom that differentiate bulimia from anorexia? [Select All That Apply]

Answer: (b). Hypertrophic cardiomyopathy. 1. Dilated cardiomyopathy: Dilated cardiomyopathy is the most common form of the disease. It typically occurs in adults between the ages of 20 and 60 years. The disease often starts in the left ventricle, but it can eventually also affect the right ventricle. Dilated cardiomyopathy can affect the structure and function of the atria, too. 2. Hypertrophic cardiomyopathy: Hypertrophic cardiomyopathy is a genetic condition in which abnormal growth of the heart muscle fibers occurs, leading to the thickening or "hypertrophy"of these fibers. The thickening makes the chambers of the heart stiff and affects blood flow. It can also increase the risk of electrical disturbances, called arrhythmias. According to the Children's Cardiomyopathy Foundation, it is the second most common form of cardiomyopathy in children. In about one-third of affected children, diagnosis occurs before the age of 1 year. 3. Restrictive cardiomyopathy: Restrictive cardiomyopathy occurs when the tissues of the ventricles become rigid and cannot fill with blood properly. Eventually, it may lead to heart failure. It is more common in older adults and can result from infiltrative conditions — those involving the accumulation of abnormal substances in bodily tissues — such as amyloidosis. 4. Arrhythmogenic cardiomyopathy: In arrhythmogenic cardiomyopathy, fibrotic and fatty tissue replaces the healthy tissues of the right ventricle, which may cause irregular heart rhythms. In some cases, this process can also occur in the left ventricle. According to research in the journal Circulation Research, arrhythmogenic cardiomyopathy increases the risk of sudden cardiac death, especially in young people and athletes. It is a hereditary genetic condition. Symptoms: In some cases, usually mild ones, there are no symptoms of cardiomyopathy. However, as the condition progresses, a person may experience the following symptoms with varying degrees of severity:

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None

b

Which of the following is a genetic condition in which abnormal growth of the heart muscle fibers occurs, leading to the thickening of these fibers?

Answer: (d). All. Pharmacists should be able to recognise red flag signs and symptoms of PND and refer these patients immediately. Red flag signs for postnatal depression:

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None

d

Pharmacists should be able to recognise red flag signs of Postnatal depression (PND) and refer these patients immediately. Which of the following is/are Red flag signs or symptoms for postnatal depression? I. Recent significant change in mental state or emergence of new psychiatric symptoms II. New thoughts or acts of violent self-harm. III. New and persistent expressions of incompetency as a mother, such as being over-critical for not recognising what the baby needs.

Answer: (a,b,c,d,e). All. Pharmacists are likely to encounter patients affected by postnatal depression, therefore the ability to identify signs of this under-recognised disorder is essential for appropriate and prompt referral for help and support. Maternal suicide remains the leading cause of death from a direct cause in the postnatal period, accounting for around 22% of maternal deaths reported in the UK between 2014 and 2016. With around 10% of women experiencing a mental health problem during pregnancy or postpartum, it is important for all healthcare professionals to understand and recognise the risk factors for perinatal mental health problems and know where to refer patients. Postnatal depression (PND) can begin at any time within one year after delivery. It is a relatively common condition that occurs in around 10–15% of women following childbirth and around 10% of new fathers, although it is thought that the true prevalence is higher than this. PND can also occur following miscarriage, stillbirth or in parents who adopt a child. In England, it is thought that particular ethnic groups (e.g. Asian women and women from a non-English speaking background) may be affected to a greater extent. This is possibly owing to cultural beliefs around depression, lack of integration and language barriers making it difficult to express difficulties in the postnatal period. Many women will be emotional or experience mild mood changes in the first week after having a baby (referred to as the ‘baby blues’), but these feelings should be self-limiting. In PND, these feelings last longer. Similar to depression, patients may experience a persistent low mood, lack of interest and enjoyment in usual activities, low self-esteem or lack of energy. In addition, they may feel as though they are a bad parent, are unable to cope with their baby or may feel indifferent to their baby. Citation: https://www.pharmaceutical-journal.com/cpd-and-learning/learning-article/postnatal-depression-recognition-and-diagnosis/20207360.article?firstPass=false

105

Multiple options

a,b,c,d,e

Which of the following statements is/are TRUE about postnatal depression (PND)? [Select All That Apply]

Answer: (d). All. Lynparza (Olaparib) is an inhibitor of the mammalian polyadenosine 5’-diphosphoribose polymerase (PARP) enzyme. Lynparza (Olaparib) tablets for oral administration contain 100 mg or 150 mg of Olaparib. It is indicated for treatments of: 1. First-Line Maintenance Treatment Of BRCA-Mutated Advanced Ovarian Cancer 2. Maintenance Treatment Of Recurrent Ovarian Cancer 3. Advanced gBRCA-Mutated Ovarian Cancer After 3 Or More Lines Of Chemotherapy 4. Germline BRCA-Mutated HER2-Negative Metastatic Breast Cancer 5. Maintenance Treatment Of gBRCA-Mutated Pancreatic cancer The recommended dose of Lynparza (Olaparib) is 300 mg (two 150 mg tablets) taken orally twice daily, with or without food, for a total daily dose of 600 mg. Myelodysplastic Syndrome, Acute Myeloid Leukemia, Pneumonitis, fatigue, nausea, vomiting and fatal toxicity are reported side effects of drug.

104

None

d

Lynparza (Olaparib) is indicated for treatment(s) of: I. Ovarian Cancer II. Metastatic Breast Cancer III. Pancreatic cancer

Answer: (a). Glaucoma is a group of eye diseases that are usually characterized by damage to the optic nerve and gradual vision loss that starts with losing peripheral (side) vision. People who have high eye pressure are at higher risk for glaucoma. Primary glaucomas: When experts don’t know what causes a type of glaucoma, that type is called a primary glaucoma. Secondary glaucomas: Sometimes glaucoma is caused by another medical condition — this is called secondary glaucoma. 1. Neovascular glaucoma Treatments: Medicines, laser treatment, surgery Neovascular glaucoma happens when the eye makes extra blood vessels that cover the part of your eye where fluid would normally drain. It’s usually caused by another medical condition, like diabetes or high blood pressure. If you have neovascular glaucoma, you may notice:

103

None

a

_______________ glaucoma happens when the eye makes extra blood vessels that cover the part of your eye where fluid would normally drain.

Answer: (c). Glaucoma is a group of eye diseases that are usually characterized by damage to the optic nerve and gradual vision loss that starts with losing peripheral (side) vision. People who have high eye pressure are at higher risk for glaucoma. Primary glaucomas: When experts don’t know what causes a type of glaucoma, that type is called a primary glaucoma. Pigmentary glaucoma is considered secondary glaucoma. 1. Open-angle glaucoma Treatments: Medicines, laser treatment, surgery Open-angle glaucoma is the most common type in the United States, where 9 in 10 people with glaucoma have the open-angle type. Many people don’t have any symptoms until they start to lose their vision, and people may not notice vision loss right away. Experts aren’t sure what causes open-angle glaucoma, but it may be caused by pressure building up in your eye. If the fluid in your eye can’t drain fast enough, it creates pressure that pushes on a nerve in the back of your eye (the optic nerve). Over time, the pressure damages the optic nerve, which affects your vision. This can eventually lead to blindness — in fact, open-angle glaucoma causes almost 2 in 10 cases of blindness in African Americans. People with high blood pressure are also at higher risk for this type. 2. Normal-tension glaucoma Treatments: Medicines, laser treatment, surgery Normal-tension glaucoma is a type of open-angle glaucoma that happens in people with normal eye pressure. About 1 in 3 people with open-angle glaucoma have the normal-tension type. You may be at higher risk for normal-tension glaucoma if you:

102

None

c

Which of the following types of glaucoma is NOT CONSIDERED a primary glaucoma?

Answer: (d) All. Refractive errors happen when the shape of your eye keeps light from focusing correctly on your retina (a light-sensitive layer of tissue at the back of your eye). Each type of refractive error is different, but they all make it hard to see clearly. Nearsightedness (myopia): Nearsightedness makes far-away objects look blurry. It happens when the eyeball grows too long from front to back, or when there are problems with the shape of the cornea (clear front layer of the eye) or the lens (an inner part of the eye that helps the eye focus). These problems make light focus in front of the retina, instead of on it. Nearsightedness usually starts between ages 6 and 14. Children who spend more time outdoors during these years are less likely to develop nearsightedness, but experts aren’t sure why. Severe nearsightedness (also called high myopia) can increase the risk of other eye conditions, like retinal detachment (when the retina is pulled away from its normal position). Farsightedness (hyperopia): Farsightedness makes nearby objects look blurry. It happens when the eyeball grows too short from front to back, or when there are problems with the shape of the cornea or lens. These problems make light focus behind the retina, instead of on it. People with farsightedness are usually born with it. Astigmatism: Astigmatism can make far-away and nearby objects look blurry or distorted. It happens when the cornea or lens has a different shape than normal, which makes light bend differently as it enters the eye. Some people with astigmatism are born with it, but many people develop it as children or young adults. People with astigmatism often have another refractive error, like nearsightedness or farsightedness. Presbyopia: Presbyopia makes it hard for middle-aged and older adults to see things up close. As you age, the lens in your eye gets harder and less flexible and stops focusing light correctly on the retina. Everyone gets presbyopia as they get older, usually after age 45. Many people have another refractive error in addition to presbyopia. Citation: https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/refractive-errors/types-refractive-errors

101

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d

Which of the following is/are Type(s) of Refractive Errors? [Select All That Apply]

Answer: (b) Ubrelvy (Ubrogepant) is indicated for the acute treatment of migraine with or without aura in adults. It is the first and only orally-administered calcitonin gene-related peptide (CGRP) receptor antagonist (gepant) for the treatment of migraine attacks once they start. Ubrelvy (Ubrogepant) provided lasting relief up to 24 hours as well. It works in a new way by blocking CGRP, a protein that is released during a migraine attack, from binding to its receptors. It works without constricting blood vessels, which some older treatments are known to do. It is non-narcotic, not scheduled, and does not have addiction potential. It has been approved with two dose strengths, 50 mg and 100 mg. The recommended dose is 50 to 100 mg by mouth for acute migraine. If needed, a patient may take second dose at least 2 hr after initial dose. Do not exceed 200 mg within 24 hours. Safety of treating greater than 8 migraines/30-day period is not established. Nausea, somnolence and dry mouth are currently reported side effects of the drug.

100

None

b

Ubrelvy (Ubrogepant) is indicated for the treatment of:

Answer: (d) Dayvigo (Lemborexant) was approved for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance in adults1. In the United States, Dayvigo (Lemborexant) will be commercially available in 5 mg and 10 mg tablets following scheduling by the U.S. Drug Enforcement Administration (DEA), which is expected to occur within 90 days. The mechanism of action of Lemborexant in the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance is presumed to be through antagonism of orexin receptors. The orexin neuropeptide signaling system plays a role in wakefulness. Blocking the binding of wake-promoting neuropeptides orexin A and orexin B to orexin receptors OX1R and OX2R is thought to suppress wake drive. Lemborexant binds to orexin receptors OX1R and OX2R and acts as a competitive antagonist with stronger inhibition effect to OX2R.

99

None

d

Dayvigo (Lemborexant), a recently approved FDA drug, is indicated for the treatment of insomnia. The probable mechanism of action of Dayvigo (Lemborexant) is:

Answer: (b) The active ingredient found in Conjupri is Levoamlodipine. It is the pharmacologically active enantiomer in Amlodipine (a racemic mixture of (R)- and (S)-Amlodipine), for the treatment of hypertension. Amlodipine is a third-generation calcium channel blocker first developed and marketed by Pfizer as Norvasc (Amlodipine besylate) tablets in 2.5 mg, 5.0 mg, and 10.0 mg in 1992. The approved Conjupri (Levoamlodipine maleate) tablets come in 1.25 mg, 2.5 mg and 5.0 mg.

98

None

b

Conjupri, a recently approved FDA drug, is the pharmacologically active enantiomer of:

Answer: (c) Rinvoq (Upadacitinib) is a Janus kinase (JAK) inhibitor indicated for the treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate. Use of Rinvoq (Upadacitinib) in combination with other JAK inhibitors, biologic DMARDs, or with potent immunosuppressants such as azathioprine and cyclosporine is not recommended. Rinvoq (Upadacitinib) may be used as monotherapy or in combination with methotrexate. The recommended dose of Rinvoq (Upadacitinib) is 15 mg once daily. It is available as extended release tablet form. It should be used with caution in patients receiving chronic treatment with strong CYP3A4 inhibitors (e.g., ketoconazole). Coadministration of Rinvoq (Upadacitinib) with strong CYP3A4 inducers (e.g. rifampin) is not recommended. Serious infections leading to hospitalization or death, including tuberculosis and bacterial, invasive fungal, viral, and other opportunistic infections, have occurred in patients receiving Rinvoq (Upadacitinib).

97

None

c

Avoid initiation or interrupt __________if absolute lymphocyte count is less than 500 cells/mm3, absolute neutrophil count is less than 1000 cells/mm3, or hemoglobin level is less than 8 g/dL.

Answer: (d) Use of Xeljanz/Xeljanz XR in combination with biologic DMARDs or with potent immunosuppressants such as azathioprine and cyclosporine is not recommended. The active ingredient found in Xeljanz is Tofacitinib. It is a Janus kinase (JAK) inhibitor. It is indicated for treatments of: 1. Rheumatoid Arthritis 2. Psoriatic Arthritis 3. Ulcerative Colitis The recommended dose is 5 mg twice daily or 11 mg once daily. It can be taken with or without food. It is available in tablet and extended release tablet forms. Do not initiate Xeljanz/Xeljanz XR in patients with an absolute lymphocyte count less than 500 cells/mm3, an absolute neutrophil count (ANC) less than 1000 cells/mm3 or who have hemoglobin levels less than 9 g/dL. Patients treated with Xeljanz/Xeljanz XR are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. If a serious infection develops, interrupt Xeljanz/Xeljanz XR until the infection is controlled.

96

None

d

Which of the following statements is NOT TRUE about Xeljanz?

Answer: (c) different indication. Tolsura (itraconazole capsules) and Sporanox (itraconazole) are azole antifungals used to treat different types of infections. Tolsura is used to treat blastomycosis, pulmonary and extrapulmonary; histoplasmosis, including chronic cavitary pulmonary disease and disseminated, non-meningeal histoplasmosis; and aspergillosis, pulmonary and extrapulmonary, in patients who are intolerant of or who are refractory to amphotericin B therapy. Sporanox is used to treat fungal infections of the lungs, mouth or throat, toenails, or fingernails. The dose of Tolsura to treat blastomycosis and histoplasmosis is 130 mg to 260 mg daily. The dose of Tolsura to treat aspergillosis is 130 mg to 260 mg daily. Dosage of Sporanox depends upon the condition for which it is being used to treat. Side effects of Tolsura and Sporanox that are similar include nausea, vomiting, skin rash, headache, diarrhea, itching, and dizziness.

95

None

c

In which way, Tolsura (Itraconazole) is different from Sporanox (Itraconazole)?

Answer (a). It must be very frustrating to have to try something new. Answer “b” does not acknowledge the patient’s feelings; answer “c” moves to finding a solution without acknowledging the patient’s feelings and “d” is placating.

94

None

a

A 35-year-old man who is a regular patient of yours comes to your pharmacy counter with a new prescription. His shoulders appear tense and his eyebrows are knit tightly. He says to you, “I can’t believe I have to fill another prescription today. I was just in three weeks ago and spent $75 dollars on some fancy new medication that didn’t do a darn thing!” What might be an appropriate active listening response to this patient?

Answer: (a, b, c and d). Naloxone was patented in 1961, was first approved by the Food and Drug Administration (FDA) in 1971, and is currently on the World Health Organization’s List of Essential Medicines. Naloxone hydrochloride is a pure opioid antagonist that competitively binds to μ-opioid receptors only when opioids are present and bound at the receptor site. Naloxone demonstrates no effect on mu, kappa, or delta receptors in a person who has not taken opioids. No tolerance or dependence is associated with naloxone use. The reversal of opioid toxicity with naloxone is dose dependent. Individuals who have used a particularly potent opioid (e.g., fentanyl), have high concentration of opioids in their system, or have used a long-acting opioid may require more frequent and/or larger doses of naloxone to reverse symptoms. When comparing the μ-opioid receptor affinity of naloxone with that of most opioids, including heroin, naloxone has a greater affinity to bind to the receptor site. This mechanism allows naloxone to remove the opioid from the receptor site and then bind it more securely. When this occurs, respiratory depression resolves partially or fully (depending on the amount, form, and route of opioids taken), hypotension resolves, and CNS depression abates. Depending on the type of opioid used, the individual may be at risk for experiencing rebound opioid toxicity and/or acute respiratory depression because of the short duration of activity of naloxone (i.e., 30–90 minutes). This effect most often occurs when an individual has taken a long-acting opioid such as methadone or extended-release oxycodone. Naloxone’s short duration of action is an important reason to convey to patients that receiving emergency medical care for an opioid overdose is important, even if the person has responded to the naloxone. Naloxone is not effective in treating overdoses of non-opioid prescription medicines like benzodiazepines or barbiturates. It also is not effective in overdoses with stimulants, such as cocaine and amphetamines, or other non-opioid illicit drugs such as MDMA (Ecstasy, Molly), GHB (G), or ketamine (Special K). However, a polysubstance overdose that includes opioids warrants the use of naloxone.

93

Multiple options

a, b, c and d

Which of the following information is/are TRUE ABOUT Naloxone? [Select All That Apply].

Answer(b): The 2016 CDC guideline for prescribing opioids suggests to reassess the evidence of “individual benefit and risk” when increasing daily dose to above 50 morphine milligrams equivalent per day, and avoidance of doses greater than 90 MME per day.

92

None

b

93. The 2016 CDC guideline for prescribing opioids suggests to reassess the evidence of “individual benefit and risk” when increasing daily dose to above ____ morphine milligrams equivalent per day.

Answer (a, b, c and d). The Centers for Medicare & Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), the Clinical Laboratory Improvement Amendments (CLIA) and parts of the Affordable Care Act (ACA. Along with the Departments of Labor and Treasury, CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and most aspects of the Patient Protection and Affordable Care Act (PPACA) of 2010 as amended. The Social Security Administration is responsible for determining Medicare eligibility, eligibility for and payment of Extra Help/Low Income Subsidy payments related to Part D Medicare, and collecting some premium payments for the Medicare program.

91

Multiple options

a, b, c and d

Which of the following are administered by Centers for Medicare & Medicaid Services (CMS)? [ Select ALL That Apply ]

Answer (a, b, c and d). Essential fatty acids, or EFAs, are fatty acids that humans and other animals must ingest because the body requires them for good health but cannot synthesize them. Only two fatty acids are known to be essential for humans: alpha-linolenic acid (an omega-3 fatty acid) and linoleic acid (an omega-6 fatty acid). Some other fatty acids are sometimes classified as "conditionally essential,"meaning that they can become essential under some developmental or disease conditions; examples include docosahexaenoic acid and gamma-linolenic acid. It is not only important to incorporate good sources of omega-3 and omega-6s in a diet, but also consume these fatty acids in the proper ratio. Omega-6 fatty acids compete with omega-3 fatty acids for use in the body, and therefore excessive intake of omega-6 fatty acids can inhibit the use of omega-3 fatty acids by the body. Ideally, the ratio of omega-6 to omega-3 fatty acids should be between 1:1 and 4:1. Instead, most Americans consume these fatty acids at a ratio of omega-6: omega-3 between 10:1 and 25:1, and are consequently unable to reap the benefits of omega-3s. This imbalance is due to a reliance on processed foods and oils, which are now common in the Western diet. To combat this issue it is necessary to eat a low-fat diet with minimal processed foods and with naturally occurring omega-3 fatty acids. A lower omega-6: omega-3 ratio is desirable for reducing the risk of many chronic diseases. Arachidonic acid is not one of the essential fatty acids. However, it does become essential if there is a deficiency in linoleic acid or if there is an inability to convert linoleic acid to arachidonic acid.

90

Multiple options

a, b, c and d

Which of the following information is/are TRUE ABOUT Essential Fatty Acids? [ Select ALL That Apply ]

Answer: Tyrosine hydroxylase.

89

Figure

c

Identify the reacting enzyme in the following figure:

Answer(a): If the patient is suffering from metabolic acidosis (low pH with low HCO ), the next step is to calculate the anion gap because the anion gap helps determining the etiology of the metabolic acidosis. The anion gap is the difference between the measured serum cations (positively charged particles) and the measured serum anions (negatively charged particles). The commonly measured cation is sodium and the measured anions include chloride and bicarbonate. Anion gap = [Na + ] - ([Cl ] + [HCO ]) The normal anion gap value is between 8 and 12. An anion gap of greater than 12 is "increased". The differential diagnosis for an elevated anion gap metabolic acidosis (simply called "anion gap acidosis") differs from the differential diagnosis for an non-elevated anion gap metabolic acidosis (simply called "non-anion gap acidosis"). So, in the above example: Anion gap = [Na + ] - ([Cl ] + [HCO ]) Anion gap = 145 - (105 + 25) Anion gap = 15 The calculated anion gap = 15(above the normal gap of 8-12), therefore there is an anion gap acidosis.

88

None

a

The laboratory finding reveals that 57 year-old patient is suffering from metabolic acidosis. What kind of metabolic acidosis is he suffering from? ABG: 7.21/32/98 100% O 2 Sat on Room Air Electrolytes: Na 145 mEq/L, K 4.5 mEq/L, Cl 105 mEq/L, HCO 3 25 mEq/L

Answer: I only is true, [Washington State Pharmacy Law July 2016 News Letter]. All 50 states, including Washington State, have rules in place allowing electronic prescriptions for controlled substances (EPCS), including Schedule II medications. Pharmacies and practitioners wishing to use EPCS must first select software that meets the requirements of Title 21 Code of Federal Regulations (CFR) §1311. The software application provider must be approved by the federal Drug Enforcement Administration (DEA), and in Washington State it must also be approved by the Commission. Practitioners may not transmit, and pharmacies may not receive, EPCS until their software provider obtains a third-party audit or certification review that determines that their software application complies with DEA’s requirements and provides the audit/certification report to the practitioner/pharmacy. Under Title 21 CFR §1300.03, electronic prescription is defined as a prescription that is generated on an electronic application and transmitted as an electronic data file. Therefore, an electronic prescription does not include prescriptions transmitted by facsimile, even if generated electronically and transmitted via fax, or printed on a computer printer. An electronic signature is defined as a method of signing an electronic message that identifies a particular person as the source of the message and indicates the person’s approval of the information contained in the message. According to DEA, electronic signatures are required on all electronically communicated prescriptions and are not allowed on CS prescriptions delivered by fax or hard copy to the pharmacy. CS prescriptions sent from fax to fax, computer to fax, printed on a computer printer, or manually written must all contain a manual signature. A manual, or wet, signature means the practitioner directly signs the prescription by hand using ink or indelible pencil. Signing a signature pad on a computer so the prescription is printed or faxed with the signature image, or stamping the prescription with a signature stamp, does not meet DEA requirements for manual signatures. This also applies to EPCS where the electronic transmission fails and the prescription is returned to the practitioner by the intermediary. These prescriptions must be manually signed by the prescriber before being faxed to the pharmacy, even if they include an electronic signature. Pharmacists should recognize they are responsible for ensuring CS prescriptions meet DEA signature requirements and contacting the prescriber whenever necessary.

87

None

a

According to Washington State Pharmacy Law, which of the following information about Electronic Prescriptions for Controlled Substances (EPCS) is/are TRUE? I. Electronic signatures are required on all electronically communicated prescriptions. II. The prescription that is generated electronically and transmitted via fax shall follow the ECPS rules. III. An ECPS cannot be used to prescribe Schedule II controlled substance.

Answer: Purple Drank. NABP reports a recent rise in forged prescriptions for promethazine with codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as “purple drank.” “Purple drank” is a combination of promethazine with codeine mixed with a carbonated soda, such as Sprite or Mountain Dew, and candy, such as crushed Jolly Ranchers, mixed in for additional flavor. The NABP has seen an increase in forged prescriptions for promethazine with codeine, and pharmacists have unknowingly filled them across United States in recent months. Pharmacists should be on the alert for promethazine with codeine prescriptions and perform due diligence in confirming that the prescription is legitimate. Look for common red flags such as a prescription being presented right before closing, an out-of-the-area prescriber you do not recognize, a patient you do not recognize, a large quantity or exact quantity for “473 mL,” or a cash-paying patient you do not know.

86

None

b

NABP reports a recent rise in forged prescriptions for Promethazine with Codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as:

Answer: (I and II only). PMP InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state’s data-access rules are enforced. It is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse. Additional information about PMP InterConnect, including a map of participants, is available in theProgramssection of the NABP website. It is NOT MANDATORY for states to participate in PMP InterConnect. Alabama, the District of Columbia, Massachusetts, and Pennsylvania have joined 38 other states by executing a memorandum of understanding with NABP to participate in NABP PMP InterConnect . These states/jurisdictions will be working toward a live connection with other states in the coming months. “A key enhancement of the Massachusetts Prescription Awareness Tool (MassPAT) is the sharing of interstate prescription data with nearly every state in the country,” said Eric J. Sheehan, JD, Acting Bureau Director, Massachusetts Department of Public Health, Bureau of Health Care Safety and Quality. “Through its collaboration with NABP, the connection between MassPAT and NABP’s PMP InterConnect will result in a more comprehensive and thorough tool for Massachusetts prescribers and dispensers to use in identifying potential opioid abuse.” In addition, the New York Prescription Monitoring Program Registry and Vermont Prescription Monitoring System joined 31 state prescription monitoring programs (PMPs) that have already implemented use of PMP InterConnect, giving authorized PMP users the ability to request and share program data across state lines: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Nevada, New Jersey, New Mexico, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, and Wisconsin. In an effort to combat prescription drug abuse and diversion with neighboring states, New York announced in apress releasethat the state began sharing PMP data with New Jersey on April 14, 2016. Governor Andrew Cuomo said, “Sharing controlled substance data with neighboring states allows us to more effectively combat prescription drug abuse and fraud . . . Prescription drug abuse impacts families nationwide, and I am proud of the crucial step we are taking to stem this epidemic.” According to the press release, New York plans to extend its PMP data sharing efforts to other PMP InterConnect participants. NABP also continues to work with other states to facilitate their participation. Three more states are currently reviewing the memorandum of understanding. NABP staff highlighted the importance of state PMPs in the fight against prescription drug abuse in a recentinterviewwith NPR.

85

None

c

Which of the following information is/are TRUE about PMP InterConnect? I. InterConnect is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse. II. InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state’s data-access rules are enforced. III. It is mandatory for all states to participate in PMP Interconnect.

Answer: (a,b,c,d and e). Tall man (uppercase) letters are used within a drug name to highlight its primary dissimilarities and help to differentiate look-alike names. Several studies have shown that highlighting sections of words using tall man lettering can make similar drug names easier to distinguish, and fewer errors are made when tall man letters are used to differentiate products with look-alike names. The Institute for Safe Medication Practices (ISMP), the FDA, The Joint Commission, and other safety-conscious organizations such as the National Association of Boards of Pharmacy (NABP) have promoted the use of tall man letters as one means of reducing confusion between similar drug names. From a survey conducted by the ISMP in 2008, most respondents appeared to agree. Nearly all of those surveyed (87%) felt that the use of tall man letters by the medical product industry helped to reduce errors in drug selection, and two-thirds (64%) reported that tall man lettering actually prevented them from dispensing or administering the wrong medication. A fully alphabetized list of drug names with tall man lettering can be found at www.ismp.org/Tools/tallmanletters.pdf. Approximately 50% of all survey respondents reported using tall man letters in conjunction with pharmacy-generated product and shelf labels, computer screens, and medication administration records. Half to three-quarters of respondents who used tall man letters with look-alike drug name pairs felt that this strategy was effective in reducing the risk of errors, depending on where it was used. Use of the tall man letters on computer-generated pharmacy labels was the most prevalent and was considered to be most effective, whereas use of the letters on preprinted order forms was among the least prevalent and was considered to be least effective. In general, between one-quarter and one-third of respondents were undecided about the effectiveness of tall man letters, but very few reported that the letters were wholly ineffective in reducing the risk of errors. The use of tall man letters was less widely reported for drugs listed on prescriber order entry screens and smart pump libraries.

84

Multiple options

a,b,c,d and e

Which of the following information is TRUE ABOUT Tall Man Letters? (Select All that apply).

Answer: (e). Sodium-glucose co-transporter2 (SGLT2), expressed in the proximal renal tubules, is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen. Canagliflozin is an inhibitor of SGLT2. By inhibiting SGLT2, Canagliflozin reduces reabsorption of filtered glucose and lowers the renal threshold for glucose (RTG), and thereby increases urinary glucose excretion (UGE).

83

None

e

Which of the following statements correctly describes the mechanism of action of Invokana (Canagliflozin)?

Answer: (a and b). Co-administration of Canagliflozin with rifampin, a nonselective inducer of several UGT enzymes, including UGT1A9, UGT2B4, decreased Canagliflozin area under the curve (AUC) by 51%.This decrease in exposure to Canagliflozin may decrease efficacy. If an inducer of these UGTs (e.g., rifampin, phenytoin, phenobarbital, ritonavir) must be co-administered with Invokana (Canagliflozin) (Canagliflozin), consider increasing the dose to 300mg once daily if patients are currently tolerating Invokana (Canagliflozin) 100mg once daily, have an eGFR greater than 60 mL/min/1.73 m2, and require additional glycemic control. Consider other antihyperglycemic therapy in patients with an eGFR of 45 to less than 60mL/min/1.73m2 receiving concurrent therapy with a UGT inducer and require additional glycemic control. There was an increase in the AUC and mean peak drug concentration (Cmax) of digoxin (20%and 36%,respectively) when co-administered with Invokana (Canagliflozin) 300mg. Patients taking Invokana (Canagliflozin) with concomitant digoxin should be monitored appropriately.

82

Multiple options

a and b

Which of the following drugs interacts with Invokana (Canagliflozin)? (Select All that apply)

Answer: (a,b,c, and d). Invokana (Canagliflozin) is a sodium-glucose co-transporter2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type2 diabetes mellitus. The recommended starting dose is 100mg once daily, taken before the first meal of the day. Dose can be increased to 300mg once daily in patients tolerating Invokana (Canagliflozin) 100mg once daily who have an eGFR of 60 mL/min/1.73m 2 or greater and require additional glycemic control. Invokana (Canagliflozin) is limited to 100mg once daily in patients who have an eGFR of 45to less than 60mL/min/1.73m2. Assess renal function before initiating Invokana (Canagliflozin). Do not initiate Invokana (Canagliflozin) if eGFR is below 45 mL/min/1.73 m2. Discontinue Invokana (Canagliflozin) if eGFR falls persistently below 45mL/min/1.73m2. It can increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue. A lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with Invokana (Canagliflozin). It causes intravascular volume contraction. Symptomatic hypotension can occur after initiating Invokana (Canagliflozin), particularly in patients with impaired renal function (eGFR <60 mL/min/1.73 m2), elderly patients, patients on either diuretics or medications that interfere with the renin-angiotensin-aldosterone system, or patients with low systolic blood pressure. Before initiating in patients with ≥1 of these characteristics, volume status should be assessed and corrected. Monitor for signs and symptoms after initiating. The most common side effects of Invokana (Canagliflozin) include genital yeast infections, urinary tract infection, and changes in urination.

81

Multiple options

a,b,c, and d

Which of the following information is TRUE about Invokana (Canagliflozin)? (Select All that apply)

Answer: (c) Before the seriousness of H. pylori infections was fully appreciated and when it was still believed that H. pylori eradication therapy could routinely cure more than 90% of patients, confirmation of cure testing was not routinely recommended. Although confirmation for cure testing is currently considered the standard of care, preferably with noninvasive tests such as the stool antigen or a urea breath test, it is often not done. Post eradication testing is not only useful to confirm H. pylori eradication but also serves to alert the clinician when resistance begins to undermine their locally effective current regimens. In this issue of Clinical Gastroenterology and Hepatology, Gatta et al report a pilot study suggesting that it may be possible to accurately assess cure using changes in serum pepsinogen II levels. A positive urea breath test (UBT), histology, culture, or rapid urease test (RUT) any time after therapy is considered as evidence of treatment failure. However, it has been recommended that posttreatment testing be delayed for at least 4 weeks after the end of therapy. This recommendation is based on the fact that it takes time for any remaining bacteria to recover and repopulate the stomach in sufficient numbers to be detected reliably. By 4 weeks, the accuracy of a negative test is in the range of 98% to 100%. There is little or no gain by repeating negative tests to ensure success (eg, 2 negative urea breath tests) as a second urea breath test has not shown an increase in accuracy and adds an incremental cost with little clinical benefit. One caveat among available noninvasive tests is that when using the stool antigen to assess outcome, it may be best to increase the interval from 4 to 6 or 8 weeks to ensure that a positive result is not false positive. The available data show that the stool antigen tests that use monoclonal anti-H. pylori antibodies are more reliable than polyclonal stool antigen tests and monoclonal antibody-based stool antigen tests are recommended.

80

None

c

After completing the therapy, H. pylori follow-up status testing shall be done within what time frame to ensure H. Pylori has been completely eradicated?

Answer: (a,c). The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice. The TST is performed by injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. The injection should be made with a tuberculin syringe, with the needle bevel facing upward. The TST is an intradermal injection. When placed correctly, the injection should produce a pale elevation of the skin (a wheal) 6 to 10 mm in diameter. The skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be rescheduled for another skin test. The reaction should be measured in millimeters of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis). Skin test interpretation depends on two factors: 1. Measurement in millimeters of the induration 2. Person’s risk of being infected with TB and of progression to disease if infected What Are False-Positive Reactions? Some persons may react to the TST even though they are not infected with M. tuberculosis. The causes of these false-positive reactions may include, but are not limited to, the following: 1. Infection with non-tuberculosis mycobacteria 2. Previous BCG vaccination 3. Incorrect method of TST administration 4. Incorrect interpretation of reaction 5. Incorrect bottle of antigen used What Are False-Negative Reactions? Some persons may not react to the TST even though they are infected with M. tuberculosis. The reasons for these false-negative reactions may include, but are not limited to, the following: 1. Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system) 2. Recent TB infection (within 8-10 weeks of exposure) 3. Very old TB infection (many years) 4. Very young age (less than 6 months old) 5. Recent live-virus vaccination (e.g., measles and smallpox) 6. Overwhelming TB disease 7. Some viral illnesses (e.g., measles and chicken pox) 8. Incorrect method of TST administration 9. Incorrect interpretation of reaction

79

Multiple options

a,c

Which of the following is/are false positive tuberculin skin test reactions? (Select All that apply)

Answer :(d). Thiazide diuretics may increase the reabsorption of uric acid from renal tubules and may cause hyperuricemia. It should NOT be used as a first line treatment for hypertension in patient suffering from gout.

78

None

d

Thiazide diuretics should NOT be used as a first line treatment for hypertension in patient suffering from:

Answer: Capitation payments are used by managed care organizations to control health care costs. Capitation payments control use of health care resources by putting the physician at financial risk for services provided to patients. At the same time, in order to ensure that patients do not receive suboptimal care through under-utilization of health care services, managed care organizations measure rates of resource utilization in physician practices. These reports are made available to the public as a measure of health care quality, and can be linked to financial rewards, such as bonuses. Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided. Capitation rates are developed using local costs and average utilization of services and therefore can vary from one region of the country to another. In many plans, a risk pool is established as a percentage of the capitation payment. Money in this risk pool is withheld from the physician until the end of the fiscal year. If the health plan does well financially, the money is paid to the physician; if the health plan does poorly, the money is kept to pay the deficit expenses. When the primary care provider signs a capitation agreement, a list of specific services that must be provided to patients is included in the contract. The amount of the capitation will be determined in part by the number of services provided and will vary from health plan to health plan, but most capitation payment plans for primary care services include the following: · Preventive, diagnostic, and treatment services · Injections, immunizations, and medications administered in the office · Outpatient laboratory tests done either in the office or at a designated laboratory · Health education and counseling services performed in the office · Routine vision and hearing screening

77

None

c

Which of the following best describes the Capitation System?

Answer (c, d and e). "Anaerobic"means without oxygen, and respiration refers to the processes in a cell that convert biochemical energy, such as that found in glucose, into usable energy in the form of ATP. Waste products like carbon dioxide are also produced during this process. The fermentation process in anaerobic respiration is roughly 5 percent as effective as what cells can do when they have access to oxygen. An aerobic cycle may produce between 36 and 38 ATP molecules, while anaerobic respiration only creates 2 ATP molecules. Since muscles often run out of oxygen during extreme exertion, anaerobic respiration keeps them running. In animals, including humans, the anaerobic cycle produces lactic acid, which causes muscle cramps. In order for these cramps to stop, oxygen must find its way back into the muscle again so these cells can switch back to aerobic respiration and stop building up lactic acid. Anaerobic respiration is also common in bacteria that live in environments without oxygen; depending on the bacteria, the products of their respiration include nitrite, nitrogen gas, hydrogen sulfide, methane and acetic acid.

76

Multiple options

c, d and e

Which of the following information is TRUE ABOUT anaerobic respiration? (Select All that apply)

Answer: (a) Below is the list of drugs that inhibit specifically CYP 3A4: 1. Amiodarone 2. Anastrozole 3. Azithromycin 4. Cannabinoids 5. Cimetidine 6. Clarithromycin 7. Clotrimazole 8. Cyclosporine 9. Danazol 10. Delavirdine 11. Dexamethasone 12. Diethyldithiocarbamate 13. Diltiazem 14. Dirithromycin 15. Disulfiram 16. Entacapone (high dose) 17. Erythromycin 18. Ethinyl estradiol 19. Fluconazole 20. Fluoxetine 21. Fluvoxamine 22. Gestodene 23. Grapefruit juice 24. Indinavir 25. Isoniazid 26. Ketoconazole 27. Metronidazole 28. Mibefradil 29. Miconazole 30. Nefazodone 31. Nelfinavir 32. Nevirapine 33. Norfloxacin 34. Norfluoxetine 35. Omeprazole 36. Oxiconazole 37. Paroxetine (weak) 38. Propoxyphene 39. Quinidine 40. Quinine 41. Quinupristin and Dalfopristin 42. Ranitidine 43. Ritonavir 44. Saquinavir 45. Sertindole 46. Sertraline 47. Troglitazone 48. Troleandomycin 49. Valproic acid

75

None

a

Which of the following inhibits CYP 3A4? (Select All that apply)

Answer: (c). Slow channel blockers inhibit the slow inward calcium current, which may prolong conduction and refractoriness in the AV node.

74

None

c

Slow channel blocking drugs will reduce the movement of which substance into smooth muscle cells? (Select All that apply)

Answer: (e). An ovulation home test is used by women to help determine the time in the menstrual cycle when getting pregnant is most likely. The test detects a rise in luteinizing hormone (LH) in the urine. A rise in this hormone signals the ovary to release the egg.

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None

e

Home ovulation tests usually detect a preovulatory surge in which of the following in the urine?

Answer: (a,b,c,d). Extrapyramidal symptoms (EPS) are drug-induced movement disorders that include acute and tardive symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), Parkinsonism (characteristic symptoms such as rigidity, bradykinesia, and tremor), and tardive dyskinesia (irregular, jerky movements). Since it is difficult to measure extrapyramidal symptoms, rating scales are commonly used to assess the severity of movement disorders. The Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), Abnormal Involuntary Movement Scale (AIMS), and Extrapyramidal Symptom Rating Scale (ESRS) are rating scales frequently used for such assessment and are not weighted for diagnostic purposes.

72

Multiple options

a,b,c,d

Which of the following rating scales is commonly used to evaluate the severity of extrapyramidal symptoms (EPS)? (Select ALL that apply)

Answer: (d), Type 4 hypersensitivity is often called delayed type. Delayed hypersensitivity does not start to be noticeable until several hours to a full day after exposure to the antigen. It may last for over a week. Poison ivy rash is caused by an allergic reaction to an oily resin called urushiol (u-ROO-she-ol). This oil is in the leaves, stems and roots of poison ivy, poison oak and poison sumac. Urushiol, which is a hapten, when absorbed through the skin from a poison ivy plant, it (urushiol) undergoes oxidation in the skin cells to generate the actual hapten, a reactive molecule called a quinone, which then reacts with skin proteins to form hapten adducts. T lymphocytes recognize the foreign substances, usually after the antigen is eaten, degraded, and presented (in pieces) by so-called antigen-presenting cells such as Langerhans cells in the skin, or macrophages. Urushiol metabolites (metabolite of Poison Ivy) are presented by this and other mechanisms. The T lymphocytes pour out inflammatory signal substances called cytokines. These call in armies of white blood cells called monocytes, which become macrophages. The macrophages become activated by the cytokines and attack everything in the vicinity, and can cause severe tissue damage. Usually, the first exposure causes only sensitization, in which there is a proliferation of effector T-cells. After a subsequent, second exposure, the proliferated T-cells can become activated, generating an immune reaction that produces typical blisters of a poison ivy exposure. In addition to poison ivy, a good example is the skin reaction to injected tuberculosis antigen. In fact, when tuberculosis bacteria infect the lung, it is the delayed hypersensitivity against them which destroys the lung. Unlike the other types, it is not antibody mediated but rather is a type of cell-mediated response.

71

None

d

Poison Ivy rash is an example of:

Answer: (b,c,e). Zurampic (Lesinurad) is a URAT1 inhibitor. It is available as blue film-coated tablets for oral administration containing 200 mg Lesinurad. It should be used in combination with a xanthine oxidase inhibitor. Lesinurad reduces serum uric acid levels by inhibiting the function of transporter proteins involved in uric acid reabsorption in the kidney. It is indicated in combination with a xanthine oxidase inhibitor for the treatment of hyperuricemia associated with gout in patients who have not achieved target serum uric acid levels with a xanthine oxidase inhibitor alone. Zurampic (Lesinurad) is not recommended for the treatment of asymptomatic hyperuricemia. Zurampic (Lesinurad) should not be used as monotherapy. Zurampic (Lesinurad) tablets are for oral use and should be co-administered with a xanthine oxidase inhibitor, including allopurinol or febuxostat. Zurampic (Lesinurad) is recommended at 200 mg once daily. This is also the maximum daily dose. Zurampic (Lesinurad) should be taken by mouth, in the morning with food and water. Zurampic (Lesinurad) causes an increase in renal uric acid excretion, which may lead to renal events including transient increases in serum creatinine, renal-related adverse reactions, and kidney stones. These renal events occurred more frequently in patients receiving Zurampic (Lesinurad) 400 mg, when used as monotherapy or in combination with a xanthine oxidase inhibitor. Kidney function is required to monitor.

70

Multiple options

b,c,e

Which of the following information about Zurampic is/are TRUE? (Select All that apply).

Answer: (a,b,d,e). Name Dose Timing Food Pitavastatin Any time of the day With or without food Simvastatin Evening N/A Atorvastatin Any time of the day With or without food Fluvastatin Evening With or without food Pravastatin Any time of the day With or without food Lovastatin Evening With food Rosuvastatin Any time of the day With or without food

69

Multiple options

a,b,d,e

Which of the following HMG-CoA inhibitors can be taken during any time of the day with or without food? (Select All that apply)

Answer: (a,b,c,d). TPN solutions are made according to a variety of formulations and compounding protocols. Thus, there are possibilities of calcium phosphate precipitates and many other chemical incompatibilities. Precipitates could develop because of a number of factors such as: the concentration, pH, and phosphate content of the amino acid solutions; the calcium and phosphorous additives; the order of mixing; the mixing process; or the compounder. The presence of a lipid emulsion in the TPN admixture would obscure the presence of any precipitate. Because of the potential for life threatening events, caution should be taken to ensure that precipitates have not formed in any parenteral nutrition admixtures. 1. The amounts of phosphorous and of calcium added to the admixture are critical. The solubility of the added calcium should be calculated from the volume at the time the calcium is added. It should not be based upon the final volume. Some amino acid injections for TPN admixtures contain phosphate ions (as a phosphoric acid buffer). These phosphate ions and the volume at the time the phosphate is added should be considered when calculating the concentration of phosphate additives. Also, when adding calcium and phosphate to an admixture, the phosphate should be added first. 2. The line should be flushed between the addition of any potentially incompatible components. 3. A lipid emulsion in a three-in-one admixture obscures the presence of a precipitate. Therefore, if a lipid emulsion is needed, either: (1). use a two-in-one admixture with the lipid infused separately, or (2). if a three-in-one admixture is medically necessary, then add the calcium before the lipid emulsion and according to the recommendations in number 1 above. If the amount of calcium or phosphate which must be added is likely to cause a precipitate, some or all of the calcium should be administered separately. Such separate infusions must be properly diluted and slowly infused to avoid serious adverse events related to the calcium. 4. A filter should be used when infusing either central or peripheral parenteral nutrition admixtures. Standards of practice vary, but the following is suggested: a 1.2 micron air eliminating filter for lipid containing admixtures, and a 0.22 micron air eliminating filter for nonlipid containing admixtures.

68

Multiple options

a,b,c,d

Which of the following information is/are TRUE about preparing TPN formulation? (Select All that apply).

Answer: (a,b). Dose adjustments may be necessary in patients with concomitant use of: Strong CYP1A2 inhibitors (e.g., fluvoxamine, ciprofloxacin, or enoxacin); Moderate or weak CYP1A2 inhibitors (e.g., oral contraceptives, or caffeine); CYP2D6 or CYP3A4 inhibitors (e.g., cimetidine, escitalopram, erythromycin, paroxetine, bupropion, fluoxetine, quinidine, duloxetine, terbinafine, or sertraline); CYP3A4 inducers (e.g., phenytoin, carbamazepine, St. John’s wort, and rifampin); or CYP1A2 inducers (e.g., tobacco smoking).

67

Multiple options

a,b

Which of the following is strong CYP1A2 inhibitor? (Select All that apply).

Answer: 7 alphanumeric characters. The U.S. Department of Health and Human Services (HHS) announced a final rule that will facilitate the United States’ ongoing transition to an electronic health care environment through adoption of new healthcare code sets for use in electronic health care transactions. This rule adopts updated versions of the code sets, under the authority of HIPAA (ICD-10 final rule). The ICD-10 code sets replace the current ICD-9-CM code set. The industry currently uses about 4,000 unique ICD-9-CM volume 3 codes to describe inpatient procedures. ICD-9 procedure codes are 3-4 digits in length (e.g., 47.01 – Laparoscopic appendectomy). With the ICD-10-PCS mandate, the length of inpatient procedure codes will increase to 7 alphanumeric characters (e.g., ODTJ4ZZ – Laparoscopic appendectomy).

66

None

a

With the ICD-10-PCS, the length of inpatient procedure codes will increase to:

Answer: Herpes zoster. The following vaccines are required to be stored in refrigerator (2 to 8 degree C): 1. HepA (Hepatitis A) 2. HepB (Hepatitis B) 3. Hib (Haemophilus influenzae type b) 4. HPV (Human papilloma virus) 5. Influenza 6. Meningococcal-combinations 7. Pneumococcal 8. Rotavirus 9. Any diphtheria/tetanus toxoid, pertussis combination The following vaccines are required to be stored in freezer (-50 to -15 degrees C): 1. VAR (Varicella) 2. HZV (Herpes Zoster Vaccine) 3. MMRV = Measles, mumps, rubella, varicella The following vaccines can be stored in refrigerator (2 to 8 degree C) or freezer (-50 to -15 degrees C): 1. MMR (Measles, mumps, rubella)

65

None

d

Which of the following vaccines is required to be stored in a freezer?

Answer: (d) II and III are true. Durlaza is an aspirin formulation for secondary prevention in high-risk CVD patients. The aspirin delivery technology in Durlaza extends the release of aspirin in a manner designed to provide a stable antiplatelet effect over the course of the day. Low-dose aspirin has been proven to reduce the risk of secondary cardiovascular events and mortality in high-risk patients with stable cardiovascular disease. This is primarily due to aspirin’s ability to inhibit platelet aggregation (blood clotting). While the body is making platelets 24-hours a day, current immediate-release traditional aspirin only stays in the blood for about a mean duration of four to six hours, with peak plasma concentrations peaking after just 30 minutes. Durlaza utilizes extended-release, microcapsule technology to prolong aspirin release. Durlaza offers the only once-daily, 24-hour antiplatelet therapy through the extended release of its 162.5mg dose, resulting in prolonged absorption, and sustained platelet exposure to aspirin. Durlaza, like immediate-release aspirin, increases the risk of bleeding and gastric ulceration, and may cause fetal harm when administered to a pregnant woman.

64

None

d

Which of the following information is/are TRUE about Durlaza? I. Clopidogrel is an active ingredient. II. Indicated for the secondary prevention of stroke and acute cardiac events, including myocardial infarction (heart attack). III. Available as 24-hour, extended release capsules formulation containing 162.5mg active ingredient.

Answer: (c). The U.S. Food and Drug Administration approved Rolapitant (Varubi) to prevent delayed phase chemotherapy-induced nausea and vomiting (emesis). Rolapitant (Varubi) is approved in adults in combination with other drugs (antiemetic agents) that prevent nausea and vomiting associated with initial and repeat courses of vomit-inducing (emetogenic and highly emetogenic) cancer chemotherapy. Rolapitant (Varubi) is a substance P/neurokinin-1 (NK-1) receptor antagonist. Activation of NK-1 receptors plays a central role in nausea and vomiting induced by certain cancer chemotherapies, particularly in the delayed phase. It is available in tablet form. Rolapitant (Varubi) inhibits the CYP2D6 enzyme, which is responsible for metabolizing certain drugs. Varubi is contraindicated with the use of thioridazine, a drug metabolized by the CYP2D6 enzyme, because use of the two drugs together may increase the amount of thioridazine in the blood and cause an abnormal heart rhythm that can be serious. The most common side effects in patients treated with Rolapitant (Varubi) include a low white blood cell count (neutropenia), hiccups, decreased appetite and dizziness.

63

None

c

Rolapitant is indicated for the treatment of:

Answer: I and II only. Homocysteine is an amino acid. Amino acids are the building blocks of proteins. It is not possible to get homocysteine from the diet. It must be made from methionine, another amino acid that is found in meat, fish, and dairy products. Vitamins B6 (pyridoxine), B12 and folic acid are needed to make this reaction occur. Foods containing methionine are transformed into homocysteine in the bloodstream. Homocysteine is converted in the body to cysteine, with vitamin B6 facilitating this reaction. Homocysteine can also be recycled back into methionine using vitamin B12-related enzymes. Cysteine is an important protein in the body that has many roles. It is involved in the way proteins within cells are folded, maintain their shape, and link to each other. Cysteine is a source of sulfide and is part of the metabolism of different metals in the body including iron, zinc and copper. Cysteine also acts as an anti-oxidant. If homocysteine cannot be converted into cysteine or returned to the methionine form, levels of homocysteine in the body increase. Elevated homocysteine levels have been associated with heart attack, stroke, blood clot formation, and perhaps the development of Alzheimer's disease.

62

None

c

Which of the following information is/are TRUE about Homocysteine? I. It is not possible to get homocysteine from the diet. II. Homocysteine can be recycled back into methionine using vitamin B12-related enzymes. III. Elevated homocysteine levels have been associated with severe bleeding.

Answer: (c). The active ingredient found in Onfi is Clobazam. It is classified as schedule IV controlled substance. Each Onfi (Clobazam) tablet contains 10 mg or 20 mg of clobazam. It is also available for oral administration as an off-white suspension containing clobazam at a concentration of 2.5 mg/mL. Onfi (Clobazam) is classified as benzodiazepine. Clobazam potentiates the GABAergic neurotransmission by binding at the benzodiazepine site of the GABAa receptor. Onfi (Clobazam) is indicated for the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome (LGS) in patients 2 years of age or older. A daily dose of Onfi (Clobazam) greater than 5 mg should be administered in divided doses twice daily; a 5 mg daily dose can be administered as a single dose. As with all antiepileptic drugs and benzodiazepines, withdraw Onfi (Clobazam) gradually. The patient should taper by decreasing the total daily dose by 5-10 mg/day on a weekly basis until discontinued. Somnolence, depression, sedation, withdrawal symptoms, serious dermatological reactions and suicidal behavior and ideation are commonly reported side effects of Onfi (Clobazam).

61

None

c

Onfi is available in which of the following dosage forms? I. Tablet II. Oral Suspension III. Capsule

Answer: HSDD. The U.S. Food and Drug Administration has recently approved Addyi (Flibanserin) to treat acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. Prior to Addyi’s approval, there were no FDA-approved treatments for sexual desire disorders in men or women. HSDD is characterized by low sexual desire that causes marked distress or interpersonal difficulty and is not due to a co-existing medical or psychiatric condition, problems within the relationship, or the effects of a medication or other drug substance. HSDD is acquired when it develops in a patient who previously had no problems with sexual desire. HSDD is generalized when it occurs regardless of the type of sexual activity, the situation or the sexual partner. Because of a potentially serious interaction with alcohol, treatment with Addyi will only be available through certified health care professionals and certified pharmacies. Addyi can cause severely low blood pressure (hypotension) and loss of consciousness (syncope). These risks are increased and more severe when patients drink alcohol or take Addyi with certain medicines (known as moderate or strong CYP3A4 inhibitors) that interfere with the breakdown of Addyi in the body. Because of the alcohol interaction, the use of alcohol is contraindicated while taking Addyi. Addyi is being approved with a risk evaluation and mitigation strategy (REMS), which includes elements to assure safe use (ETASU). The FDA is requiring this REMS because of the increased risk of severe hypotension and syncope due to the interaction between Addyi and alcohol. The REMS requires that prescribers be certified with the REMS program by enrolling and completing training. Certified prescribers must counsel patients using a Patient-Provider Agreement Form about the increased risk of severe hypotension and syncope and about the importance of not drinking alcohol during treatment with Addyi. Additionally, pharmacies must be certified with the REMS program by enrolling and completing training. Certified pharmacies must only dispense Addyi to patients with a prescription from a certified prescriber. Additionally, pharmacists must counsel patients prior to dispensing not to drink alcohol during treatment with Addyi.

60

None

c

FDA has recently approved Addyi (Flibanserin). It is indicated for the treatment of:

Answer: (b) I and II only. Levetiracetam (Spritam) is indicated for the treatment of partial onset seizures, myoclonic seizures and primary generalized tonic-clonic seizures in adults and children with epilepsy. Spritam utilizes Aprecia's proprietary ZipDose Technology platform, a groundbreaking advance that uses three-dimensional printing (3DP) to produce a porous formulation that rapidly disintegrates with a sip of liquid.1 While 3DP has been used previously to manufacture medical devices, this approval marks the first time a drug product manufactured with this technology has been approved by the FDA. ZipDose Technology enables the delivery of a high drug load, up to 1,000 mg in a single dose. As a result, Spritam enhances the patient experience - administration of even the largest strengths of Levetiracetam (Spritam) with just a sip of liquid. In addition, with Spritam there is no measuring required as each dose is individually packaged, making it easy to carry this treatment on the go. The recommended daily dose is 1000 to 3000 mg per day. Sleepiness, weakness, dizziness, infection, tiredness, acting aggressive, nasal congestion, decreased appetite, and irritability are commonly reported side effects of Levetiracetam (Spritam). Levetiracetam is also available under the trade names Keppra and Elepsia.

59

None

b

Which of the following information about Spritam is/are TRUE? I. The active ingredient is Levetiracetam (Spritam). II. It is the first FDA approved drug that uses ZipDose technology. III. It is indicated for the treatment of depression.

Answer: High risk for misuse, [https://www.nabp.net]. NARXCHECK is an automatic prescription drug abuse assessment and management tool for health care providers. Once integrated into the facility's system, NARxCHECK automatically queries the state PMP database to generate a report that includes a score for three different drug classes: narcotics, sedatives, and stimulants. These three-digit scores (000-999) help practitioners to decide whether or not they need to review a patient history before prescribing additional medications. The score is easy to read using the following guidelines: 1. Less than 200 = Be confident - low risk for misuse. 2. 200 - 500 = Be curious - moderate risk for misuse. 3. Greater than 500 = Be cautious - higher risk for misuse.

58

None

d

Using the NARxCHECK, a pharmacist is receiving a scaled score of 650 for a particular patient. Which of the following statements based on this scaled score is TRUE?

Answer: Green. As used in this section, "cryogenic vessel"means an insulated metal container in the form of a cylinder or other design used to hold gases that have been liquefied by extreme reductions in temperature. (C). Each cryogenic vessel subject to this section shall meet the following requirements: (1). The vessel shall be properly labeled according to the medical gas contained in the vessel. (2). The vessel shall be color coded as follows: (a). Air - yellow; (b). Carbon dioxide - gray; (c). Cyclopropane - orange; (d). Helium - brown; (e). Nitrogen - black; (f). Nitrous oxide - blue; (g). Oxygen - green. The colors specified in this division shall not be used for any medical gas other than those specified in this division.

57

None

b

The cryogenic vessel shall be properly labeled and color coded according to the medical gas contained in the vessel. Which of the following color-code is used for medical oxygen?

Answer: I and II are true. Mifepristone (Mifeprex) is a synthetic steroid with antiprogestational effects. Mifepristone (Mifeprex) is indicated for the medical termination of intrauterine pregnancy through 49 days' pregnancy. For purposes of this treatment, pregnancy is dated from the first day of the last menstrual period in a presumed 28 day cycle with ovulation occurring at mid-cycle. The duration of pregnancy may be determined from menstrual history and by clinical examination. Ultrasonographic scan should be used if the duration of pregnancy is uncertain, or if ectopic pregnancy is suspected. Any intrauterine device (“IUD”) should be removed before treatment with Mifepristone (Mifeprex) begins. Patients taking Mifepristone (Mifeprex) must take 400 μg of Misoprostol two days after taking Mifepristone (Mifeprex) unless a complete abortion has already been confirmed before that time. Day One: Mifeprex Administration Patients must read the MEDICATION GUIDE and read and sign the PATIENT AGREEMENT before Mifeprex is administered. Three 200 mg tablets (600 mg) of Mifeprex are taken in a single oral dose. Day Three: Misoprostol Administration The patient returns to the health care provider two days after ingesting Mifeprex. Unless abortion has occurred and has been confirmed by clinical examination or ultrasonographic scan, the patient takes two 200 μg tablets (400 μg) of misoprostol orally. During the period immediately following the administration of Misoprostol, the patient may need medication for cramps or gastrointestinal symptoms. The patient should be given instructions on what to do if significant discomfort, excessive vaginal bleeding or other adverse reactions occur and should be given a phone number to call if she has questions following the administration of the Misoprostol. In addition, the name and phone number of the physician who will be handling emergencies should be provided to the patient. Day 14: Post-Treatment Examination Patients will return for a follow-up visit approximately 14 days after the administration of Mifeprex. This visit is very important to confirm by clinical examination or ultrasonographic scan that a complete termination of pregnancy has occurred. Pregnancy termination by surgery is recommended in cases when Mifepristone (Mifeprex) and misoprostol fail to cause termination of intrauterine pregnancySerious and sometimes fatal infections and bleeding occur very rarely following spontaneous, surgical, and medical abortions, including following Mifepristone (Mifeprex) use. Ensure that the patient knows whom to call and what to do, including going to an Emergency Room if none of the provided contacts are reachable, if she experiences sustained fever, severe abdominal pain, prolonged heavy bleeding, or syncope, or if she experiences abdominal pain or discomfort or general malaise (including weakness, nausea, vomiting or diarrhea) more than 24 hours after taking Misoprostol.

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b

Which of the following information is/are TRUE about Mifepristone? I. It is commonly known as RU-486. II. It is indicated for the medical termination of intrauterine pregnancy through 49 days' pregnancy. III. The recommended dose is one (200 mg Mifepristone) as a single oral dose.

Answer: True. The terms "prescription" and "drug order" do not include an order for medication requiring a prescription to be dispensed, which is provided for the immediate administration to the ultimate user or recipient.

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a

The terms "prescription"and "drug order"do not include an order for medication requiring a prescription to be dispensed, which is provided for the immediate administration to the ultimate user or recipient. True or False

Answer: (c) All. Diabetes Risk Factors: 1. Physical inactivity. 2. First-degree relative with diabetes. 3. Women who delivered a baby >9 lb or were diagnosed with GDM. 4. High-risk race/ethnicity. 5. A1C ≥5.7%, Impaired Glucose Tolerance (IGT), or Impaired Fasting Glucose (IFG) on previous testing. 6. Hypertension (≥140/90 mm Hg or on therapy). 7. HDL-C <35 mg/dL ± TG >250 mg/dL.

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c

Which of the following is/are considered Diabetes Risk Factor(s)? I. Physical inactivity. II. Women who delivered a baby greater than 9 lb. III. First-degree relative with diabetes. IV. High-risk race/ethnicity V. Hypertension ≥ 140/90 mm Hg

Answer: (c) 240 mg/dl. Below is the chart that describes the correlation between A1C% and blood glucose concentration in mg/dl.

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c

According to ADA 2015 guidelines, the value of A1C% 10 reflects the mean plasma glucose level:

Answer: (b) Ultraviolet light can cause oxidation, hydrolysis and loss of potency to sensitive meds in solution. This loss can be greatly minimised by protecting from light. Amber glass protection is expensive, foil wrapping is cumbersome and time consuming. Amber Bags offer a fast, cost effective solution. They effectively filter out 96.7% of the rays in the ultraviolet spectrum, providing the required safety.

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b

For I.V light sensitive drugs, Amber Bags offer a fast, cost effective solution. They effectively filter out ___% of the rays in the ultraviolet spectrum, providing the required safety.

Answer: (c) Interferons are proteins produced by tumor cells or host cells that are infected with viruses, bacteria and other unknown nucleic acids. Interferons also activate other cells that serve as part of the immune system and destroy invading pathogens. Interferons are classed as: alpha (from white cells), beta (from fibroblasts) and gamma (from lymphocytes). Interferons enhance the immune system in many ways so can be used to treat different conditions involving the immune system. Interferons used therapeutically are manufactured using recombinant DNA technology. Interferon alphas are used to treat viral infections (chronic hepatitis, human papillomavirus) and treating cancer (hairy cell leukemia, AIDS related - Kaposi sarcoma, malignant melanoma). Interferon betas are used to treat or slow down the progression of multiple sclerosis. Interferon gamma is used to treat chronic granulomatous disease.

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c

Interferons are proteins produced by tumor cells or host cells that are infected with viruses, bacteria and other unknown nucleic acids. Interferons that are obtained from lymphocytes are generally classified as:

Answer: (c) The Z-drugs, which include Eszopiclone (Lunesta), Zolpidem (Ambien), and Zaleplon (Sonata), are benzodiazepine receptor agonists. That means they work in a similar way to the benzodiazepine drugs inside the brain. They are GABA agonists meaning they somewhat mimic the action of gamma-Aminobutyric acid, the inhibitory neurotransmitter and thereby induce sleepiness. These drugs are sometimes referred to as non-benzodiazepine hypnotics or just non-benzodiazepines. That’s a dumb name, if you ask us. Too unspecific and vague, especially if you are not in the context of sleep medicine. Further, even within sleep medicine, there are compounds that are non-benzodiazepine hypnotics that would not be considered part of this class: antihistamines and Ramelteon, for instance. One problem is that the chemists don’t have a category that these drugs all fall into which is narrow enough to signify what medical practitioners are talking about. These drugs are in the categories pyrazolopyrimidines, imidazopyridines or cyclopyrrones, but they are not all in the same category. Therefore, we prefer the term Z-drugs. The generic names for these drugs all contain the letter Z, and it is as good a name as any.

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c

Which of the following is commonly known as “Z-Drug”?

Answer: (e) Esomeprazole (Nexium). Esomeprazole (Nexium) is the S-Isomer of Omeprazole (Prilosec). It is classified as a Proton Pump Inhibitor (PPI). It is indicated for the treatment of duodenal ulcer, gastric ulcer, Zollinger Ellison Syndrome and GERD. The OTC version of Esomeprazole (Nexium) 24 HR is also commonly known as “Purple Pill”. It is supplied in delayed-release capsules and in packets for a delayed-release oral suspension. Each delayed-release capsule contains 20 mg, or 40 mg of Esomeprazole (Nexium). Each packet of Esomeprazole (Nexium) for delayed-release oral suspension contains 2.5 mg, 5 mg, 10 mg, 20 mg, or 40 mg of Esomeprazole (Nexium), in the form of the same enteric-coated granules used in Esomeprazole (Nexium) delayed-release capsules. The recommended dose is 20 to 40 mg once daily for 4 to 8 weeks. Diarrhea, nausea, flatulence, abdominal pain, constipation, and dry mouth are commonly reported side effects of Esomeprazole (Nexium).

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e

Which of the following is commonly known as “Purple Pill”?

Answer: (c) 1:750. Benzalkonium chloride is indicated for prophylaxis and treatment of skin infections. It is antimicrobial against a wide variety of bacteria, fungi and protozoa. A 1:750 concentration of benzalkonium chloride is used for preoperative skin preparation, treatment of minor wounds, and lacerations, as a surgical scrub, and for sterilizing metallic instruments. The antimicrobial action of benzalkonium chloride is attributed to its ability to inactivate bacterial enzyme.

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c

In what concentration is Benzalkonium chloride normally used for preoperative skin preparation and treatment of minor wounds?

Answer: (d) II and III only. All Coricidin HBP (High Blood Pressure) products are free of decongestants and therefore they can safely be used in patients suffering from high blood pressure. The active ingredients found in Coricidin HBP Night are 500mg Acetaminophen, 10mg Dextromethorphan Hydrobromide and 2mg Chlorpheniramine. The active ingredients found in Coricidin HBP Day are 10mg Dextromethorphan Hydrobromide and 200mg Guaifenesin. It is indicated for the symptomatic relief of cold and cough, runny nose and sneezing, and bronchial irritation. Since Coricidin HBP Night contains anti-histamine (Chlorpheniramine), it shall be carefully prescribed to patients suffering from glaucoma or BPH. The recommended dose is 1 tablet every 6 hours, not more than 4 tablets in 24 hours. Nausea, vomiting, sedation, drowsiness, dizziness and blurred vision are commonly reported side effects of the drug.

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d

Coricidin HBP Night is contraindicated to use in patients suffering from: I. Hypertension II. Glaucoma III. BPH

Answer: (c) Beta-Sitosterol. Beta-sitosterol is a substance found in plants. Chemists call it a “plant sterol ester.” It is found in fruits, vegetables, nuts, and seeds. It is used to make medicine. Beta-sitosterol is used for heart disease and high cholesterol. It is also used for boosting the immune system and for preventing colon cancer, as well as for gallstones, the common cold and flu (influenza), HIV/AIDS, rheumatoid arthritis, tuberculosis, psoriasis, allergies, cervical cancer, fibromyalgia, systemic lupus erythematosus (SLE), asthma, hair loss, bronchitis, migraine headache, and chronic fatigue syndrome. Men use beta-sitosterol for enlarged prostate (benign prostatic hyperplasia or BPH). Beta-sitosterol supports the good prostate health primarily by maintaining healthy male hormone balance. Some women use it for symptoms of menopause.It is also used for enhancing sexual activity. Marathon runners sometimes use beta-sitosterol to reduce pain and swelling after a run. Some people apply beta-sitosterol to the skin for treating wounds and burns.

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c

Which of the following supports the good prostate health primarily by maintaining healthy male hormone balance?

Answer: (c) is NOT TRUE. Folic acid is a water-soluble vitamin that has antidepressant, antiproliferative, anti-teratogenic, gingival and anti-inflammatory effects. It is indicated for prevention of neural tube defects in pregnancy. It is also indicated for the treatment of megaloblastic anemia. It shall not be used in presence of pernicious and megaloblastic anemia due to Vit B12 deficiency. The recommended daily allowance is 400 mcg (NOT mg) per day. Erythema, pruritus, urticaria, irritability, nausea, bloating and flatulence are reported side effects of the drug.

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c

Which of the following information about Folic acid is NOT TRUE?

Answer:(d). The active ingredient found in Bydureon is Exenatide indicated for the treatment of type II diabetes mellitus. It is an incretin mimetic agent. Incretins, such as glucagon-like peptide-1 (GLP-1), enhance glucose-dependent insulin secretion and exhibit other antihyperglycemic actions following their release into the circulation from the gut. Bydureon is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion by the pancreatic beta-cell, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying. Bydureon is an extended-release formulation of Exenatide, administered as an injection once every 7 days (weekly). It is also available under the trade name Byetta. Byetta is an immediate release solution of Exenatide administered by SC route. Byetta should be initiated at 5 mcg administered twice daily at any time within the 60-minute period before the morning and evening meals (or before the two main meals of the day, approximately 6 hours or more apart). Nausea, vomiting, diarrhea, dyspepsia, injection site reactions, constipation and hypoglycemia are commonly reported side effects of Bydureon.

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d

A pharmacist receives a new prescription. The prescription reads: Bydureon 2mg SC every day for type II diabetes x 30 days. Refill: 5 times Which of the following is the most appropriate action by a pharmacist?

Answer:(b), Loratadine. Normally, the active ingredient found in Tavist is Clemastine. It is indicated for the treatment of seasonal and perennial allergic rhinitis; and chronic idiopathic urticaria. The recommended dose is 1.34 mg orally twice a day. Dosage may be increased as required, but not to exceed 2.68 mg orally 3 times a day. Sedation, sleepiness, dizziness, disturbed coordination, epigastric distress, thickening of bronchial secretions are commonly reported side effects of Clemastine (Tavist). The active ingredient found in Tavist ND is 10 mg Loratadine.

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b

The active ingredient found in Tavist ND is/are: I. Clemastine II. Pseudoephedrine III. Loratadine

Answer: (d). Ledipasvir and Sofosbuvir (Harvoni) . Ledipasvir and Sofosbuvir (Harvoni) is the first combination pill approved to treat chronic HCV genotype 1 infection. It is also the first approved regimen that does not require administration with interferon or ribavirin, two FDA-approved drugs also used to treat HCV infection. Ledipasvir and Sofosbuvir (Harvoni) is a once-daily NS5A inhibitor and nucleotide analog polymerase inhibitor fixed-dose combination for the treatment of chronic hepatitis C genotype 1 infection. Both drugs in Harvoni interfere with the enzymes needed by HCV to multiply. Sofosbuvir is a previously approved HCV drug marketed under the brand name Sovaldi. Harvoni also contains a new drug called ledipasvir. Ledipasvir and Sofosbuvir (Harvoni) is the third drug approved by the FDA in the past year to treat chronic HCV infection. The FDA approved Simeprevir (Olysio) in November 2013 and Sofosbuvir (Sovaldi) in December 2013. The most common side effects reported in clinical trial participants were fatigue and headache.

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d

Which of the following is the first combination pill approved to treat chronic HCV genotype 1 infection?

Answer: (b). Oxybutynin (Ditropan XL) is an antispasmodic, anticholinergic agent. Each Oxybutynin (Ditropan XL) Extended Release Tablet contains 5 mg, 10 mg, or 15 mg of Oxybutynin chloride USP, formulated as a once-a-day controlled-release tablet for oral administration. Oxybutynin (Ditropan XL) uses osmotic pressure to deliver oxybutynin chloride at a controlled rate over approximately 24 hours. Oxybutynin (Ditropan XL) is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency. It is also indicated in the treatment of pediatric patients aged 6 years and older with symptoms of detrusor overactivity associated with a neurological condition (e.g., spina bifida). Oxybutynin (Ditropan XL) must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed. It may be administered with or without food. The recommended starting dose of Oxybutynin (Ditropan XL) in adult is 5 or 10 mg once daily at approximately the same time each day. Dosage may be adjusted in 5-mg increments to achieve a balance of efficacy and tolerability (up to a maximum of 30 mg/day). For pediatric patients aged 6 years of age and older, the recommended starting dose of Oxybutynin (Ditropan XL) is 5 mg once daily at approximately the same time each day. Dosage may be adjusted in 5-mg increments to achieve a balance of efficacy and tolerability (up to a maximum of 20 mg/day). Dry mouth, constipation, blurred vision and vasodilation are commonly reported side effects of Oxybutynin (Ditropan XL).

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b

Which of the following Oxybutynin formulations is indicated for the symptoms of detrusor overactivity associated with a condition called Spina bifida? I. Ditropan II. Oxytrol III. Ditropan XL

Answer: d. Amiodarone (Cordarone) is a member of a class of antiarrhythmic drugs with predominantly Class III (Vaughan Williams' classification) effects, available for oral administration as pink, scored tablets containing 200 mg of Amiodarone hydrochloride. Amiodarone (Cordarone) contains 37.3% iodine by weight. Therefore, it shall be carefully prescribed to patients suffering from hypo-hyper-thyroidism. Because of its life-threatening side effects and the substantial management difficulties associated with its use, Amiodarone (Cordarone) is indicated only for the treatment of the following documented, life-threatening recurrent ventricular arrhythmias when these have not responded to documented adequate doses of other available antiarrhythmics or when alternative agents could not be tolerated. 1. Recurrent ventricular fibrillation. 2. Recurrent hemodynamically unstable ventricular tachycardia. Loading doses of 800 to 1,600 mg/day are required for 1 to 3 weeks (occasionally longer) until initial therapeutic response occurs. Administration of Amiodarone (Cordarone) in divided doses with meals is suggested for total daily doses of 1,000 mg or higher, or when gastrointestinal intolerance occurs. If side effects become excessive, the dose should be reduced. When adequate arrhythmia control is achieved, or if side effects become prominent, Amiodarone (Cordarone) dose should be reduced to 600 to 800 mg/day for one month and then to the maintenance dose, usually 400 mg/day. Since grapefruit juice is known to inhibit CYP3A4-mediated metabolism of oral amiodarone in the intestinal mucosa, resulting in increased plasma levels of Amiodarone, grapefruit juice should not be taken during treatment with oral Amiodarone. Since amiodarone is a substrate for CYP3A4 and CYP2C8, drugs/substances that inhibit CYP3A4 may decrease the metabolism and increase serum concentrations of Amiodarone. Hepatic injury, hypothyroidism, hyperthyroidism, tremor, poor coordination and pulmonary fibrosis are commonly reported side effects of Amiodarone (Cordarone).

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d

Amiodarone shall be carefully prescribed to patients suffering from:

Answer: Serum potassium level. Eplerenone (Inspra) is a blocker of aldosterone binding at the mineralocorticoid receptor. It is available for oral administration contains 25 mg or 50 mg of Eplerenone (Inspra). It is indicated for the treatment of Congestive Heart Failure Post-Myocardial Infarction and Hypertension. Treatment should be initiated at 25 mg once daily and titrated to the recommended dose of 50 mg once daily, preferably within 4 weeks as tolerated by the patient. Eplerenone (Inspra) may be administered with or without food. Serum potassium should be measured before initiating Eplerenone (Inspra) therapy, within the first week, and at one month after the start of treatment or dose adjustment. Serum potassium should be assessed periodically thereafter. For hypertensive patients receiving moderate CYP3A4 inhibitors (e.g., erythromycin, saquinavir, verapamil, and fluconazole), the starting dose of Eplerenone (Inspra) should be reduced to 25 mg once daily. In all patients taking Eplerenone (Inspra) who start taking a moderate CYP3A4 inhibitor, check serum potassium and serum creatinine in 3-7 days. Hyperkalemia, dizziness, diarrhea and abdominal pain are reported side effects of Eplerenone (Inspra).

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c

Which of the following shall be measured before initiating Inspra therapy?

Answer: (d). Ezetimibe (Zetia), administered alone, is indicated as adjunctive therapy to diet for the reduction of elevated total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B), and nonhigh- density lipoprotein cholesterol (non-HDL-C) in patients with primary (heterozygous familial and nonfamilial) hyperlipidemia. The combination of Ezetimibe (Zetia) and Atorvastatin or Simvastatin is indicated for the reduction of elevated total-C and LDL-C levels in patients with Homozygous Familial Hypercholesterolemia (HoFH). It is also indicated as adjunctive therapy to diet for the reduction of elevated sitosterol and campesterol levels in patients with homozygous familial sitosterolemia. The recommended dose of Ezetimibe (Zetia) is 10 mg once daily with or without food. Liver enzyme abnormalities, rhabdomyolysis and myopathy are commonly reported side effects of Zetia.

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d

Zetia is indicated for the treatment of: I. Hyperlipidemia II. Homozygous Familial Hypercholesterolemia III. Sitosterolemia