BCACP Medication Management 2 — Questions and Answers
Question 1: A patient with CKD stage 3b (eGFR 38 mL/min/1.73m²) is prescribed metformin. What is the most appropriate action?
- Continue metformin at full dose
- Reduce metformin dose and monitor renal function every 3 months (Correct answer)
- Discontinue metformin immediately
- Switch to insulin only
Correct answer: Reduce metformin dose and monitor renal function every 3 months
Metformin can be continued with dose reduction at eGFR 30-45 mL/min/1.73m² with close monitoring, but should be discontinued if eGFR falls below 30.
Question 2: Which fluoroquinolone interaction most significantly prolongs the QT interval and requires monitoring?
- Ciprofloxacin with antacids
- Moxifloxacin with amiodarone (Correct answer)
- Levofloxacin with warfarin
- Ciprofloxacin with metformin
Correct answer: Moxifloxacin with amiodarone
Moxifloxacin combined with amiodarone poses a serious additive QT prolongation risk that can lead to torsades de pointes.
Question 3: A patient on warfarin begins fluconazole therapy for a vaginal yeast infection. What is the expected pharmacokinetic effect?
- Decreased warfarin levels due to CYP2C9 induction
- Increased warfarin levels due to CYP2C9 inhibition (Correct answer)
- No significant interaction expected
- Decreased warfarin levels due to reduced absorption
Correct answer: Increased warfarin levels due to CYP2C9 inhibition
Fluconazole is a potent CYP2C9 inhibitor that dramatically increases warfarin exposure, requiring INR monitoring and likely dose reduction.
Question 4: Which medication requires a REMS program due to risk of serious dermatologic reactions, including Stevens-Johnson syndrome?
- Carbamazepine in patients of Asian ancestry (Correct answer)
- Amoxicillin in penicillin-allergic patients
- Lisinopril in patients with ACE inhibitor cough
- Metoprolol in asthmatic patients
Correct answer: Carbamazepine in patients of Asian ancestry
Carbamazepine carries a REMS and Black Box Warning for SJS/TEN, particularly in patients of Asian ancestry who may carry the HLA-B*1502 allele.
Question 5: A 68-year-old patient is taking simvastatin 40 mg and is started on diltiazem for rate control. What is the most appropriate intervention?
- Continue both medications without changes
- Reduce simvastatin dose or switch to a non-CYP3A4-metabolized statin (Correct answer)
- Double the simvastatin dose to overcome the interaction
- Discontinue diltiazem and use a beta-blocker instead
Correct answer: Reduce simvastatin dose or switch to a non-CYP3A4-metabolized statin
Diltiazem inhibits CYP3A4 and significantly increases simvastatin levels, raising myopathy risk; switching to pravastatin or rosuvastatin avoids this interaction.
Question 6: Which parameter is most important to monitor when initiating spironolactone in a patient with heart failure already on an ACE inhibitor?
- Serum sodium
- Serum potassium and renal function (Correct answer)
- Liver enzymes
- Complete blood count
Correct answer: Serum potassium and renal function
Both spironolactone and ACE inhibitors increase potassium retention, creating a significant risk of life-threatening hyperkalemia requiring close monitoring.
Question 7: A patient with gout and hypertension is on losartan. The physician wants to switch to a different ARB. Which property of losartan is beneficial to retain for this patient?
- Losartan has the longest half-life among ARBs
- Losartan has uricosuric properties that lower serum uric acid (Correct answer)
- Losartan is the only ARB with renal protective effects
- Losartan has the fewest drug interactions among ARBs
Correct answer: Losartan has uricosuric properties that lower serum uric acid
Losartan uniquely among ARBs has uricosuric activity by blocking URAT1 in the renal tubule, making it the preferred ARB for patients with comorbid gout.
BCACP Medication Management 2
A patient with CKD stage 3b (eGFR 38 mL/min/1.73m²) is prescribed metformin.
What is the most appropriate action?