1. Interaction of grapefruit juice with fexofenadine, Itraconazole, Clopidogrel,
Cyclophosphamide and Losartan In all these interactions, the level of the medication is decreased, which is contrary to the interaction of grape fruit juice with other medications, where the level of the medication is enhanced. The exact mechanism is not well established Apple and orange juice had effects similar to those of grapefruit juice Management is to avoid grape fruit juice. If used in combination, monitor for decreased effectiveness 2. Disease drug interaction for a patient with hyperthyroidism using Amiodarone for his ventricular arrhythmia Thyroid dysfunction (Hypo or hyperthyroidism) may occur, since it contain iodide in its formulations Thyroid function should be monitored prior to treatment and periodically thereafter. Because of the slow elimination of amiodarone and its metabolites, high plasma iodide levels, altered thyroid function tests may persist for several weeks or even months following Cordarone (Amiodarone) withdrawal. 3. Pregnant lady using anti-epileptic medications such as CBZ, valproic acid, Gabapentin and lamotrigine Here there is a risk of birth defects due to use of the above medications during pregnancy to avoid seizures of the mother, and risk of neural tube defects (NTDs) in fetus. So for the management, we monitor serum drug levels throughout pregnancy as concentrations may fluctuate. Also giving supplements of Vitamin K and Folic acid 4. Patient with asthma using Zafirlukast tablet. He is 20 years old, and intolerant to lactose Zafirlukast contains in its tablet lactose and hence the patient should be monitored for GI problems. If severe avoid using it, and substituted by other antiasthmatic preparations 5. Asthmatic patient with infection (sore throat) using Zafirlukast and Erythromycin Here there is a drug-drug interaction, and Erythromycin decreases plasma level of Zafirlukast by 40%
6. Olizapril 5 mg once daily. Diminished effect at the end of the day i.e. during dose monitoring of BP of the patient rises at the end of the day. Management is by splitting the dose to twice daily or increasing the dose to 10mg.
7. Female patient with Pagets disease, her Doctors prescribed for her 35mg Actonel Risedronate every week for treatment of Pagets disease. Here the dose of the medication is wrong since that dose is for osteoporosis and the recommended regimen for Pagets disease is Actonel (Risedronate) 30mg daily for two months taken orally. Retreatment may be considered if the treatment fails to normalize serum alkaline phosphatase
8. Patient with renal failure having D.M.which is not controlled. He is currently taking pioglitazone 30mg po qd and Glyburide 5mg BID. He is develop hypoglycemia. The doctor thinks that his hypoglycemia is due to the combination effect potentiated by Pioglutazone, in addition to the renal failure which potentiates both medications, and initiated a dose reduction of both medications The DRP here is hypoglycemia and the dose reduction should be with glyburide only since pioglitazone is only 15%-30% is excreted from the kidney and no dose adjustment is required in renal diseases. CPS monograph of Actos (Pioglutazone)
9. Patient using warfarin 3mg, he is weak, tired and needs multiple vitamins Here there is a DRP since multivitamins contain vitamin K which reduces the INR value
10. Patient using Advair diskus for his asthma treatment. He is allergy to milk Here there is a DRP since Advair diskus 250 contains lactose which result in allergic reaction. To manage that, it is better to tell the doctor to switch the patient to advair diskus 250 is one inhalation twice daily i.e. half the dose 11. Doctor switches a patient from Amprenavir 50mg capsule in an HIV regimen to amprenavir oral solution 15mg/ml (3.33ml) The DRP here is that Amprenavir capsule and solution are not interchangeable on mg-mg basis Amprenavir solution is 14% less bioavailability than the Amprenavir capsule (CPS monograph of Amprenavir) 12. Patient using Amprenavir 15mg/ml solution and he is experiencing renal failure. His CrCl is 30ml/min The DRP here is that Amprenavir contains propylene glycol which results incase of renal failure in glyco-associated adverse events including seizures, stupor, tachycardia, hyperosmolality, lactic acidosis, renal toxicity and hemolysis Amprenavir capsule as soon as they are able to take the capsule formulation 13. Patient taking Captopril 25mg for his hypertension and also taking Allopurinol 200mg once daily or any dose of allopurinol There is DRP in general ACEI when administered concurrently with allopurinol, there is a risk of increase of hypersensitivity reactions like Stevens-J ohnson syndrome
14. Patient 60 years old using Carbolith (Lithium) for his bipolar depression, and was given Amitriptyline for his depression A DRP will result from that combination since the use of Amitriptyline in patient with bipolar disorder may precipitate a hypomanic or manic state.
15. A Patient with post M.I. developed depression. His doctor wants to prescribe Amitriptyline for him There is a DRP since Amitriptyline is not recommended during the acute recovery phase following M.I. or in the presence of CHF due to arrhythmias and conduction abnormalities.
16. Patient with sore throat using Amoxicillin 500mg capsule qid, and also using MTX for his rheumatoid arthritis The DRP here is that penicillin in general compete with renal tubular secretion of MTX, decreasing its clearance. Concomitant use may increase MTX serum concentrations resulting in increase in the risk of toxicity e.g. neutropenia Management for that DRP is to monitor MTX toxicity 17. Doctor wants to prescribe Tetracyclines (e.g. Doxycycline, minocycline, tetracycline) with Amoxicillin for mixed aerobic infection A DRP exists here since the bacteriostatic action of tetracycline may inhibit bactericidal activity of penicillins, so avoid this combinations
18. A patient taking warfarin for his supra ventricular tachycardia, and developed sore throat and his doctor wants to prescribe Ampicillin 500mg QID Effects of warfarin may be increased resulting in increased risk of bleeding INR should be monitored upon addition of Ampicillin and withdrawal of Ampicillin. INR should be periodically reassessed for at least 3 weeks after ampicillin D/C, since adjustment in the warfarin dose may be necessary to maintain an effective level of anticoagulation 19. Patient who is diabetic with advanced prostatic cancer was given for him Cyproterone acetate as an anti-androgen A DRP results since cyproterone may impair carbohydrate metabolism. Fasting blood glucose and glucose tolerance test should be examined carefully in all patients
20. Doctor prescribes Androderm patch with usual starting dose of 5mg applied in the morning It should be applied at night preferably @ 10:00pm and worn for 24 hours providing a total dose of 5mg of testosterone/day To ensure proper dosing, the morning serum testosterone concentration may be measured following patch application the previous evening (CPS monograph of adroderm) 21. Patient with a history of seizures, he is experiencing anemia due to chronic renal failure. His Doctor wants to prescribe Dabepoetin alfa There is DRP here since seizures have occurred in patients with chronic renal failure taking Darbepoetin. Therefore monitoring is important closely during the first several months of therapy Also it is recommended that the dose of Darbepoetin be decreased if the Hb increase exceeds 10g/L 22. 5-ASA (Asacol) and the doctor wants to add lactulose 5-ASA is a colon targeted tablet with a special coating. Giving lactulose will lower the pH of the stool snd the tablet can be disintegrated in the colon since it requires acidic medium
23. Patient with thrombocytopenia. His doctor wants to prescribe him inactivated Hepatitis A i.m. vaccine since he is raveling I.M. may result in bleeding, so the vaccine may be infected by the s.c. route, however this may be associated with a higher risk of local reaction including injection site nodule
24. Pharmacist dispenses Clindamycin phosphate, Benzoyl peroxide, mixes the ontent and dispenses it to the patient The DRP is that the pharmacist should put an expiration date of 3 months after mixing on the label
25. Doctor prescribes clobazam 5mg/day for an adult patient experiencing anxiety disorder. The DRP here is that Clobazam is used for seizure disorder. The doctor can substitute that by alprazolam, Bromazepam, chlordiazepoxide, and many others
26. Meclizine 12.5 mg tablet for 8-year-old child one hour before traveling as for prophylaxis from motion sickness The DRP is that meclizine as with all antihistamines may cause hyperexcitability in children. So for children relying on non- pharmacological way is the best choice to avoid motion sickness
27. A physician is tapering the dose of Duragesic 100 patch by ddecreasing the dose by 25%, so he tapers every 3 days by giving 75 patch then 50 patch then 37.5 patch then 25 patch and lastly 12.5 patch which is least patch strength The decrease in decrements is not correct for the last dose because when the physician switches from patch 25 to 12.5 he is decreasing by 50% and not by 25% as the CPS mentions which result in withdrawal symptoms In Addition to that the physician at patch 25 and because he cant swotch to patch 12.5, he should calculate the equivalent dose of Duragesic patch to oral morphine which is 60-134mg/day. So consider 20mg/day, then he should taper each day by 25% i.e. 45, 30, 15 28. Patient requires thyroid replacement therapy. He is also under glucocorticoid activity The DRP here is that patient with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation treatment with levothyroxin sodium Failure to do so may precipitate an acute adrenal crisis when thyroid hormone is initiated due to increase metabolic clearance of glucocorticoids by thyroid hormone 29. Dr prescribes Docasanol cream 10% 5 times daily for acute cold sore in lips and for 10 days The DRP is that Docasanol is prescribed for recurrent cold sores
30. Ciclopiroxolamine lotion 1% once daily for the nail infection The DRP here is that concentration 1% is for Tenia pedis or T cruris while 8% is for nail infection
31. Pregnant woman with a fixed dose of 100ug Levothyroxine before pregnancy, during pregnancy and after delivery The DRP is that during pregnancy, serum T4 may decrease and serum TSH may increase since elevations in serum TSH may occur as early as 4 weeks gestation, pregnant woman taking L-thyroxine should have their TSH measured during each trimester An elevated TSH should be corrected by increasing the dose of levothyroxine. In post partum the TSH decreases and T4 increases, thus reducing the dose of levothyroxine is important 32. A patient with major depressive disorder, he is taking fluoxetine 60mg/day since 28 months ago. He is allergic to Amitriptyline. His doctor wants to prescribe CBZ 100mg BID for 5 days, then 200mg BID for 1 month, for his grand mal epilepsy DRP here is that CBZ has the structure of TCA and since the patient is allergic to amitriptyline i.e. TCA, then taking CBZ for his grand mal epilepsy will result in hypersensitivity reaction
33. Androderm patch 12.5mg po qd am The DRP here is that the patch should be applied at night due to circadian variation
34. Patient with symptoms of gastric malignancy was given Cimetidine 200mg BID to reduce the signs and symptoms of stomach upset The DRP here is that cimetidine may mask the symptoms of gastric malignancy
35. A patient with NSAID-induced lesions and symptoms in GIT was given 800mg/day in one or two divided doses for 6 months The DRP here is the duration of treatment. The duration should be for recurrent duodenal or gastric ulcer (Ref: CPS monograph of Cimetidine) 36. A 10-year-old patient using methyl phenydate. He is exercising severely to reduce his hyperactivity The DRP here is that severe physical exercise with methyl phenidate will result in arrhythmia (Ref: ESP monograph of concerta under warnings and precautions) 37. Patient with proctitis, his doctor prescribed for him corteneme (H.C.) for 3 weeks. In his profile he started Riseperidone 0.25mg once daily since a week ago due to first episode psychosis The DRP here is that corteneme is contraindicated in acute psychosis, and hence in this case the patient should be switched to oral 5-ASA full dose to treat his proctitis (T.C. Pg 761)
38. Patient suffering from fibromyalgia, his doctor prescribed for him cyclobenzaprine 5mg t.i.d for 3 weeks. In his profile he is using Tranyl cypromine for his major depressive disorder The DRP here is that concurrent use of MAOI with cyclobenzaprine is contraindicated so avoid the use of both medications together. Any NSAID may be given to relieve pain if not contraindicated
39. Dr. initiated treatment of Caduet (Amlodipine +Atorvastatin) for a patient that is hypertensive with high cholesterol level The DRP here is that Caduet is not for initial treatment. The dose of Caduet should be determined by the titration of individual components
40. Nifedipine 10mg INR was prescribed for a patient with hypertension Nifedipine IR and in combination therapy is indicated for angina and not hypertension Nifedipine XL 30mg may be used for hypertension or angina 41. Patient taking cholestyramine for his dyslipidemia and MTX for his rheumatoid arthritis Cholestyramine interferes with enterohepatic recirculation of MTX, thereby reducing the elimination t and increasing the rate of clearance of the drug To manage this condition, replace cholestyramine by another class of antilipidemia. Adjust the dose of MTX to compensate for reduced exposure during treatment with cholestyramine. Monitor for altered response to MTX when initiating, discontinuing or changing the dose of cholestyramine 42. Patient using Danazol as a treatment regimen for fibrocystic disease for one year The treatment course should be limited to 3-6 months maximum (Ref: CPS monograph of cyclamen (danazol)) 43. Clindamycin vaginal cream used by a lady for a week, starting from first day of menstruation to treat her vaginosis The Clindamycin vaginal cream should not be used during menstruation and the treatment should not be used delayed until menstruation is complete
44. Deca-Durabolin (Nandrolone) used by an athlete to enhance his activity Nandrolone is not used to enhance activity but it may increase the weight of the athlete
45. Lady is using Depo-provera (Medroxy-progesterone acetate) 100mg for 3 moonths for contraception) The Depo-provera 150mg is used for contraception while progesterone 50mg and 100mg are used for 2 weeks in endometriosis
46. A pregnant lady taking Diclectin (Doxylamine +Pyridoxine) on prn. Diclectin tablets of a delayed release formulation should not be prescribed on prn It is important that Diclectin is taken daily for optimal effect. 47. Patient with Pagets disease using etidronate for 1 year Etidronate should be monitored every 3-6 months and retreatment should not be initiated until the patient has had at least a three month drug-free interval to determine whether remission has occurred and to promote mineralization of any unmineralized osteoid which may have develop
48. Cabergoline capsule 0.5mg is given for a lady for the purpose of suppression of already established post partum lactation Cabergoline is indicated for the prevention of the onset of physiological lactation in the puerperium for clearly medical reasons (Ref: CPS monograph of dosfinex (cabergoline) 49. Patient traveling to a tropical area, he took dukoral first dose and traveled the 2 nd
day Protection against ETEC diarrhea and cholera can be expected approximately one week after primary immunization is concluded
50. Doctor is tapering Duragesic dose of 100ug/hr as such 100, 50, 25, 12.5. Steps of 25% is recommended i.e. 100, 75, 50, 37.5, 25.
51. Woman taking oral estrogen. Her doctor stopped oral Estrogen and gave her estrogen gel Women who are currently taking oral estrogen treatment with estrogen gel can be initiated 1 week after withdrawal of oral therapy or sooner if symptoms reappear before the weeks end (Ref: CPS monograph of estrogel) 52. A 55-year-old patient is on Paroxetine 20mg/day. His doctor wants to switch him to sertraline 50mg/day, and he is doing in a vacation for 90 days. Best therapy is a) Give 90 tabs of sertraline 50mg b) Give 30 tabs of sertraline 50mg c) Give 180 tabs of sertraline 25mg d) Give 30 tabs of sertraline 25mg e) Give 60 tabs of sertraline 25mg (E) Here the switching is within the same class and there is no need for washout period. However since the doctor switch the patient to a new medication, then the supply should be for one month since the doctor may adjust the dose later on; and because he is traveling, there is possibility that the patient cannot tolerate sertraline 50mg tab and therefore it is better to give him sertraline 25mg, just in case if he cannot tolerate the one daily dose of 50mg, then he can split the dose to two tabs of 25mg. The supply of 90 days is not acceptable since the patients dose may be adjusted by the doctor 53. 60 year old patient taking 100mg imipramine once daily. He develop sore throat and his doctor prescribe for clarithromycin 50mg qid The problem here is not because clarithromycin here is an enzyme inhibitor of 3A4, but the problem rises since both affect Torsade de pointes resulting in arrhythmia. So the solution is to ask the patient for the main purpose of using imipramine. So if it is for neuropathic pain, he may take Imipramine until the end of the dose of clarithromycin and substitute imipramine by codeine or NSAIDs until the end of the dose of Clarithromycin This applies also for intermittent use of imipramine for insomnia. However if imipramine is used for depression, then in that case, there is no choice other than calling the doctor to change clarithromycin to another antibiotic like Azithromycin or Amoxicillin 54. A 55-year-old patient who is taking Tramacet 200mg 1x3 for wrist pain with Tylenol #3 1x3/ He has been using these two medications for the last 15 days. Now his doctor decided to prescribe him citalopram 20mg/day to correct his depression that developed from his condition. The main concern of the pharmacist there is: a) Major interaction of citalopram with tylenol #3 b) Major interaction with tramacet (Tranodol and acetaminophen) c) Major interaction of citalopram with tramacet and tylenol #3 d) The acetaminophen that is in tramacet and Tylenol #3 e) No concern about any interaction (B) The major interaction which of the highest concern is between Tramadol and Citalopram resulting in the serotonin syndrome. However there is a minor interaction between codein and Tylenol #3 and citalopram but it is not as major as that of tramadol and citalopram The combination of acetaminophen in Tylenol #3 and tramacet according to dose and direction will not reach 4g/day and therefore it is safe to be given together 55. A 70-year-old patient is taking Paroxetine 20mg/day and ketorolac 30mg/dose for which his ankylosing spondylitis. The patient should be monitored for a) Increased sedation of paroxetine caused by ketorolac b) No monitoring is required c) Monitor in the increase in BP due to sodium retention caused by ketorolac d) Monitor GI upset caused by ketorolac e) Monitor GI upset due to the combination (E) SSRI and NSAIDs increase the risk of GI bleeding
56. A 35-year-old patient who is pregnant in her second trimester is experiencing allergic rhinitis and requesting an antihistamine medication for her itchiness. She is a housewife. Best Medication to be given for her as an OTC medication is: a) Desloratidine tab b) Diphenhydramine tab c) Loratidine tab d) Diphenhydramine and Loratidine e) Desloratadine and Loratadine (D) Diphenhydramine and loratadine are given in pregnancy and they are under category (B) while desloratidine is under category (C) So we can tell the patient that there is a good evidence for the use of diphenhydramine and loratadine in pregnancy 57. A 45-year-old patient was diagnosed to have vaginal yeast infection. Her doctor started to give her itraconazole 200mg/day for 7 days to treat her vaginal lesions. In her profile she is using lansoprazole 50mg BID. Best therapy is: a) To continue on both medications as both of them were prescribed by her doctor b) Itraconazole increases the concentration of lansoprazole and therefore lansoprazole should be given once daily c) Reduce the dose of itraconazole to a level to keep lansoprazole at its therapeutic level d) Call the doctor to switch the patient from itraconazole to fluconazole to avoid any drug interaction e) None of the above (E) The best thing is to stop for 1 week lansoprazole until the patient completes his cycle of itraconazole since lansoprazole increases the pH of the stomach and affects the absorption Switching is not popular if we can handle the situation safely by keeping the same medication in this case itraconazole and discontinuing lansoprazole just for a short period of time which is one week 58. A 56-year-old patient is using pantoprazole 40mg once daily. In this profile, the patient is using itraconazole 200mg/day for 21 days for esophageal lesions, which were resistant to fluconazole. After receiving his new prescription for pantoprazole the pharmacist should: a) Do not dispense the new prescription since pantoprazole reduces the absorption of itraconazole which may result in flare ups b) Space apart pantoprazole with at least 46 hours from itraconazole c) Call the doctor to switch the patient to nebeprazol d) No problem we can give both medications together e) None of the above (E) In this scenario pentolac is a long acting medication and thats why it is given once daily, so spacing apart or switching to another PPI or even H2 blocker will not solve the problem. Discontinuation of pantolac for 21days will result in GI problem. So the best thing is that the pharmacist should advise the patient to take itraconazole with pop (any acidic beverages) to enhance absorption 59. A 44-year-old patient came to the pharmacy with a new prescription for salbutamol inhaler to use 2 puffs qid prn, and coActifed tab for dry cough which contains codeine to be used as TID. In his profile he is using advair diskus (salmeterol plus fluticasone) as 1 puff BID. The pharmacist should counsel the patient on the following: a) Stop using advair since you are using salbutamol b) Stop using CoActifed since it suppresses cough and hence it masks the signs and symptoms of asthma c) There is no drug interaction or any DRP and the pharmacist should counsel on each medication in the new prescription d) Call the doctor to switch the patient from Actifed tab to first generation antihistamine e) None of the above (E) The DRP here is that the CoActifed is a cough suppressant and thus it will mask the signs and symptoms of any asthmatic attack which make the patient unaware of his worst condition especially his doctor has started to give him 8 puffs prn which is the highest dose so that the pharmacist should counsel now is that during the use of CoActifed to treat the cough of the patient should use his salbutamol puffer regularly to avoid any mask of symptoms that may happen during the use of cough suppressant after recovery from his cough. The use of antihistamine (first generation) in asthma may aggrevate asthma, resulting in dryness and crushings Stop using Co-actifed is not a good option since all the cough medications that are used for dry cough they contain either codein or dextromethorphan 60. A 53-year-old lady came to the pharmacy with a prescription for Wellbutrin 150mg SR. Her profile shows that she was on Wellbutrin 150mg XL. The pharmacist asked the patient whether she is aware of any changes thata her doctor made for her therapy, and she replied that nothing her doctor told her about that. The best action the pharmacist should do is: a) Dispense Wellbutrin 150mg SR since there is no difference between the two b) Dispense Wellbutrin XL as in her profile c) Call the doctor to see if he has intended to change XL to SR d) Give the generic Bupropion SR e) None of the above (C) Wellbutrin XL is once a day and Wellbutrin SR is twice a day but could be given once a day, so the best option is to call the doctor that the patient was on XL and not on SR since the patient was not aware of any changes that her doctor has made
61. The patient is 44 years old and her doctor prescribed for her varenicline starter pack (o.5mg tab) for two weeks. Best action the pharmacist should do to the patient is: a) Dispense the medication as it is written and counsel the patient on quitting smoking within 2 weeks b) Give the patient varenicline 1mg since it is stronger c) Dispense varenicline starter pack and varenicline 1mg tab pack d) Call the doctor e) None of the above (E) In this particular case we should ask the patient before calling the doctor whether she has any appointment after two weeks or not since varenicline starter (champix 0.5mg starter) ends up after two weeks. So, if the patient says I have an appointment after two weeks, then, there is no need to call the doctor, however if it says yes no, then we have to call the doctor for continuation of therapy. The therapy should be at least for three months. Two weeks for the starter pack and ten weeks for the continuation pack. Stopping the smoking should be within the first two weeks, at the starter dose should onefal (0.5mg) for the three days, then 0.5mg twice daily for the consecutive four days an in week two the patient three hours use 1mg twice daily in the same starting pack which is of different color the medication may cause sedation, with food and pleats of water.
62. A 55 years old patient using His profile shows that he was on paroxetine 40mg/day three months ago, of then he was switched six weeks ago to venlafaxine 75mg once daily. Now he came with a new prescription of venlafaxine 75mg of paroxetine 40mg daily the pharmacist should interact with patient as follows a) Disperse both medications b) Call the doctor for washout period of venlafaxine c) Dont dispense the two medications, since they may cause sertonin syndrome d) Call the doctor to switch the patient to ECT e) None of the above (E) In case if there is no response after the second treatment (four to six weeks), the doctor should prescribe either paroxetine plus bupropion or mirtazapine. Another option is to prescribe venlafaxine plus bupropion or mirtazapine. CBT should be attempted with medications. ECT in the patient cannot tolerate the medications. Mirtazapine should not be prescribed if the patient has over weight.
63. A 62 years old patient came to the pharmacy with a new prescription for venlafaxine 112.5 mg to treat his depression. His profile shows that he was on venlafaxine 75mg for the past six weeks. He is not experiencing any except sedation. Best action of the pharmacist is; a) Call the doctor that there is no venlafaxine 112.5mg b) Call the doctor to reduce the dose since he is experiencing sedation c) Call the doctor to change the dose to either 75mg or 150mg which are available in the market d) Try to make a compound for venlafaxine of 112.5mg e) None of the above (E) Venlafaxine 112.5mg could be dispensed by making two transactions; one transaction is for venlafaxine 75mg cap the other transaction is for venlafaxine 37.5mg cap. So tell the patient to use one cap of 75mg along with one capsule of 37.5mg. He can swallow both of them, or sprinkle them on food or apple sauce, and it is better to be taken with food.
64. A 70 years old patient he has the history of heart failure and is using Digoxin 0.25mg Recently the patient was experiencing sore throat and the doctor prescribed for him Biaxin 500mg tech (clarithromycin 500mg tal). He has no allergy to any medication. Best action should the pharmacist do is; a) Dispense clarithromycin and there is no problem of any interaction b) Call the doctor to switch the patient from clarithromycin 500mg to Azithromycin 500mg c) Call the doctor to switch the patient to Amoxycillin 500mg TFD d) Stop Digoxin for the period of using clarithromycin e) None of the above (C) Clarithromycin, Azithromycin, doxycycline and tetracycline except Amoxycillin kill the bacterial flora in the brush boarder of the small intestine which may result in crease in the absorption of Digoxin. The problem here is not that digoxin may be deceased excretion due to clarithromycin CYPY50 3 Digoxin is not a substrate of CYP3AY.
65. A patient 5 years old experiencing common cold, sneezing, runny nose. His mother approaches you for an OTC product. Best selection of OTC to treat his common cold is; a) Desloratidine syrup (Aerius) b) Claritin syrup c) Fexofenadine syrup d) Combination of an antihistamine plus a decongestant e) None of the above (E) Under six years of age no cough and cold remedies. The patient may be provided with saline drop for his decongestant nose, and acetaminophen syrup if he has fever, humidifiers and eucalyptus are also good for him. All first generation antihistamines with the decongestants should be reserved for the children that are above six years of age.
66. A 22 years old patient had broken his wrist after a baseball game. Best recommendation his doctor should prescribe for his severe pain is; a) Diclofenac 75mg b) Oxycodone 10mg 4-6 Hpru c) Endodan 40mg (oxycodone +ASA) d) Tramadol +acetaminophen e) None of the above (C) Since any broken limb result in swealling, there fore a pain killer with an antiinflammatory agent should be siren while all the others are considered as pain killer. Diclofenac although it is an antiinflammatory and a pain killer since it is an NSAID, however it is not potent as oxycodone plus ASA, and secondly diclofenac 75mg is a sustained release medication which has not an immediate action.
67. A patient 55 years old experiencing rheumatoid arthritis. He is using 25mg MTX weekly for three months. His doctor decided to prescribe folic acid 5mg. The best administration of folic acid is; a) Take folic acid concurrently with MTX in the same day b) Space apart folic acid from MTX at least 4 6 hours c) It is better to give 0.4mg 1mg folic acid d) Give folic acid another day in which the patient does not take folic acid e) None of the above (D) To avoid drug antagonism by folic acid it is better to give in a day where the patient does not take any dose of MTX. If MTX was given in alternating days, again it is preferable to give folic acid in those days that the patient is using MTX.
68. A 45 years old female patient experiencing vaginal infection. Her doctor prescribed for her fluconazole 150mg tal (Diflucan 150mg). In her profile she is using chlordiazepoxide 5mg once daily. Best recommendation from the pharmacist to the patient is; a) There is no DRP between chlordiazepoxide and Diflucan 150mg since Diflucan is used once daily b) Space apart Diflucan and chlordiazepoxide at least 4 6 hours c) Call the doctor to replace fluconazole by another azole that does not interact with chlordiazepoxide d) Tell the patient not to use chlordiazepoxide in that day of using fluconazole e) None of the above (D) There is a severe drug drug interaction between fluconazole and chlordiazepoxide and the literature mentrous that increased and prolong psychomotor impairment and depression. Possibly continuing a few days after fluconazole discontinuation. However, because here the dose of fluconazole is for one day, then we can advise the patient to stop using chlordiazepoxide for one day and to resume using it after 24 hours.
69. A 33 years old patient experiencing migraine. Her doctor prescribed for her rizatriptan 10mg tab for five days. The strength that is available is 5mg RPD tablets. The number of tablets that should be provided to the patient is a) 10 tablets b) 20 tablets c) Call the doctor and tell him 10mg tablets is not available d) 30 tablets e) None of the above (B) Because the dose of Rizatriptan may be repeated in 24 hours. Then we should give 20 tablets of 5mg. Rizatriptan tablets. This also apples for all triptans whether tablets or injections.
70. A patient 35 years old was prescribed topiramate 250mg for the first week and to increase the dose of topiramate by 25mg each week till she reaches the maintenance dose of 350mg per days. It take the patient a) 7 weeks to reach the maintenance dose b) 6 weeks to reach the maintenance dose c) 5 weeks to reach the maintenance dose d) 4 weeks to reach the maintenance dose e) None of the above (E) First week 250mg, each week till 100 till it reaches 350mg dose.
71.For the above patient the number of pills prescribed for the patient will be a) 30 tablets topiramate 250mg and 30 tablets topiramate 25mg b) 30 tablets topiramate 250mg and 35 tablets topiramate 25mg c) 35 tablets topiramate 250mg and 70 tablets of topiramate 25mg tablets d) 30 tablets topiramate 250mg and 70 tablets of topiramate 25mg tablets e) None of the above (C) Since he is taking the each week 250mg, then 35tablets of topiramate 250mg for 5 weeks to read the maintenance dose. For topiramate 25mg it is not used for the first week of the dose is titrated up by one tablet starting form the second week thus. 2 nd week 3 rd week 4 th week 5 th week 7 tablets 14 tablets 21 tablets 28 tablets The combination is; 7 +14 +21 +28 =70 tablets of topiramate 25mg and 35 tablets of topiramate 250mg tablets.
72.A patient 70 years old was admitted to the hospital due to severe congestive heart failure. The nurse practitioner in the hospital called the pharmacy where the admitted patient has his profile to send the profile of the patient. In his profile the following medications were seen; 1. Digoxin 0.25mg GD active 2. Bisoprolol 0.125mg BID deactivated 3. Carvidilol 0.25mg BID on hold 4. Carvidilol 0.25mg BID active 5. Spironolactone 12.5mg GD on hold The pharmacist is his report to the nurse practitioner the following; a) All of them b) Only 1, 2, 3 and 4 c) Only 1, 4, 5 d) Only 1 and 4 e) Only 2 (D) The pharmacist should provide only the medication that the patient is using from 3 and 4 only. 4 since it is active and 3 is on hold not using it and the deactivated we dont list them since the patient is not using them. However if the patient profile was containing only on hold and deactivated medication, later the on hold only should be provided to the nurse since the deactivated ones reflect the on hold medication, which he is using them currently.
73. A 65-year-old patient has red eye. His doctor wants to prescribe him an eye drop that is mast cell stabilizer. The patient has a problem with compliance Best antihistamine/mast cell stabilizer that suites this patient is a) Emedastine b) Ketotifen fumarate c) Iodoxamide d) Nedocromil e) Olopatidine (D) Nedo-cromil (Alocril) is used as 1-2 drops BID while the rest ranges from TID to QID
74. 45-year-old patient has diabetis and currently experiencing anxiety disorders. His profile shows that he is on metformin 500mg BID and used alprazolam 1mg QID. He approaches your counter with a new prescription. The new prescription to treat his anxiety disorder in which has not improved yet is: a) Should contain higher dose of alprazolam b) Should contain pregabalin 150mg/day c) Gabapentin 300mg/day d) Riseperidone 1mg/day e) None of the above (c) Gabapentin is not a first-line agent, and maybe useful in patients not responding to first line measures. Pregabalin causes peripheral edema and should not be used in peripheral circulatory impairment as in diabetes. Resiperidone is used as augmentation therapy with first line agents in PTSD
75. 10 years patient with ADHD. His doctor diagnosed his condition and prescribed methyl phenidate CR capsule 10mg twice daily. Best thing the pharmacist should do is a) Call the doctor to switch the patient to methylphenidate SR tab 20mg/dose since the later is given in divided doses b) Call the doctor to ensure him that methylphenidate SR is given once daily and not twice daily c) Dispense the prescription as it is d) Call the doctor to prescribe him methyl since the capsule can be opned and sprinkled on soft foods e) None of the above (B) methylphenidate SR is given as 20mg/dose 8 hours apart and controlled release as a single dose
76. 33-year-old patient experiencing insomnia. His profile shows that he used temazepam 30mg/day 2months ago. He still experiencing insomnia and came wih new prescription from his doctor. Best therapy his doctor should recommend is: a) Continue Zopiclone b) Continue on Zopiclone and none pharm c) Melatonine herbal product d) L-tryptophan e) Zopiclon and temazepam (D) L-tryptophan with 1-3g 20 min before bedtime is an alternative to BZD and non-BZD agonists Melatonine differs from batch to batch since it is a herbal product. Non-pharm always be recommended but it appears in this case that they will not improve the patient condition since he has already used a BDZ with no benefits which indicates the necessity to go to the alternative medication in addition to the non-pharm which should be followed too
77. A 60-year-old patient came to the pharmacy with a prescription for citalopram 10mg tablet for 30 days. The patient has problem with compliance and requested to be put in a blister pack. The pharmacist in this case should: a) Tell the patient to sign a form because he is ordering a blister pack (dosette) b) Dispense the medication in one week blister pack c) Dispense the medication in a blister pack as it is written in the prescription d) Dispense the medication in a blister pack for 4 weeks only e) None of the above (D) The pharmacist can not dispense for 30 days in a blister pack. Blister packs are only on weekly basis There is no form for blister packs. Forms are for non-child resistant vials or when the patient requests the medication to be given to an agent.
78. Doctor prescribes citalopram 60mg QD to a patient who didnt find any improvement in his citalopram 40mg QD. The available citalopram in the pharmacy is 10mg, 20mg, 40mg. Best thing the pharmacist should do is: a) Call the doctor to fell him that the pharmacy does not have that strength b) Order citalopram 60mg from warehouse c) Give citalopram 20mg along with citalopram 40mg tablet d) Call other pharmacies to provide the pharmacy with citalopram 60mg tablet e) None of the above (C) We can give citalopram 20mg tab along with citalopram 40mg tab
79. Health Canada wants to recall prevacid medication. The pharmacist should call the patients using this medication for at least: a) 1 month ago b) 2 months ago c) 3 months ago d) 1 year ago e) 1 week ago (c) At least 3 months ago since such kind of PPIs may be supplied up to 90 or 100 days
80. Health Canada wants to recall Amoxicillin 250 medication. The pharmacist should call the patient using this medication for at least: a) 1 week ago b) 2 weeks ago c) 1 month ago d) 3 months ago e) 6 months ago (B) Since antibiotics especially Amoxicillin is not for long periods of time, then 2 week supply is generally sufficient
81. The pharmacist should keep the inventory of his medication for at least a) 1 month b) 2 months c) 3 months d) 6 months e) 1 year (C) At least 3 months are required to cope with the idealistic turnover of his medications 82. A pharmacist is processing a prescription signed by the pharmacist himself for glucose strips. He is doing that instead of selling it over the till directly because a) Strips can not be sold over the till b) It is more organized to process it in that way c) To release an official receipt that could be submitted to the third party d) Doctors do not issue prescriptions for glucose strips e) None of the above (C) If we scan the medication over the till, there is no official receipt unless the prescription is processed
83. A pharmacist during in putting a prescription into the computer forgot to enter the number of refills that were indicated in the prescriptions, and the patient pick up his medication from the pharmacy and went home. The best action the pharmacist should do: a) Call the patient to tell him that you forgot to put the number of refills b) No problem, next time when he comes you can tell him to go to his doctor to write other refills c) Dont tell the patient that you forgot to put the refills d) Call the patient inform him that you forgot to put the refills and tell him that you are going to enter the refills into the computer e) None of the above (E) We have to call the patient inform him about the error, and input the number of refills into the computer, and issue a drug incident error for that and inform the manager or district manager about that, and take the steps of not repeating this error again
84. A customer comes to the pharmacy requesting 2 packs of birth control portia 21 tabs (1 qd ud). When the pharmacist checks the profile of the customer he sees that she has taken the medication one month ago. Best action the pharmacist should do is: a) Call the doctor and tell him if he accepts the early refill b) Refuse to dispense the birth control due to early refill c) Dispense the portia d) Tell the customer to go to walk-in-clinic to bring a new prescription e) None of the above (C) Because the medication direction is UD which means as directed, then this birth control medication might be given continuously, which means 42 days (30) (42) =70. Any medication medication if was requested after 2/3 period has past could be given the refills of that medication except for narcotics. So in such conditions, there is no need to call the doctor to get his permission for refill nor to call the third party drug plans if the patient is covered.
85. Doctor wants to prescribe methotrexate vial 25mg/ml 52per week for 6 months. The vial has the volume of 2 ml. The quantity authorized by the doctor to treat that condition is: a) 26 ml. Or 13 vial b) 52 ml. Or 26 vials c) 24 ml. Or 12 vials d) 48ml. Or 24 vials e) none of the above (B) the quantity authorized is 52ml. Or 26 vials, however, the patient is going to inject 1ml each week and discard the other ml since the vial of 2ml does not contain any preservative
86. Patient calls a pharmacy X, he wants to fax his prescription to the pharmacy. Best action the pharmacist should do: a) Accept the fax b) Call the doctor to see whether the fax is true or not c) Dont accept any fax from a patient d) Ask the patient to tell you what medications are in the fax so that to release a verbal prescription e) None of the above (E) We can tell the patient to fax and also to bring the original prescription when he comes to the pharmacy
87. A pharmacist wants to pull out his close to expiration date medications from the shelves so that not to dispense them to the patients. He is now out the end of 3 rd week of September. He decided to pull out October and November ahead of time. He has the following medications that expired on November: 1- Ceftin suspension 2- Apo-Risperidone suspension 3- Azithromycin capsule 4- Tramacep capsule 5- Fluconazole tablet
a) All of them should be pulled out b) Only 2 and 4 c) Only 1,3 and 5 d) Only 1 and 3 e) Only 5 (B) Since 1, 3 and 5 are all antibiotics, and there is no need to pull them two months ahead. The quantity of the dispensed antibiotic is for one or two weeks in the majority of cases
88. 65-year-old patient broke his knee 15 days ago while he was playing soccer. His doctor prescribed for him endocef (Percocet) tab to be taken as one tab QID. His profile shows that he is still using Tylenol #3 which was filled 15 days ago. Best action the pharmacist should do: a) Refuse to fill the prescription b) Call the doctor to inform him that he still has Tylenol #3 and using it c) Dispense the new prescription and caution the patient about the addiction of codeine d) Tell the patient to D/C Tylenol #3 e) None of the above (E) The patient should be cautioned about the high dose intake of acetaminophen which should not exceed 4 years/day and not for codeine or oxycodon which is in addition to that our concern here is the relieving of pain as not the addiction
89. A 45-year old approaches your counter with a new prescription for Zyban m150mg. In your pharmacy, there is no Zyban but you have other generics of Bupropion of the same strength. The best action you should do: a) Dispense Sandoz-Bupropion 150mg or any generic of the same strength b) Call the doctor to change the medication from Zyban to any other generic c) Tell the patient that you dont have Zyban and you can choose other OTC smoking cessation medications d) Tell him sorry I dont have that now e) None of the above (E) You should order Zyban from the warehouse if you dont have it. Sorry I dont have it is not serving the patient property Any generic is not interchangeable with Zyban since Zyban is specific for smoking cessation and not to treat depression
90. Doctor wants to prescribe methadone as a part of methadone program for a patient who is addicted to morphine for more than 1 year. The dosage form of methadone to treat that condition should be: a) Capsule b) Tablet c) Suppository d) Injection e) Liquid form (E) Always should be in liquid form which the other solid forms could be in hidden under the tongue and not used The solid dosage forms and injections may be kept for acute cases of pain The pharmacist should keep talking with the patient to ensure that he swallowed the dose The dose should be witnessed by the pharmacist. For holidays, the physician should release another prescription to be bought from another pharmacy
91. A patient wants to quit smoking and he wants to do that by a short duration. He has hypertension which is under control. Best shortest therapy is: a) Nicoderm transdermal patch b) Varnicline c) Zyban d) Nortriptylline e) Clonidine (Dixarit) (E) Clonidine (Dixarit) 0.1mg po BID. Increase by 0.1mg/day once per week if needle. Duration of therapy ranges from 3-10 week. B.P. and heart rate should be monitored especially for a patient with hypertension during treatment initiation. The dose should be tapered off gradually to avoid rebound hypertension.
92. A 35 years old lady, her doctor wants to prescribe a medication for his migraine which starts usually few days before her period. Best medication to prevent her migraine that suits her condition is; a) Atenolol b) flunan zin c) Topiramate d) Ibuprofen 400mg e) Naproxen sodium 275mg (Anaprox) (E) It is useful in preventing premenstrual migraine attacks when taken twice daily perimenstrually for two weeks, starting 7days before menses.
93. A 45 years old patient was admitted to the hospital experiencing severe and prolonged migraine headache. His doctor in the hospital prescribed for him dihydroergotamine to be taken parenterally as 0.25mg/dose i.v. to be repeated three times every 20 minutes. Best action from the clinical pharmacist in this situation is; a) Dispense the prescription as it is b) Call the doctor to switch him to Triptans since he is experiencing severe prolonged migraine c) Counsel the patient on flushing tingling of extremities, and N&V d) Call the doctor to prescribe DHE nasal spray so that to discharge the patient e) None of the above (E) The clinical pharmacist should call the doctor to prescribe metoclopramide 0.2mg/kg/dose (maximum 20mg) 30minutes prior to iv DHE to prevent the nausea and vomiting due to DHE counselling the patient on N&V is not enough in this situation since the patient requires prescription medication (metoclopramide) to prevent the N&V prior to i.v. administration of DHE. DHE nasal spray is not used for severe prolonged condition, but to moderate cases of migraine.
94. A 55 years old patient is experiencing Trigemeninal neuralgia. His doctor prescribed for him Baclofen and carhazepine without any meaningful effect. Now his doctor decided to add phenytoin and stop baclofen. Best action the community pharmacist in this situation should do is a) Dispense as the doctor prescribes b) Call the doctor to tell him that gabapentin is better than phenytoin to be added to the rgimen since there is no drug interetion c) Caution the patient on the sedative effect d) Call the doctor to continue baclofen to make the patient get better response. e) None of the above (E) The doctor should be called to D/C Baclofen gradually.
95. A 35 years old patient his doctor prescribed for him Tramadol CR 150mg daily (Zytram). Currently he is using paroxetine 20mg/daily. The pharmacist should caution the patient on; a) Respiratory depression b) Serotonin syndrome c) Decrease seizure threshold (All) Tramadol is ----- to respiratory depression and serotonin syndrome with SSRI, it may cause a decrease in seizure threshold when combined with SSRI.
96. A 65 years old patient is experiencing chronic spasticity. His doctor prescribed for him Nizatidine with no benefit. Now his doctor added Baclofen to the regimen. Best action should the pharmacist do is; a) Dispense the prescription as it is b) Call the doctor to switch the patient to gabapentin c) Call the doctor to switch the patient to Dantrolene. d) Call the doctor to increase the dose of Nizatidine without prescribing Baclofen for him e) None of the above (E) Calling the doctor telling him that Nizatidine is for stomach ulcer and not for chronic spasticity. Tizanidine is for chronic spasticity and this error may occur due to close nomenclature of the two medications. Switching the patient to gabapentin may be done it there is a treatment failure for Baclofen and Tizanidine. In this particular condition the doctor may initiate the treatment with the patient on a monotherapy like Tizanidine since the patient was not taking the right medication.
97. A 70 years old patient is experiencing nocturnal leg cramps. His doctor prescribed for him Quinine sulfate to be given as 300mg QHS for 6 months, with one refine. His cramps are frequent and severe. Best action the pharmacist should do is; a) Call the doctor to refer the patient to a specialist b) Dispense as it is c) Call the doctor to tell him that with draw therapy is every 3 months to assess therapy, and his recommendation is a leng treatment d) Call the doctor to consider only non-pharm e) Call the doctor to start with a single dose dopamine agonist 1-2 hours prior to bedtime and to titrate to effectiveness. (C) Quinine use should be assessed regularly as cramps can resolve spontaneously or after a short period of therapy. Cramps rarely need referral unless associated with other neurologic complaints or signs. The use of dopamine agonists is for restless leg syndrome which is different from muscle cramps which are sudden involuntary contractions of one or more muscle groups. Non-pharm should be tried along with Quinine sulfate, since the cramps were severe and frequent.
98. A 34 years old patient is experiencing grand mal epilepsy. His doctor initiated a monotherapy treatment with phenytoin (Dilantin) 400mg/day. The main concern of the pharmacist is; a) Long term cosmetic adverse effects b) Skin rash c) Increase in liver enzymes d) Dose related encephalopathy e) None of the above (E) When phenytoin is used the main concern of the pharmacist is thy loading dose, which should be administered carefully.
99. A 38 years old patient her doctor prescribed for her topiramate 100mg/day to be by 100mg every 3days till it reaches 400mg/day to continue then as a maintenance dose. The main concern of the pharmacist is; a) The medication is expensive b) Cognitive problems which are common c) Narrow spectrum of activity d) Fast titrating dose e) None of the above The dose should be titrated slowly. The medication is abroad spectrum, safe and few drug interactions. It is also a potent AED. Cognitive problems commonly limit its use but come in concern after the rapid titrating dose.
100. A 70 years old patient had a cataract surgery and his doctor prescribed for him Gentamicin drop post operatively for two weeks. Now the patient is seen in the patient selected area to look for a decongestant eye drop, and requests that from the pharmacist. Best recommendation the pharmacist should do; a) Give Naphazoline adult eye drop b) Give Polysporin eye drop c) Refer to doctor d) Tell the patient to D/C Gentamicin e) None of the above (D) This drop should be used for 7-10 days only. Extended use may cause conjunctivitis or epitheliopathy reactions to the eye.
101. A 75 years old patient was discharged after cataract surgery. His doctor wants to discharge him and to prescribe a Fluoroquinolone with higher activity against gram- positive organisms. Best recommendation the physician should do is; a) Prescribe ciprofloxacin drop 7-10days. b) Gatifloxacin drop 7- 10 days c) Ofloxacin drop (Ocuflox) 7-10 days d) Ciprofloxacin oral 500mg Pa 12 hours 7-10 days e) None of the above (B) 4 th generation fluoroquinolone has improved broad spectrum activity especially against gram positive organisms.
102.A 80 years old patient was discharged after cataract surgery, her doctor prescribed for her fluorometholone (FML) drop for 3-4 weeks. The main concern of the pharmacist here is; a) Long duration of use b) Short duration of use c) Call doctor to switch her to NSAID drop which are safer d) Antiinflammatory effects can mask signs of infection e) None of the above (D) Since the treatment is considered as a long duration, so in this particular case and since the patient is 80 years old which make him more prove to eye infection after operation. NSAIDs are used as a substitute for steroids to inflammation without the risk of elevating intraocular pressure. In this case the patient has no history of glaucoma, and the risk of elevation of intraocular pressure should be considered beyond that duration of time. 103. A 65 years old patient was discharged from the hospital after cataract surgery. His doctor prescribed for him Brimonidine 0.2% (Alphagan) two days ago. Now he came to the pharmacy with red eye itchiness, requesting an OTC eye drop to treat his itchiness and redness. Best recommendation the pharmacist should do is; a) Give Naphazoline eye drop as decongestant b) Call the doctor and suggest to him Brimonidine 0.15% (Alphagan P) c) Call the doctor to tell him to switch the patient to other PGs drops d) Ensure the patient that these signs and symptoms are temporary and they will go off as the patient continues using the drop e) None of the above
Ans: (B) Brimonidine 0.15% contains purite as preservative rather than Benzalkonium chloride which makes it to have slightly lower incidence of ocular allergy than Brimonidine 0.2%
104. For the above patient if the doctor was not satisfied about giving Brimonidine 0.15%, the pharmacist should suggest I. Dorzolamide 2% (Trusopt) II. Brinzolamide 1% (Azo patient) III. Dorzolamide 2% preservative free (Trusopt)
Ans: (III) Since it is advantageous for patients with allergies to Benzalkonium chloride
105. 65 year old patient experiencing glucoma. His doctor prescribed for him latanoprost us 0.005% (Xalatan) twice daily to continue on it for six months. After one month he came to the pharmacy requesting advice from the pharmacist for his eye condition that has not been progressed. The main concern of the pharmacist in this particular condition is: a) non-compliance of the patient towards his medication b) not storing the medication in the fridge c) Incorrect recommendation from the doctor about the direction of use of the drug d) Incorrect recommendation from the doctor about the direction of use of the drug e) Patient is not following the non-pharm.
Ans: (D) Once daily dosing should not be exceeded more frequent administration may reduce effectiveness
106. 16-year-old patient came the pharmacy with a new prescription for his glaucoma. His doctor prescribed for him pilocarpine 2% QID. The major concern of the pharmacist in this particular case is: a) High dose b) Better to be switched to isoptocarpine 2% gel since it is given one time only c) Pilocarpine is poorly tolerated in young adults d) It is better to start with cholinergic medication rather than cholinergic drops e) None of the above
Ans: (C) Pilocarpine is poorly tolerated in children and younger adults
107. 33-year-old patient was using naphazoline eye drop since a week ago as 1-2 drops Q 3-4H prn. Now she came requesting something from the pharmacist to help her reduce the redness of her eye. Best recommendation the pharmacist should take is: a) Recommend to see her doctor for a prescription medication b) Give her oxymetazoline (Claritin eye allergy relief) c) Tell the doctor her previous medication d) Tell her that these might be signs and symptoms of glaucoma and it is better to see a doctor e) None of the above
Ans: (C) Ophthalmic vasoconstrictors are used for occasional and short term use like 3-4 days even if they are used as prn. Overuse may cause rebound hyperemia
108. A 30-year-old patient was diagnosed as bacterial conjunctivitis, and this was confirmed by culture and sensitivity test as having pseudomonas infection. His doctor prescribed chloramphenicol (pentamycetin) eye drop for him as 1 drop q3h from 48 hours, then frequency may decrease. The major concern of the pharmacist is: a) High dose of chloramphenicol drop b) Chloramphenicol is not the first choice and it is better to initiate with fusidic acid drop c) It is better yo start with fluoroquinolone eye drops d) It is better to start with systemic antibiotics e) It is better to start with antibiotic eye ointments since they persist on the eye for longer period of time
Ans: (C) Fluoroquinolones should be reserved for serious infection such as pseudomonas
109. 55-year old patient presented to the pharmacy with a prescription of Trifluridine (Viroptic) to treat his eye from his herpes simplex. His doctor told him ti use it as 1 drop q2h while awake, maximum of 9 drops/day, until lesion is reepithelialized, then 1 drop q4h, maximum five drops for 30 days. Major concern of the pharmacist; a) Trifluridine drop is used for herpes-zoster rather than herpes simplex b) High dose is given c) Call the doctor about the duration of use d) It is better to give prednisolone 5mg/day as an adjunct to trifluridine to treat the viral infection e) None of the above
Ans: (C) chronic use of trifluridine may result in corneal epithelial toxicity
110. 223-year-old patient is experiencing ocular allergy due to contact lease wearing. His doctor can prescribe all these medication to be instilled four times daily EXCEPT: a) Sodium cromoglycate eye drop b) Emadastine (Emadine) eye drop c) Fodoxamide eye drop (Alomide) d) Nedocromil (Alocril) eye drop e) Olopatadine (Petanol)
Ans: (D) Nedocromil eye drop is given as 1-2 drops BID. All the rest as 3-4 times daily. Ketotifen fumarate (Zadilor) is given as 1 drop in 8-12 hours, however it was not mentioned as one of the above options. Antihistamines/mast cell stabilizers ophthalmic are mostly given for ocular allergies, contact lens wears or contact artificial eyes
111. The auxiliary labels with respect to Synthroid should be I. Take it in the morning II. Avoid other medications at least 4-6 hrs III. To be taken on empty stomach Ans: All
112. In the above example, if the patient was using nitroglycerine pump and metoprolol. The best initiating dose is: a) Start with 100mg/day b) Start with 50mg/day c) Start with 12.5-25mg/day d) Start with liothyronine 25mg BID e) None of the above
Ans: (C) starting dose is 12.5-25mg/day in those with the risk of angina
113. The onset of action of insulin glulisine is I. 10-15 minutes II. 15-30 minutes III. 5 minutes
Ans: (I) Insulin as part (NOVO rapid, insulin glulisine (Apidra), and Insulin lispro (Humalog) is 10-15minutes and it peaks in 60-90 minutes and duration is 4-5h
114. Patient 65-year old his doctor switched him from novolinged 40/60 to insulin glargine i.m. to be taken once daily i.m. to be taken once daily as 100ml/day. The main concern of the pharmacist a) The patient is taking high dose b) The patient is taking low dose c) The patient should take the medication as I.V. d) The patient should take the medication S.C. e) None of the above
Ans: do not inject lantus im or iv except sc
115. All of the following insulins should appear cloudy EXCEPT: a) Insulin glulisine b) Insulin NPH c) Insulin detemir d) ATC e) Humulin 20/80
Ans: (D)
116. A 58-year old patient is experiencing typw II D.M. his doctor prescribed him 240 mg once daily. The main concern of the pharmacist is: a) Gliclazide (Diamicron) causes prolonged hypoglycemia b) High dose is given c) Low dose is given d) Gliclazide has an antiplatelet effect which may result in bleeding e) None of the above
Gliclazide when is given in a daily dose 160mg should be given in divided doses
117. 73-year old patient is experiencing Diabetes type II, his blood glucose is undercontrol, but because he is an old patient his doctor wants to keep him on a maintenance dose that can avoid non-compliance problems. Best therapy for this patient if the doctor wants to prescribe sulfonylurea for him is/are: I. Gliclazide 200mg in two divided doses II. Glimpiride 4mg once daily III. Gliclazide, long acting as 120mg once daily.
Ans: (D) II and III, they are given once daily
118. 57-year old patient with type II D.M. since 20 years ago. Currently his blood glucose level is not under control. His doctor gave him metformin 1350mg (one tab 830 metformin +500 tab metformin). His glucose level is still not under control and his doctor wants to give him 2200 metformin as (2 tab of 850mg) and (1 tab of 500mg). The major concern of the pharmacist is: a) High dose of metformin b) Lactic acidosis of the medication c) Little additional benefit above 1500mg/day d) Weight gain e) None of the above Ans: (C) little additional benefit above 1500mg/day
119. 55-year old patient has been diagnosed as DM type II. His doctor prescribed him metformin 850mg BID without controlling the blood glucose level. Doctor wants to add acarbose as 50mg TID. Patient profile reveals that the patient has inflammatory bowel disease. Best thing the pharmacist should do: a) Call the doctor to reduce the dose of metformin b) Call the doctor to reduce the dose of Acarbose to twice daily with major meal c) Call the doctor t inform him that acarbose should not be recommended d) Dispense as it is e) None of the above
Ans: (c) Acarbose is contraindicated in irritable bowel syndrome or inflammatory bowel disease
120. 35-year old lady patient has a prescription from her doctor Orlistat (Xenical) as 120mg TID with each meal containing fat. Best action that the pharmacist should do in dealing with this prescription is: a) Dispense as it is b) Call the doctor since it is a high dose c) Warn the patient about the decreased absorption of vitamin A,D,E,K. d) Tell the patient to use non-pharm as an adjunct e) None of the above
Ans: (E) Advise patients to take a multivitamins daily 2 hours before or after orlistat or at bedtime. Warning is not sufficient. Non-pharm plus medication without advising for multivitamins is insufficient therapy
121. A 60-year old patient has zinc deficiency which resulted in impairment of his immune system. His diet is poor, and the doctor started a long term treatment of Zn 50mg/day. Main concern of the pharmacist to this therapy is a) It is a high dose if Zn b) It is a low dose of Zn c) It is a wrong medication to enhance the immunity d) Zinc is used for shortening the duration of common cold e) None of the above Ans: (E) long-term high dose of Zinc intake may block iron and copper absorption
122. The monitoring parameters for Ezetimibe is/are I. Liver function II. CK III. Back pain Ans: (C or I and II) Only liver function and CK. Back pain, arthralgia, fatigue and headache are adverse effects of the medication which may appear or not.
123. A 65-year old patient has high lipid profile and the doctor wants to initiate a treatment for high lipid by prescribing Rosuvastatin (Crestor) 10mg/day as an initial dose. The patient has some hemoglobinopathies and is using currently cyclosporin. Best action the pharmacist should do: a) Dispense the prescription as it is b) Call the doctor to reduce the dose of cyclosporin c) Call the doctor to half the dose of Rosuvastatin d) Call the doctor to switch him to atorvastatin e) None of the above
Ans: (C) Asian patients and those receiving cyclosporine, initial dose should be 5mg/day
124. 65-year-old male has a prescription of duoloxetine 30mg/day. His profile shows that he is currently on tramadol (150mg CR once daily). Best Action the pharmacist should do is: a) Dispense the prescription as it is b) Call the doctor to switch the patient to Bupropion c) Call the doctor to switch the patient to immediate release tramadol in order to space apart with tramadol d) Tell the patient to stop using tramadol due to drug-drug interaction between tramadol and duoloxetine e) None of the above Ans: (E) The patient should be warned to monitor serotonin syndrome and lowering in seizure threshold, and if these signs and symptoms happen tramadol, and if these signs and symptoms happen tramadol should be stopped immediately with contracting the physician. In addition to that the patient should be stopped immediately with contacting the physician. In addition to that the patient should be counseled on lowest dose of tramadol and on a short duration.
125. 78-year-old comes to the pharmacy requesting an advice from the pharmacist since he was experiencing insomnia, depression and vivid dreams. The pharmacist checked in his computer to see the profile of the patient, and the patient had no profile. After questioning the patient about the medications he uses, he said that he used some medications to decrease cholesterol and other for his blood pressure, and stable angina. The pharmacist should realized that the medication is using most probably: a) Atenolol b) Atorvastatin c) Propranolol d) Amlodipine e) Verapamil
Ans: (C) Propranolol is most likely to cause CNS side effects
126. The doctor of a 63-year-old patient prescribed him ASA coated 81mg nitroglycerin puff and nitroglycerin topical ointment TID. After a period of stable condition, he started to use the nitroglycerin pump more frequently. The major concern of the pharmacist is: a) Nitroglycerine ointment is expired b) Non-compliance of the patient c) The doctor should switch him to nitroglycerin isosorbide d) The Doctor should add a beta blocker to the regimen e) None of the above
cts.
Ans: (E) The major concern of the pharmacist is to ensure a 10-20h nitrate-free period daily to prevent tolerance. Non-compliance means the patient is either reducing the number of doses such as from three applications to two and such a condition, there is no problem it could be used BID- TID or forgetting to use it and in such a condition will end up in heart attack with no benefit of nitroglycerin pump in severe conditions Switching to other nitrates is just in case if the patient is experiencing certain side effects like local reactions of the ointment or allergic dermatitis due to the ointment, or due to certain side effects
127. A 63-year-old patient is using Indomethacin for her rheumatoid arthritis. She uses EE 30mg drospirenone 3mg (Yasmin) as an oral contraceptive, major action of the pharmacist is: a) Indomethacin may increase BP of the patient b) Call the doctor to switch her to OTC Advil c) Call the doctor to switch her to Alesse d) Call the doctor to give a potassium depleting diuretic e) None of the above
Ans: (E) The pharmacist should caution the patient about the hyperkalemia that may result from drospirenone in the oral contraceptive and NSAID, indomethacin which reduces the renal perfusion resulting in hyperkalemia (T.C. Pg 458)
128. A 70-year-old patient is on Digoxin 0.25mg/day. After playing sport, his wrist was broken, and his doctor prescribed him naproxen 500mg TID. The major concern of the pharmacist is: a) High dose of naproxen b) Naproxen may cause peptic ulcer c) Hyperkalemia d) Naproxen is ineffective and requires codeine preparations e) None of the above
Ans: (C) same as #127 (TC pg 458)
129. A 63-year old patient came to you with a new prescription for Quetiapine (Serquel) 25-50mg po 6h prn, milt 30 tablet of 25mg. After looking at her profile it was shown that 30 days ago it was filled by a specialist for two weeks as Seroquel 100mg to be taken two at bed time, followed by two another prescription by a family physician for 1 month which she still has for coming couple of weeks. Her recent prescription was from a specialist. Best action the pharmacist should take is: a) Call the specialist to inform him about double doctoring b) Call the family physician to inform him about double doctoring c) Educate the patient and caution him about the sedative effect of taking higher dose of Seroquel d) Call the police to arrest the patient due to double doctor e) None of the above
Ans: (E) The patient is simply taking an add/on dose from the specialist. His Seroquel 200mg may not be sufficient. The patient went to the family physician could be due to unavailability of the specialist and the family physician prescribed as the same strength as the specialist, so no double doctoring and it is clearly seen that the recent prescription is on need basis which reveals as add/on therapy.
130. A 67-year old taking Seroquel 100mg tab as two tabs at bedtime, and now he came with a new prescription containing Seroquel 200mg, two at bed time and Seroquel 25- 50mg q6h prn. To be dispensed as 25mg tablet Best action the pharmacist should under take is a) Call the doctor to fix the dose of prn as 25mg and 50mg b) Dispense as it is c) Call the doctor to dispense either one but not both of them d) Dispense both of them and warn the patient about the sedative effect e) None of the above
Ans: (B) Here again Seroquel is being given due to the end dose effect, where the level goes below the therapeutic valve which makes the patient excited and not stabilized, so the prn dose is not elevating the dose, however it is stabilizing the dose within the therapeutic level to prevent any end dose effect which may result in flare up of the sign and symptoms of the patient so counselling the patient to be aware of dizziness or drowsiness due to the prn dose is important to keep you at the required therapeutic level and to keep him with compliance with his medications.
131. A 44-year-old using Spiriva one daily. He comes to the pharmacy requesting scopolamine patches since he is going to travel abroad. Best action the pharmacist should do is: a) dispense scopolamine patches b) Give the patient dimenhydrinate instead of scopolamine patches c) Give patient gravol ginger d) Refer him to the doctor e) None of the above
Ans: (C) Any scopolamine or dimenhydrinate will increase dryness so best thing is ginger. Referring is incorrect
132. 57-year-old patient came with a prescription for magnesium glucoheptonate syrup to be taken as 1 tablespoon daily as a magnesium supplement for the patient who has hypoglycemia. Best thing the pharmacist should do is/are: I. Tell him to use it with food II. Tell him to drink plenty of water III. Tell him to avoid salty food
Ans: I and II only. It is important to tell the patient to take it with food to lessen diarrhea due to magnesium and also to drink plenty of water just to replenish the fluid loss in case of diarrhea.
133. A 55 years old patient came to your pharmacy requesting sugar strips and lancets. He has no prescription from the doctor but he told you that he is diabetic and he wants the strips and lancets since he has run out of them. He also wants an official receipts that is printed when dispensing prescription medications to submit it to his drug plan insurance company in order to reimburse him. Best action the pharmacist should do is: a) Refer him to the doctor t prescribe for him. The glucose strips and the lancets b) Tell him that we can give him a slip from the register us a receipt but not as a prescription receipt. c) The pharmacist should issue a prescription containing the strips and the lancets and sigh it and input in it the computer and process it as a prescription d) Tell the patient that the strips and lancets must be bought with the glucometer e) None of the above Ans: (C) Because the medication is an OTC, the pharmacist can issue an and process it under his signature and give official receipts as a prescription medication. Referring is not acceptable since you are not offering any help to the patient where you can do this for the patient.
134. A child 20 months old is experiencing watery diarrhea 5 times daily for the past two days. His mother says that he eats too. Best recommendation from pharmacist is: a) Stop eating and give him electrolytes b) Tell the mother to give him Kaopectate c) Tell the mother to give him ORS plus peptobismol d) Tell the mother to give him plenty of fluids e) None of the above Ans: (E) In this situation since the child has been experiencing diarrhea for the last two days, it is better to refer the patient to avoid dehydration, the mother may be advised to give her child ORS.
135. A 55 years old patient came to the pharmacy with a new prescription for his dry cough (co-Actifed syr). His profile shows that he is hypertensive ans using lisinopril tab 10mg BID. Best action from the pharmacist is: a) Dispense the Px as it is b) Call the doctor since co-Actifed was in pseudo ephedrine c) Dispense dextromethorphan syr (OTC) instead of co-Actifed d) Give him non-pharm only and tell him that you can not dispense the Px due to drug-drug-interaction e) None of the above Ans: (E) We just tell the patient to monitor his blood pressure by measuring it on daily basic, since the cough syr. has a substance which may increase her B.D.