2012 ACCP Clinical Pharmacy Challenge

Local Competition Exam Key

The following examination will consist of three (3) segments:
Trivia/Lightning
Participants will have the opportunity to answer up to 15 true-false or multiple-choice questions.
Each item answered correctly will be worth 75 points. The subject content for questions in this
segment will be selected from the following categories:

Pharmacology (including, but not limited to, mechanism of action, adverse effect
profiles, drug interactions, dosing, approved indications, and monitoring parameters)

Pharmacokinetics/Pharmacodynamics and/or Pharmacogenomics

Clinical Pharmacy History

Biostatistics

Health Outcomes

Clinical Case
Participants will be presented with a clinical case vignette (500 words or less) and a series of five
one-best-answer questions based on the information in the case text and/or supporting laboratory,
physical examination, and/or medical history information contained therein. Point values for each
question in this category will be assigned on the basis of difficulty (one 100-point item, two 200point items, and two 300-point items).
Jeopardy Style
Participants will have an opportunity to answer questions of varying point values (100, 200, or
300 points) in five predetermined categories and may answer as many as possible within the
allotted time. All items in this segment will be multiple choice. Items in the segment will be
selected from five (5) of the following categories:
Anticoagulation

Asthma/COPD

Biostatistics

Cardiovascular Disorders

Clinical Trial Design

Critical Care

Dermatology

Drug Information

Emergency Medicine

Endocrinology

Geriatrics

GI/Liver/Nutrition

Hematology/Oncology

Immunology/Transplantation

Infectious Diseases

Nephrology

Pain and Palliative Care

Pediatrics

Psychiatry/CNS Disorders

Vaccinations

Womens Health

CNS = central nervous system; COPD = chronic obstructive pulmonary disease; GI =

gastrointestinal.

Follow the instructions given by your local faculty member or proctor for
each segment of the examination.
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Do NOT open the examination booklet until instructed to do so.

2012 ACCP Clinical Pharmacy Challenge

Local Competition Examination

Team/Individual ID ______________________

Total Score ________

For Administrative Use Only

Trivia/Lightning Section
This section consists of 15 items. Each correct answer is worth 75 points. Please circle your
answer for each question.
Question 1
Which diuretic would cause increased excretion of sodium, potassium, magnesium, and calcium
and would promote the reabsorption of uric acid?
1. Bumetanide
2. Hydrochlorothiazide (HCTZ)
3. Spironolactone
4. Triamterene
Answer: 1. Bumetanide
Rationale: The correct answer is bumetanide. HCTZ decreases the excretion of calcium.
Spironolactone and triamterene are potassium sparing.
Citation: Drugs for hypertension. Treat Guidel Med Lett 2009;7:110.
Question 2
Which antimicrobial has nearly equivalent oral and parenteral bioavailability?
1.
2.
3.
4.

Ampicillin
Cefuroxime
Linezolid
Vancomycin

Answer: 3. Linezolid
Rationale: Linezolid has a documented oral bioavailability of nearly 100%.
Citation: Linezolid [prescribing information]. New York: Pharmacia and Upjohn, 2012.
Question 3
Which drug would require a dosing adjustment for a documented creatinine clearance of less than
30 mL/minute?
1. Ceftriaxone
2. Metronidazole
3. Pantoprazole

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4. Ranitidine
Answer: 4. Ranitidine
Rationale: Dosage adjustments are only necessary for ranitidine with a creatinine clearance of 35
mL/minute. The rest do not need adjustments.
Citation: Ranitidine [prescribing information]. Princeton, NJ: Sandoz, 2011.
Question 4
Which agent is the best treatment option for a patient taking warfarin with an international
normalized ratio of 11.0 and no signs of bleeding?
1.
2.
3.
4.

Cyanocobalamin
Phytonadione
Protamine
Tocopherol

Answer: 2. Phytonadione
Rationale: The correct answer is phytonadione (vitamin K). Warfarin acts as an anticoagulant
through inhibition of the vitamin Kdependent clotting factions II, VII, IX, and X. Administration
of phytonadione is indicated in warfarin overdose. Protamine is used to reverse heparin overdose.
Tocopherol is a form of vitamin E and has no role in reversing warfarin overdose.
Cyanocobalamin is vitamin B12 and is commonly used to treat pernicious anemia.
Citations: Holbrook A, Shulman S, Witt DM, et al. Evidence-based management of anticoagulant
therapy: antithrombotic: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines (9th Edition). Chest 2012;141:e152Se184S.
Phytonadione [prescribing information]. Lake Forest, IL: Hospira, 2004.
Question 5
Which drug class is considered the pharmacologic first-line treatment of choice for posttraumatic
stress disorder (PTSD)?
1.
2.
3.
4.

Anticonvulsants
Atypical antipsychotics
Benzodiazepines
Selective serotonin reuptake Inhibitors (SSRIs)

Answer: 4. SSRIs
Rationale: SSRIs are recognized by several resources as the first-line treatments (together with
psychotherapy).
Citation: Jeffreys M. Clinicians Guide to Medications for PTSD; Department of Veterans Affairs.
Available at http://www.ptsd.va.gov/professional/pages/clinicians-guide-to-medications-forptsd.asp. Accessed February 24, 2012.

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Question 6
A 5-year-old boy is given a diagnosis of mild croup. Which medication would be most
appropriate to recommend?
1.
2.
3.
4.

Oral dexamethasone
Nebulized albuterol
Nebulized racemic epinephrine
Nebulized 3% saline

Answer: 1. Oral dexamethasone

Rationale: The correct answer is 1, oral dexamethasone (it is used to decrease pharyngeal
inflammation). Racemic epinephrine is first line but, in severe episodes, not mild. Albuterol is
beta-specific and will not help with edema in the upper airway. This is also true for 3% saline,
which is used in bronchiolitis.
Citation: Bjornson C, Johnson DW. Croup. Lancet 2008;371:32939.
Question 7
An elderly nursing home resident develops diarrhea that is caused by Clostridium difficile. Which
agent is contraindicated?
1.
2.
3.
4.

Cholestyramine
Diphenoxylate/atropine
Kaolin-pectin
Psyllium

Answer: 2. Diphenoxylate/atropine
Rationale: The correct answer is diphenoxylate/atropine. With toxin-mediated diarrhea, use of
agents to slow motility would be contraindicated. In addition, this agent should be avoided in
elderly patients, if possible, because of the increased risk of anticholinergic adverse effects in this
population. Kaolin-pectin, cholestyramine, and psyllium are all acceptable options for symptom
control for this type of diarrhea.
Citation: Oral Lomotil, Drug-Disease Contraindications. Available at
http://www.medscape.com/druginfo/dosage?
drugid=6876&drugname=Lomotil+Oral&monotype=default. Accessed March 28, 2012.
Question 8
A new osteoporosis drug is being tested to prevent fractures. If 25 of 100 patients in the control
group experience a fracture compared with 5 of 100 patients in the treatment group, what is the
number needed to treat (NNT)for the new drug?
1.
2.
3.
4.

0.2
0.8
5
20

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Answer: 3. 5 patients
Rationale: The correct answer is 5. The NNT is calculated as 1/absolute risk reduction (ARR). In
this case, the ARR is 0.2 (difference in event rates between drug and placebo = 0.25 0.05). The
relative risk (RR) is 0.2 (event rate drug/event rate placebo = 0.05/0.25), and the OR (odds ratio)
is 0.2 (odds of event on drug/odds of event on placebo = [5/25]/[95/75]).
Citation: Riegelman RK, Hirsch RP. Studying a Study and Testing a Test: How to Read the Health
Science Literature, 3rd ed. Philadelphia: Lippincott-Raven, 1996:33, 35, 52.
Question 9
Which sedative is most likely to cause transient adrenal insufficiency when used for rapid
sequence intubation?
1.
2.
3.
4.

Etomidate
Ketamine
Midazolam
Propofol

Answer: 1. Etomidate
Rationale: The correct answer is etomidate. The other agents have no known effect on adrenal
function or cortisol production.
Citation: Etomidate [prescribing information]. Bedford, OH: Bedford Laboratories, 2004.
Question 10
A 70-year-old man with stage IV renal cell carcinoma is beginning sorafenib therapy. In
consultation with the patient, which adverse effect should you discuss the potential development
of?
1.
2.
3.
4.

Hypertension
Neutropenia
Peripheral neuropathy
Renal failure

Answer: 1. Hypertension
Rationale: Hypertension may develop within the first few weeks of therapy or slowly over the
continuance of therapy. The exact etiology of hypertension is unclear, but it may be the result of
pressor stimulation responses, increasing extracellular volume, and/or decreasing vascular
compliance. Although trials continue to investigate the etiology of hypertension, effective
management is critical to minimizing the long-term sequelae of treatment-induced hypertension.
Citation: Shenhong W, Chen JJ, Kudelka A, et al. Incidence and risk of hypertension with
sorafenib in patients with cancer: a systematic review and meta-analysis. Lancet Oncol
2008;9:11723.
Question 11

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Which condition may result in a decrease in total phenytoin concentration in patients who
routinely take phenytoin?
1.
2.
3.
4.

Addition of isoniazid therapy

Chronic alcohol abuse
Stage II chronic kidney disease (CKD)
Metabolic alkalosis secondary to diuretic therapy

Answer: 2. Chronic alcohol abuse

Rationale: Choice 2 is correct because a decrease in liver function from chronic alcohol abuse
will result in a decrease in albumin production, thus decreasing the total phenytoin protein bound
concentration, resulting in an increase in phenytoin-free fraction.
Choice 1 is incorrect because the addition of isoniazid will decrease the metabolism of phenytoin,
potentially increasing the total phenytoin concentration. Choices 3 and 4 are incorrect because
neither affects phenytoin binding to albumin.
Citation: Johannessen SI, Johannessen Landmark C. Antiepileptic Drug Interactions Principles
and Clinical Implications. Curr Neuropharmacol 2010;8:25467.
Question 12
A propofol infusion provides the following amount of nutrition per volume:
1.
2.
3.
4.

10 kcal/mL
9 kcal/mL
4 kcal/mL
1.1 kcal/mL

Answer: 4. 1.1 kcal/mL

Rationale: An intravenous anaesthetic agent, propofol, provides 1.1 kcal of nutrition per milliliter
to the patient, which is identical to a 10% intravenous lipid emulsion.
Citation: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based
Approach-The Adult Patient, 2nd ed. Silver Spring, MD: A.S.P.E.N., 2007:634.

Question 13
Which regimen is the MOST appropriate first-line therapy for the management of postherpetic
neuralgia?
1.
2.
3.
4.

Venlafaxine 25 mg orally 3 times/day

Nortriptyline 25 mg orally at bedtime
Diclofenac 1.3% topical patch applied twice daily
Lidocaine 5% topical patch applied for 12 hours/day

Answer: 4. Lidocaine 5% topical patch applied for 12 hours/day

Rationale: The correct answer is lidocaine 5% patch applied for 12 hours/day. Lidocaine 5%
patches are U.S. Food and Drug Administration (FDA) approved for postherpetic neuralgia, and

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they provide analgesia within hours after application. Venlafaxine and nortriptyline must be
administered for at least 12 weeks before a therapeutic response is seen and therefore may not
be considered first-line therapy. Diclofenac and other nonsteroidal anti-inflammatory drugs
(NSAIDs) are not typically effective for the management of neuropathic pain.
Citation: Dworkin RH, OConnor AB. Pharmacologic management of neuropathic pain:
evidence-based recommendations. Pain 2007;132:23751.
Question 14
Which cytochrome P450 (CYP) isoenzyme is MOST likely responsible for the drug-drug
interaction between clopidogrel and proton pump inhibitors?
1.
2.
3.
4.

CYP1A2
CYP2C9
CYP2C19
CYP3A4

Answer: 3. CYP2C19
Rationale: Competitive inhibition of CYP2C19 by proton pump inhibitors decreases the
availability of the active metabolite of clopidogrel and thereby decreases its effect on platelet
function.
Citation: Riche DM, Call RJ. PPIs and Plavix: so, what to do now? Pharmacotherapy
2010;30:477e478e. Available at
http://www.pharmacotherapy.org/avp/Pharm3012_Riche_AVP.pdf. Accessed February 13, 2012.
Question 15
This agent allows lower maintenance doses or complete discontinuation of calcineurin inhibitors.
1.
2.
3.
4.

Alemtuzumab
Azathioprine
Sirolimus
Tacrolimus

Answer: 3. Sirolimus
Rationale: The correct answer is sirolimus. Sirolimus is a mammalian target of rapamycin
inhibitor that is used in conjunction with or to replace calcineurin inhibitors in calcineurin
inhibitorsparing protocols. Tacrolimus is a calcineurin inhibitor. Alemtuzumab is a humanized
monoclonal antibody that has been approved for use in chronic lymphocytic leukemia and that
has been used off-label for kidney transplant induction therapy. Azathioprine is a purine
antimetabolite that is used in conjunction with calcineurin inhibitors.
Citation: Krensky AM, Vincenti F, Bennett WM. Immunosuppressants, tolerogens, and
immunostimulants. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilmans The
Pharmacological Basis of Therapeutics. New York: McGraw-Hill, 2006:chap 52.

Team/Individual ID

_____________________________

For Administrative Use Only

Trivia Segment Score ________

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You have reached the end of the

Trivia/Lightning Segment of the exam.
Do NOT proceed to the next segment of
the exam until instructed to do so.

Clinical Case Segment

Page 8 of 22

This segment consists of a case vignette and five items based on the vignette information.
Case Vignette:
A 66-year-old man presents to clinic for his routine visit. He has had increasing fatigue during the
past month that interferes with his daily activities. He has knee pain when he plays golf, for
which he self-medicates with over-the-counter naproxen. He is adherent to all of his prescribed
therapy, including dietary restrictions.
Medical History:
Hypertension
Diabetes mellitus
Chronic kidney disease (CKD) secondary to hypertension
Gout
Gastroesophageal reflux disease (GERD)
Benign prostatic hyperplasia (BPH)
Osteoarthritis
Current Medications:
Glipizide 10 mg/day x 6 years
Insulin glargine 15 units at bedtime x 3 months
Enalapril 40 mg/day x 6 years
Allopurinol 100 mg/day x 6 years
Doxazosin 4 mg at bedtime x 2 years
Ranitidine 75 mg/day x 5 years
Calcium carbonate 500 mg 3 times/day with meals x 6 months
Naproxen 250 mg twice daily x 2 weeks
Recent Laboratory Values:
Sodium 136 mEq/L (136 mmol/L)
Potassium 4.7 mEq/L (4.7 mmol/L)
Chloride 101 mEq/L (101 mmol/L)
HCO3 23 mEq/L (23 mmol/L)
Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L)
Serum creatinine (SCr) 3.2 mg/dL (282 micromoles/L)
Estimated glomerular filtration rate (Modification of Diet in Renal Disease [MDRD]) 20
mL/minute/1.73m2
Glucose, random 156 mg/dL (8.7 mmol/L)
Hemoglobin A1c 7.8%
Phosphate 6.0 mg/dL (1.9 mmol/L)
Calcium 10.5 mg/dL (2.63 mmol/L)
Albumin 2.8 g/dL (28 g/L)
White blood cell count 4500/microliter (4.5 x 109/L)
Hemoglobin 9.9 g/dL (99 g/L)
Hematocrit 29.6% (0.296)
Platelet count 175,000/microliter (175 x 109/L)
Ferritin 120 ng/mL (270 pmol/L)
Transferrin saturation 23%
Proceed to the following page to answer Clinical Case Questions 15.
Question 1 100 points

Page 9 of 22

The patient has which complication of CKD?

1.
2.
3.
4.

Anemia
Hyperkalemia
Metabolic acidosis
Uremic platelet dysfunction

Answer: 1. Anemia
Rationale: According to the Kidney Disease Quality Outcomes Initiative (KDOQI) guidelines,
anemia is defined as a hemoglobin value of less than 13.5 g/dL in males. Potassium and serum
bicarbonate values are all within the normal range for their assays. Uremic platelet dysfunction
cannot be determined by the patients laboratory results.
Citation: KDOQI Anemia Guidelines 2007. Available at
http://www.kidney.org/professionals/KDOQI/guidelines_anemia/guide2.htm#cpr11. Accessed
March 28, 2012.
Question 2 200 points
This patient is best described as having which stage of CKD?
1.
2.
3.
4.

Stage 1
Stage 2
Stage 3
Stage 4

Answer: 4. Stage 4
Rationale: The patients estimated glomerular filtration rate (eGFR) is 20 mL/minute, which
categorizes him as having stage 4 CKD (GFR 1529 mL/minute).
Citation: KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation,
Classification, and Stratification. Part 4. Definition and Classification of Stages of Chronic
Kidney Disease. Available at
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g2.htm. Accessed February
13, 2012.
Question 3 200 points
A fasting lipid panel is to be obtained. What is this patients low-density lipoprotein (cholesterol)
(LDL) goal?
1.
2.
3.
4.

Less than 100 mg/dL (2.59 mmol/L)

Less than 130 mg/dL (3.36 mmol/L)
Less than 160 mg/dL (4.13 mmol/L)
Less than 190 mg/dL (4.91 mmol/L)

Answer: 1. Less than 100 mg/dL (2.59 mmol/L)

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Rationale: CKD is considered a coronary artery disease risk equivalent. In addition, this patient
has type 2 diabetes mellitus, which is considered a coronary heart disease (CHD) risk equivalent.
For this reason, the LDL goal for this patient should be that of the highest risk group. Based on
the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)
guidelines, the LDL goal for the highest risk group is less than 100, with an alternate goal of less
than 70.
Citations: American Heart Association Councils on Kidney in Cardiovascular Disease, High
Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Kidney disease
as a risk factor for development of cardiovascular disease. Circulation 2003;108:215469.
The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. ATP 3 Final Report. Available at
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. Accessed March 28, 2012.
NCEP Report: Implications of Recent Clinical Trials for the National Cholesterol Education
Program Adult Treatment Panel III Guidelines. Circulation 2004;110:22739. Available at
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.pdf. Accessed March 28, 2012.
Reference for conversion for LDL to SI units: Katz A, Ferraro M, Sluss PM. Laboratory reference
values. N Engl J Med 2004;351:154863.
Question 4 300 points
Which is the most appropriate adjustment to make in his phosphate binder therapy?
1. Discontinue calcium carbonate.
2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
3. Continue calcium carbonate at the current dose and add aluminum hydroxide 600 mg 3
times/day.
4. Continue calcium carbonate at the current dose and add sevelamer carbonate 800 mg 3
times/day.
Answer: 2. Discontinue calcium carbonate and initiate sevelamer carbonate 1600 mg 3 times/day.
Rationale: Because the patient has a serum phosphate value that is above the normal range, he
requires phosphate binder therapy. He has an elevated calcium level, as evidenced by his
laboratory values (10.5 mg/dL), which, if corrected for a low serum albumin using the correction
equation (Ca, adj = SCa + 0.8 (4-albumin), would be estimated as 11.46 mg/dL. Hypercalcemia
can cause acute kidney injury through vasoconstriction of the afferent arterioles in the kidney.
Calcium-based binders are not recommended in hypercalcemia, so discontinuing the calciumbased binder is warranted in this patient. Aluminum should be avoided as long-term phosphate
binder therapy. Sevelamer is the best option in this patient.
Citations: KDIGO CKD-MBD Guidelines, 2009. Available at
http://www.kdigo.org/guidelines/mbd/guide4.html#chap41. Accessed March 28, 2012.
Abeulo JG. Normotensive ischemic acute renal failure. N Engl J Med 2007;357:797805.
KDIGO CKD-MBD Guidelines, 2009. Available at
http://www.kdigo.org/guidelines/mbd/guide4.html#chap41. Accessed March 28, 2012.

Page 11 of 22

Question 5 300 points

By what mechanism could the patients choice of naproxen be adversely affecting his renal
function?
1.
2.
3.
4.

Direct toxic effect on the renal tubules

Constriction of the afferent arteriole
Dilation of the efferent arteriole
Decreased tubular reabsorption of sodium

Answer: 2. Constriction of the afferent arteriole

Rationale: NSAIDs such as naproxen can cause many different types of injury to the kidney. The
most likely short-term problem with taking an NSAID for this patient is functional acute kidney
injury, resulting from a decreased production of vasodilatory prostaglandins, which act on the
afferent arterioles of the kidney. In patients who rely on afferent arteriole vasodilation to maintain
their GFR, this causes a drop in GFR. Choice 1 is incorrect because there is no direct toxic effect
on the renal tubules. Choice 4 is incorrect because the inhibition of PGE2 syntheses can lead to
increased sodium reabsorption, causing peripheral edema, which is the most common renal effect
of NSAIDs. Edema and sodium retention are usually mild, resulting in weight gain of 12 kg.
Citation: Abeulo JG. Normotensive ischemic acute renal failure. N Engl J Med 2007;357:797
805.

You have reached the end of the

Clinical Case Segment.
Do NOT proceed to the next segment of
the exam until instructed to do so.

Team/Individual ID

_____________________________

Case Segment Score ________

For Administrative Use Only

Jeopardy Segment
This segment will consist of 15 items in five predetermined categories. Point values for each item
are indicated below. Please circle your answer for each item.

Page 12 of 22

Cardiovascular Disorders
Item 1 (100 points)
The U.S. Preventive Services Task Force (USPSTF) recommends aspirin for the primary
prevention of cardiovascular disease in a 62-year-old man when his 10-year CHD risk is equal to
or greater than what level:
1.
2.
3.
4.

3%
5%
7%
9%

Answer: 4. 9%
Rationale: The USPSTF created a recommendation statement on the use of Aspirin for the
Prevention of Cardiovascular Disease. In this statement, the USPSTF balances the risk of CHD
with the risk of bleeding in patients using aspirin for the primary prevention of CHD. The cut
point for benefit in the male age group of 6069 is having a 10-year CHD risk of 9% or more.
Citation: U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular
disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med
2009;150:396404.
Item 2 (200 points)
Which medication is considered the first-line agent for the treatment of leg pain secondary to
intermittent claudication?
1.
2.
3.
4.

Aspirin
Cilostazol
Clopidogrel
Pentoxifylline

Answer: 2. Cilostazol
Rationale: The treatment of choice for patients experiencing leg pain caused by intermittent
claudication is cilostazol. Pentoxifylline has been shown to be comparable to placebo; therefore,
the American College of Cardiology/American Heart Association (ACC/AHA) guidelines have
designated it a second-tier therapy. Although aspirin and clopidogrel are used for peripheral
arterial disease to reduce cardiovascular mortality, these agents have not shown a reduction in
ischemic leg pain.
Citation: Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA guidelines for the management of
patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal
aortic): executive summary: a collaborative report from the American Association for Vascular
Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions,
Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the
ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the
Management of Patients With Peripheral Arterial Disease). 2011 ACCF/AHA Focused Update of

Page 13 of 22

the Guideline for the Management of Patients with Peripheral Artery Disease (Updating the 2005
Guideline). J Am Coll Cardiol 2011;58:202045.
Item 3 (300 points)
A hemodynamically stable patient with systolic heart failure is initiated on amiodarone for an
irregularly irregular rhythm. The patient currently receives lisinopril 20 mg orally once daily,
metoprolol succinate 25 mg orally once daily, furosemide 40 mg orally once daily, and digoxin
0.25 mg orally once daily. Physical examination reveals no lower extremity edema or pulmonary
crackles. What medication adjustment should occur immediately?
1.
2.
3.
4.

Change furosemide 40 mg orally to 20 mg intravenously daily.

Increase lisinopril to 40 mg orally once daily.
Decrease digoxin to 0.125 mg orally once daily.
Switch metoprolol succinate 25 mg once daily to metoprolol tartrate 12.5 mg orally twice
daily.

Answer: 3. Decrease digoxin to 0.125 mg orally once daily.

Rationale: Amiodarone reduces the clearance of digoxin by inhibiting P-glycoprotein. This drug
interaction is predictable and clinically significant, requiring a proactive 50% reduction in
digoxin. An increase in furosemide is not necessary in a patient without edema or crackles. This
patient is currently receiving the target dose of lisinopril, and an increase beyond the target dose
is not needed. An equipotent dose change from metoprolol succinate to tartrate is unnecessary in
a hemodynamically stable patient with systolic heart failure.
Citation: Nademanee K, Kannan R, Hendrickson J, Ookhtens M, Kay I, Singh BN. Amiodaronedigoxin interaction: clinical significance, time course of development, potential pharmacokinetic
mechanisms and therapeutic implications. J Am Coll Cardiol 1984;4:1116.

Endocrinology
Item 1 (100 points)

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A 68-year-old woman with hypertension, chronic heart failure, and stage 3 CKD has just received
a diagnosis of type 2 diabetes mellitus. Laboratory values include hemoglobin A1c 8.8%, serum
creatinine (SCr) 1.6 mg/dL, potassium 4.0 mEq/L, aspartate aminotransferase 18 IU/L, and
alanine aminotransferase 20 IU/L. Which of the following is the most appropriate initial therapy?
1. Glipizide
2. Metformin
3. Pioglitazone
4. Sitagliptin
Answer: 1. Glipizide
Rationale: Glipizide is the only tier 1 American Diabetes Association (ADA)/European
Association for the Study of Diabetes (EASD) therapy listed, and it is not contraindicated in this
patient. The agent will likely provide the hemoglobin A1c reduction needed. Although metformin
is also a tier 1 therapy, it is contraindicated because of the patients elevated SCr. Sitagliptin is not
recommended as a first-line therapy because of the lack of compelling efficacy data. Pioglitazone
is not a tier 1 therapy, and it has a relative contraindication in patients with heart failure.
Citation: Nathan D, et al. ADA EASD Consensus Statement. Diabetes Care 2009;32:193203.
Item 2 (200 points)
A 65-year-old woman with hypothyroidism treated with levothyroxine 0.75 mg/day has been
euthyroid for the past 4 years. Since her last clinic visit 6 months ago, she has been given
diagnoses of hyperlipidemia, osteoporosis, and nonvalvular atrial fibrillation, and she has been
initiated on the following medications:
Alendronate 70 mg once weekly
Calcium carbonate 1200 mg/vitamin D 800 IU supplement daily
Simvastatin 20 mg/day
Warfarin 2.5 mg/day
Her thyroid-stimulating hormone (TSH) level today is 6.9 mIU/L. Which medication most likely
contributed to the loss of a euthyroid state?
1.
2.
3.
4.

Alendronate
Calcium carbonate/vitamin D supplement
Simvastatin
Warfarin

Answer: 2. Calcium carbonate/vitamin D supplement

Rationale: Calcium carbonate decreases the absorption of levothyroxine, thereby decreasing
T3/T4 levels, which results in an increased TSH. There is no interaction between levothyroxine
and alendronate or simvastatin. Warfarin does not affect levothyroxine levels; however, a change
in thyroid status can affect the metabolism of vitamin Kdependent clotting factors and
precipitate a need for altered warfarin dosing.
Citation: Synthroid (Levothyroxine) [prescribing information]. North Chicago, IL: Abbott
Laboratories, 2011.

Page 15 of 22

Item 3 (300 points)

A 72-year-old woman presents with lower back pain. She has a history of vertebral-crush
fractures caused by osteoporosis (T-score of 3.0 at spine). She has severe gastroesophageal
reflux disease (GERD). Which is the most appropriate initial treatment?
1. Alendronate
2. Calcitonin
3. Teriparatide
4. Zoledronic acid
Answer: 4. Zoledronic acid
Rationale: The correct answer is zoledronic acid for this patient because of the type of fracture
and the presence of GERD. Bisphosphonates such as an alendronate would be the initial choice;
however, because this patient has severe GERD, only an intravenous bisphosphonate would be an
option. Teriparatide would be a second-line choice or first line if the T-score were 3.5.
Calcitonin is a fourth-line choice in this patient. Although pain relief is believed to be a benefit
with calcitonin, current practice is to manage pain and fracture risk separately.
Citation: Gaudio A, Morabito N. Pharmacological management of severe postmenopausal
osteoporosis. Drugs Aging 2005;22:40517.

Emergency Medicine
Item 1 (100 points)

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In which clinical situation would a shock be recommended during resuscitation efforts when there
is no pulse?
1. Asystole
2. Atrial fibrillation
3. First-degree heart block
4. Ventricular fibrillation
Answer: 4. Ventricular fibrillation
Rationale: The Advanced Cardiac Life Support (ACLS) Cardiac Arrest algorithm within the
cardiopulmonary resuscitation and emergency cardiovascular care guidelines by the AHA has two
major branches: rhythms that are amenable to shock and those that are not. Ventricular fibrillation
and ventricular tachycardia can be shocked; it is recommended that asystole and pulseless
electrical activity not be shocked. Both atrial fibrillation and first-degree heart block would be
considered pulseless electrical activity in the above question because the victim has no pulse.
Citation: Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life
support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010;122:S729S767.
Question 2 (200 points)
A patient presents to the emergency department with sedation, miosis, and decreased bowel
sounds. Respiratory rate is 6 breaths/minute; temperature is 98.2F (37.2C). Which medication
would likely cause this collection of symptoms?
1. Benztropine
2. Oxycodone
3. Fluoxetine
4. Methylphenidate
Answer: 2. Oxycodone
Rationale: Toxidromes are a collection of signs and symptoms. All of the above are consistent
with an opioid toxidrome. Anticholinergics (benztropine) would produce mydriasis, not miosis;
fluoxetine is relatively safe, but it can cause serotonin syndrome, which would result in increased
reflexes and temperature. Methylphenidate would cause agitation, mydriasis, and hyperthermia.
Holstege CP, Dobmeier SG, Bechtel LK. Critical care toxicology. Emerg Med Clin North Am
2008;25:71539.

Question 3 (300 points)

Assuming a potentially toxic ingestion for each of the substances listed, in which situation would
activated charcoal be expected to have the greatest benefit to decrease the chances of toxicity?

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1.
2.
3.
4.

Lithium ingestion 45 minutes ago

Kerosene ingestion 5 minutes ago
Acetaminophen 90 minutes ago
Digoxin 52 minutes ago

Answer: 4. Digoxin 52 minutes ago

Rationale: Activated charcoal is most beneficial when used within 60 minutes of the ingestion.
There are situations within this window when activated charcoal is not indicated, including drugs
that do not bind well to activated charcoal (lithium) or when there is a risk of aspiration
(kerosene, a hydrocarbon).
Citation: American Academy of Clinical Toxicology and European Association of Poison Centers
and Clinical Toxicologists. Position paper: single-dose activated charcoal. Clin Toxicol
2005;43:6187.

Psychiatry/CNS Disorders

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Item 1 (100 points)

A patient presents to the emergency department experiencing drug withdrawal. Which drug poses
the greatest risk of death because of withdrawal?
1.
2.
3.
4.

Cocaine
Amphetamines
Morphine
Ethanol

Answer: 4. Ethanol
Rationale: Central nervous system stimulants do not result in medically serious signs. Although
morphine produces significant withdrawal signs and symptoms, rarely does withdrawal result in
death. With ethanol, death may result from exhaustion or unknown causes if patients enter
delirium tremens (5% of withdrawal population).
Citations: Doering PL. Chapter 74. Substance-Related Disorders: Overview and Depressants,
Stimulants, and Hallucinogens. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee
GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill;
2011. http://0-www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?
aID=7987346. Accessed March 29, 2012.
Doering PL, Li RM. Chapter 75. Substance-Related Disorders: Alcohol, Nicotine, and Caffeine.
In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A
Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://0www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?aID=7987625. Accessed
March 29, 2012
Item 2 (200 points)
A 25-year-old woman is experiencing her first major depressive episode. She was initiated on
sertraline a few months ago and titrated up to 100 mg/day to achieve better control of symptoms.
What is the optimal duration of antidepressant therapy in this patient?
1.
2.
3.
4.

3 months after the acute phase of her illness subsides

6 months after the acute phase of her illness subsides
1 year after the acute phase of her illness subsides
1 year from the onset of the depressive episode

Answer: 2. 6 months after the acute phase of her illness subsides

Rationale: When treating the first depressive episode, antidepressants must be given for an
additional 49 months after the acute episode has resolved.
Citations: Jackson CW, Cates ME, Feldman JM. Major depressive disorder. In: Chisholm MA,
Schwinghammer TL, Wells BG, eds. Pharmacotherapy Principles and Practice, 2nd ed. New
York: McGraw-Hill, 2010:664.
American Psychiatric Association Practice Guidelines. Treatment of Patients with Major
Depressive Disorder, 3rd ed. 2010. Available at

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http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_7.aspx. Accessed March 28,

2012.
Item 3 (300 points)
A 66-year-old man with a long-standing history of Parkinson disease (diagnosed 12 years ago)
presents to the clinic for assessment. His current medications include carbidopa/levodopa 25100
mg every 4 hours, pramipexole 1.5 mg 3 times/day, entacapone 200 mg every 4 hours, and
benztropine 2 mg/day.
He experiences uncontrollable involuntary movements of his legs and arms that usually occur
around the time for his next medication dose. Which drug on his current profile is most likely
causing this symptom?
1.
2.
3.
4.

Benztropine
Entacapone
Levodopa
Pramipexole

Answer: 3. Levodopa
Rationale: The correct answer is levodopa. A substantial number of patients develop levodopainduced complications within several years of starting this drug. These include motor fluctuations
(the wearing-off phenomenon), involuntary movements known as dyskinesia, abnormal postures
of the extremities and trunk known as dystonia, and a variety of complex fluctuations in motor
function. This phenomenon may be explained by the observation that dopamine nerve terminals
are able to store and release dopamine early in the course of disease, but when disease is more
advanced and there is increasing degeneration of dopamine terminals, the concentration of
dopamine in the basal ganglia is much more dependent on plasma levodopa levels. Ways to treat
this include decreasing the levodopa dose, using a dopamine agonist, replacing sustained-release
levodopa with regular levodopa in dyskinesias occurring in the late afternoon, or using levodopa
dosing more frequently.
Citation: Chen JJ, Nelson MV, Swope DM. Parkinsons disease. In: DiPiro JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach, 7e:
http://0-www.accesspharmacy.com.millennium.midwestern.edu/content.aspx?aID=3204031.
Accessed March 28, 2012.

Infectious Diseases
Item 1 (100 points)

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What is the most appropriate empiric treatment regimen for a patient with community-acquired
pneumonia who needs admission to the general medical ward of a hospital?
1.
2.
3.
4.

Doxycycline and azithromycin

Ceftriaxone and azithromycin
Moxifloxacin and ceftriaxone
Vancomycin and ceftriaxone

Answer: 2. Ceftriaxone and azithromycin

Rationale: The correct answer is ceftriaxone and azithromycin. The doxycycline and
azithromycin combination does not have adequate coverage for S. pneumoniae. Moxifloxacin
could be used alone and does not need to be added to ceftriaxone in this patient. Vancomycin
would only be used in health careassociated infections with risk of methicillin-resistant
Staphylococcus aureus.
Citation: Mandell LA, Wunderlink RG, Anzueto A, et al. Infectious Diseases Society of
America/American Thoracic Society consensus guidelines on the management of communityacquired pneumonia in adults. Clin Infect Dis 2007;44:S27S72.

Item 2 (200 points)

A 44-year-old man is initiated on fluconazole for fungemia. His blood cultures are currently
growing Candida spp. If identified by culture, which of species of Candida would warrant a
change in antifungal therapy?
1. Candida parapsilosis
2. Candida tropicalis
3. Candida glabrata
4. Candida albicans
Answer: 3. Candida glabrata
Rationale: Fluconazole covers all Candida spp. except Candida glabrata and Candida krusei.
Citations: Pappas PG, et al. Clinical practice guidelines for the management of candidiasis: 2009
update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48:50335.
Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy. Sperryville, VA: Antimicrobial
Therapy, 2007:109.

Item 3 (300 points)

A 30-year-old man with a history of poorly controlled schizophrenia secondary to poor adherence
to his antipsychotic medications has newly diagnosed human immunodeficiency virus (HIV) and
hepatitis B virus (HBV) coinfection.

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His initial laboratory values are:

HIV viral load 625,000 copies/mL
CD4 count 75 cells/microliter (SI 0.075 x 109/L)
HBV viral load 500 copies/mL
SCr and liver enzymes are within normal limits.
The HIV genotype reveals no significant mutations.
Which regimen would be the best recommendation for initial therapy in this patient?
1. Efavirenz/tenofovir/emtricitabine 1 tablet by mouth once daily
2. Tenofovir/emtricitabine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once
daily, and atazanavir 300 mg by mouth once daily
3. Abacavir/lamivudine 1 tablet by mouth once daily, ritonavir 100 mg by mouth once daily,
and atazanavir 300 mg by mouth once daily
4. Tenofovir/emtricitabine 1 tablet by mouth once daily and lopinavir/ritonavir 400-mg/100mg tablet 2 tablets by mouth twice daily
Answer: 2. Tenofovir/emtricitabine (Truvada) 1 tablet by mouth once daily, ritonavir (Norvir) 100
mg by mouth once daily, and atazanavir (Reyataz) 300 mg by mouth once daily
Rationale: According to U.S. Department of Health and Human Services (DHHS) guidelines,
first-line highly active antiretroviral therapy (HAART) regimens should include a backbone of
two nucleoside reverse transcriptase inhibitors (NRTIs), with tenofovir/emtricitabine (Truvada) as
the preferred NRTIs. Moreover, Truvada is recommended as part of the HAART regimen in
patients with hepatitis B coinfection. In addition to the NRTI backbone of Truvada, the initial
regimen should include efavirenz, ritonavir-boosted atazanavir, or raltegravir. Efavirenz would
not be the best option given its potential to exacerbate psychotic symptoms in patients with a
history of psychiatric illness.
Citation: Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of
Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. U.S. Department of Health and
Human Services, January 10, 2011; 1166. Available at
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed March 28, 2012.

Team/Individual ID

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Jeopardy Segment Score ________

For Administrative Use Only

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