CAOP - Competency Assessment of Overseas Pharmacist Therapeutic Area Review Questions and Answers — Questions and Answers
Question 1: A 25-year-old patient with asthma reports using their salbutamol (SABA) inhaler 4-5 times a week for symptom relief. They have a prescription for a daily inhaled corticosteroid (ICS) but admit to only using it 'when they feel wheezy'. When conducting a therapeutic review, which finding indicates the most urgent need for intervention according to the Australian Asthma Handbook?
- The patient's reliance on their preventer therapy is inconsistent.
- The patient is using more than two salbutamol inhalers per year. (Correct answer)
- The patient is not using a combination ICS/LABA inhaler.
- The patient has not been provided with a spacer device.
Correct answer: The patient is using more than two salbutamol inhalers per year.
According to the Australian Asthma Handbook and global guidelines, overuse of SABA (defined as using more than two canisters a year) is a significant marker of poor asthma control and is associated with an increased risk of severe exacerbations and mortality. While inconsistent preventer use is the underlying cause, the SABA overuse is the key clinical indicator of high risk requiring immediate intervention, such as education and regimen adjustment. The other options are important considerations but do not represent the same level of immediate risk as SABA overuse.
Question 2: A 68-year-old male with type 2 diabetes and hypertension has a medication profile that includes metformin, perindopril, and atorvastatin. His latest pathology results show an estimated Glomerular Filtration Rate (eGFR) of 28 mL/min/1.73m². Based on this new information, which therapeutic review action is most appropriate?
- Recommend adding an SGLT2 inhibitor to improve renal outcomes.
- Suggest increasing the dose of perindopril for better renal protection.
- Advise the prescriber to cease the metformin due to the risk of lactic acidosis. (Correct answer)
- Recommend switching atorvastatin to rosuvastatin.
Correct answer: Advise the prescriber to cease the metformin due to the risk of lactic acidosis.
Australian guidelines recommend that metformin be discontinued when a patient's eGFR falls below 30 mL/min/1.73m² due to the increased risk of accumulation and subsequent lactic acidosis. While SGLT2 inhibitors are beneficial for renal protection, they are generally not initiated when the eGFR is below 20-30 mL/min/1.73m². Increasing the ACE inhibitor dose would be inappropriate without further assessment, and switching statins is not the priority concern raised by the pathology results.
Question 3: An 82-year-old female patient with a history of osteoporosis, hypertension, and urinary incontinence presents her medication list for a therapeutic review. The list includes alendronate, hydrochlorothiazide, and oxybutynin. She reports increased confusion and a recent fall. Which medication is most likely contributing to these new symptoms?
- Alendronate
- Hydrochlorothiazide
- Oxybutynin (Correct answer)
- A drug-drug interaction between all three medications
Correct answer: Oxybutynin
Oxybutynin has strong anticholinergic properties, which are well-known to cause central nervous system side effects like confusion, dizziness, and cognitive impairment, especially in the elderly. These effects significantly increase the risk of falls. While hydrochlorothiazide can cause dizziness and alendronate has its own side effect profile, the presentation of confusion makes oxybutynin the most probable cause due to its high anticholinergic burden.
Question 4: A 60-year-old man with hypertension and a history of gout is currently managed with losartan. His blood pressure remains elevated, and his GP considers adding a diuretic. During the therapeutic review, which of the following is the most important consideration for the pharmacist to highlight?
- Combining losartan with any diuretic increases the risk of hyperkalemia.
- Hydrochlorothiazide is contraindicated in patients with a history of gout.
- Losartan has a mild uricosuric effect that may partially counteract diuretic-induced hyperuricemia. (Correct answer)
- Chlorthalidone is a safer alternative to hydrochlorothiazide regarding gout risk.
Correct answer: Losartan has a mild uricosuric effect that may partially counteract diuretic-induced hyperuricemia.
Losartan is unique among angiotensin II receptor blockers for its mild uricosuric effect, meaning it promotes the excretion of uric acid. Thiazide diuretics, like hydrochlorothiazide, are known to increase uric acid levels and can precipitate gout attacks. Highlighting that losartan's effect may help mitigate the hyperuricemic effect of a thiazide is a key therapeutic point. While thiazides can trigger gout, they are not absolutely contraindicated, and the risk is dose-dependent.
Question 5: During a therapeutic review for a 72-year-old woman treated for osteoporosis with oral alendronate, the pharmacist notes she has also been taking esomeprazole (a PPI) daily for the last two years for reflux. Which of the following potential issues should be the primary focus of the review?
- Increased risk of C. difficile infection due to long-term PPI use.
- Reduced absorption of alendronate due to the increased gastric pH.
- An association between concurrent use and an increased risk of fractures. (Correct answer)
- The potential for esomeprazole to cause hypomagnesemia.
Correct answer: An association between concurrent use and an increased risk of fractures.
Several studies and meta-analyses suggest that the concurrent use of bisphosphonates (like alendronate) and proton pump inhibitors (PPIs) is associated with an increased risk of fractures, potentially attenuating the therapeutic benefit of the bisphosphonate. While the other points are valid concerns with PPI use, the potential for treatment failure for the primary condition (osteoporosis) is the most critical issue to address in this specific therapeutic context.
Question 6: A pharmacist is reviewing the medications of a 78-year-old patient with stable chronic heart failure (ejection fraction 35%), type 2 diabetes, and chronic kidney disease (eGFR 50 mL/min/1.73m²). The patient is on metoprolol, ramipril, and metformin. The GP is considering adding a new agent for glycemic control and cardiovascular/renal benefits. Which of the following would be the most appropriate recommendation?
- Sitagliptin, due to its neutral effect on heart failure and good safety profile in renal impairment.
- Gliclazide, as it provides effective glucose lowering.
- Dapagliflozin, as SGLT2 inhibitors are indicated for heart failure and CKD benefits, independent of diabetes. (Correct answer)
- Pioglitazone, as it can improve insulin sensitivity.
Correct answer: Dapagliflozin, as SGLT2 inhibitors are indicated for heart failure and CKD benefits, independent of diabetes.
Sodium-glucose co-transporter 2 (SGLT2) inhibitors, such as dapagliflozin and empagliflozin, have demonstrated significant benefits in reducing hospitalizations for heart failure and slowing the progression of chronic kidney disease in patients with and without type 2 diabetes. Given this patient's comorbidities (HFrEF and CKD), an SGLT2 inhibitor is a guideline-recommended choice. Pioglitazone is generally avoided in heart failure due to the risk of fluid retention. Gliclazide does not offer the same cardiorenal benefits, and while sitagliptin is safe, it lacks the proven benefits of an SGLT2 inhibitor in this specific clinical triad.
CAOP - Competency Assessment of Overseas Pharmacist Therapeutic Area Review Questions and Answers
A 25-year-old patient with asthma reports using their salbutamol (SABA) inhaler 4-5 times a week for symptom relief.
They have a prescription for a daily inhaled corticosteroid (ICS) but admit to only using it 'when they feel wheezy'.
When conducting a therapeutic review, which finding indicates the most urgent need for intervention according to the Australian Asthma Handbook?