1. Therapeutics IV Tutoring Lisa Hayes lhayes3@uthsc.edu April 2, 2016

2. Outline GI Lab/Procedures Upper GI Bleed Stress Related Mucosal Damage/SUP GERD Peptic Ulcer Disease Adult Liver Disease Pediatric Liver Disease Drug-Induced Liver Disease Hepatitis Pancreatitis

3. GI LAB/PROCEDURES

4. Which of the follow is not a “warning symptom” that requires further work- up? A – intractable vomiting B – weight loss C – constipation D – anemia E – dysphagia

5. Which of the following are used in the diagnosis of pancreatitis? A – AST/ALT B – Amylase/lipase C – Ammonia D – PT/INR

6. Which liver marker has the longer half life? A – AST B – ALT

7. Which drug is not known to cause gastric mucosal irritation? A – NSAIDs B – iron C – potassium D – cetirizine

8. Which antibiotic is known to cause esophagitis? A – cephalexin B – ciprofloxacin C – doxycyline D – metronidazole

9. Which drug can contribute to GERD? A – HCTZ B – lisinopril C – metoprolol D – nifedipine

10. UPPER GI BLEED

11. What are the 3 types of injection therapy that can be used in endoscopy to treat a UGIB? A – 1:1000 epinephrine + isotonic saline + absolute alcohol B – 1: 10000 epinephrine + isotonic saline + 70 % ethanol C – 1: 1000 epinephrine + hypertonic saline + 70% ethanol D – 1: 10000 epinephrine + hypertonic saline + absolute alcohol

12. BB is a patient with a UGIB. She presents with vomiting bright red blood. She has a history of afib, osteoarthritis, and depression. She is waiting for endoscopy. What should you recommend at this time? A – Octreotide drip alone B – Zantac 50mg IV q8h C – Protonix 8mg/hr, 80mg bolus IV D – Protonix 8mg/hr, no bolus

13. FK is a patient with advanced cirrhosis who presents to the ED with his second GI bleed in 3 months. His last GIB was determined to be a result of a variceal bleed. Which would be best for the management of his variceal bleed today? A – Vasopressin 0.03units/min B – Vasopressin 0.4 units/min C – Octreotide 50mcg bolus + Octreotide 10mcg/hr D – Octreotide 25mcg bolus + Octreotide 50mcg/hr

14. The attending wants to know if there is anything he can prescribe for FK to help prevent further variceal bleeding. What do you tell him? A – Imdur 20mg daily B – Propranolol 20mg BID C – Nadolol 40mg TID D – Metoclopramide 10mg ACHS

15. STRESS RELATED MUCOSAL DAMAGE/SUP

16. TH is a patient in your ICU. She was in a car accident 7 days ago where her face/head was badly damaged in addition to a severe femur fracture. She has been on mechanical ventilation since her arrival. Today her BP has dropped significantly with an increase in HR. Additionally, on the AM labs, you have noticed her Hgb has dropped by 2.5g/dl. Her Hgb had stabilized before today’s reading. It appears she has developed SRMD. What should have been done to prevent her development of this disease? A – enteral feeding B – PPI prophylaxis C – H2B prophylaxis D – enteral feeding + PPI prophylaxis

17. TH is a patient in your ICU. She was in a car accident 7 days ago where her face/head was badly damaged in addition to a severe femur fracture. She has been on mechanical ventilation since her arrival. Today her BP has dropped significantly with an increase in HR. Additionally, on the AM labs, you have noticed her Hgb has dropped by 2.5g/dl. Her Hgb had stabilized before today’s reading. It appears she has developed SRMD. Her BP is 95/70. What should be done now to treat the patient? A – octreotide infusion B – protonix infusion C – dopamine infusion

18. SH is a patient in your ICU after a ATV accident where he had a severe brain bleed and broke his pelvis. He is currently on enteral feeds; he is tolerating these well. He was admitted to the ICU 48 hours ago. He only required mechanical ventilation for 24 hours after his admission to the ICU. What is your recommendation for SUP at this time. A – Add PPI IV once daily B – no additional recommendations at this time C – Add H2B IV once daily

19. CH is a patient in your ICU who presented 4 days ago with sepsis. He has advanced cirrhosis with a history of GI bleed 8 months ago. Labs were WNL this AM except for INR = 1.7. He has been ventilated since his admission. He has been receiving enteral feeds with a BCAA formulation since day 2 of his admission. What is your recommendation for SUP? A – Add PPI IV Qday B – no additional SUP required C – Add sucralfate down NG tube QID

20. GERD

21. The LES and meds/other agents that act on it can contribute to GERD. Determine the number of factors that could be acting on the LES in the following case: AA is a patient who has 2 cups of coffee daily in addition to her glass of wine each night with dinner. She enjoys tomato based pastas and laying down in bed to watch television right after dinner. She drinks 1 diet coke with lunch each day. Her BMI is currently 35. Her favorite meal is buffalo wings with extra spicy sauce. A – 4 B – 5 C – 6 D – 7

22. WR has been diagnosed with erosive esophagtitis as a result of not being properly counseled on her tetracyline for acne prevention. How long should we recommend use of PPI? A – 2 weeks B – 4 weeks C – 8 weeks D – 12 weeks

23. Which medication irreversibly blocks the H/K/ATPase system? A – Rantidine B – Sucralfate C – Nexium D – Misoprostol

24. BY is a patient who had a stent placed 3 months ago and has been on Plavix therapy since that time. The patient has some GERD symptoms and the physician would like to try a short course of PPI. He wants to know which would be the best to choose as he heard a lot of controversy about the combination of these 2 medications. A – Omeprazole, cheapest option B – Protonix, less drug interactions C – Nexium, available OTC now D – doesn’t matter, just pick one

25. TW is a 73 year old AA female who has been on PPI therapy for 2 years. She refuses to come off her PPI for fear of GI symptoms. You perform a point of care bone density exam on her and discover she has some osteopenia and you want to recommend a calcium supplement. What would be the best choice. A – Calcium citrate B – Calcium carbonate

26. VA is a mom who has brought her baby to clinic for increased reflux symptoms. VA wants to try non-pharmacologic things for the reflux before any medications as her son is only 2 months old and she is scared to give him any medications routinely unless it is absolutely necessary. What would you recommend to VA? A – elevate HOB B – smaller, more frequent feedings C – optimize burping D – thicken formula with rice cereal

27. JH is a patient with mild symptoms of GERD. What would you recommend for him. A – lifestyle changes only B – lifestyle changes + antacids PRN C – lifestyle changes + antacids PRN + omeprazole 40mg daily D – lifestyle changes + antacids PRN + Zantac 75mg daily

28. PEPTIC ULCER DISEASE

29. In therapy for PUD, what cell do we focus our efforts on? A – parietal cells B – chief cells C- foveolar cell (mucus neck cells) D – G cells

30. PPIs are drugs that are used to treat PUD. Common PPIs are omeprazole and pantoprazole. What are common SE of chronic use of these drugs? A – hypokalemia and increased risk for CDiff B – hypomagnesemia and B12 deficiency C – low bicarbonate and hyperkalemia D – B12 deficiency and hyponatremia

31. What are some issues associated with H2Blockers (Rantidine, Famotidine, etc)? A – drug, drug interactions + cost B – cost + BID dosing C – drug, drug interactions + not comparable between agents D – tachyphylaxis + drug interactions

32. 1. What is the drug class of Misoprostol? 2. What are SE that most often warrant its discontinuation by patients? A – 1. PPI – 2. cramping, diarrhea B – 1. prostaglandin – 2. cramping, diarrhea C – 1. H2 blocker – 2. pregnancy

33. A patient, EQ, has been diagnosed with H. pylori infection with a urea breath test. It has been decided he needs treatment for eradication of this infection. Which of the following regimens would you recommend given he has not yet undergone any treatment for this infection. He is allergic to Zosyn– anaphylaxis. A – PPI daily, Clarithromycin 500 BID, Metronidazole 500 BID B – PPI BID, Pepto 525mg QID, Metronidazole 500mg QID, Tetracycline 500mg QID C – PPI BID, Clarithromycin 500 BID, Metronidazole 500 BID D – PPI BID, Clarithromycin 500 BID, Amoxicillin 1gm BID

34. EQ came back for follow up after completion of the regimen you recommended. On follow-up, he is still experiencing symptoms and it is discovered he still has active H. pylori infection. The attending asks you to recommend a proper second course of antibiotic eradication therapy. A – Repeat prior course. Ensure compliance B – PPI BID on days 1-10; Amoxicillin 1gm on days 1-5; Metronidazole 500mg BID on days 6- 10; Clarithromycin 500mg on days 6-10 C – PPI BID, Pepto 525mg QID, Metronidazole 500mg QID, Tetracycline 500mg QID D – PPI BID; Pepto 525mg QID; Levofloxacin 250mg BID; Tetracyclin 500mg QID

35. EW is a 67 year old patient who has been using diclofenac sodium 100mg BID for treatment of his osteoarthritis. Other pertinent history includes: 1ppd smoker, 3 OH drinks/wk. Meds: 81mg ASA for heart health, 20mg paxil for depression. He presents to clinic with complaint of increased heartburn and GI discomfort. It is determined that he has a ulcer. You as an astute pharmacist notify the team that is likely secondary to the NSAID use. What is your recommendation? A – Add PPI in addition to diclofenac indefinitely B – Add PPI for short term healing of ulcer (2-4 wk) and continue diclofenac after PPI course C – Add PPI for short term healing of ulcer (2-4 wk) + change to APAP for treatment of OA D – Add PPI for short term treatment of ulcer (2- 4wk). Add misoprostol to diclofenac regimen indefinitely

36. Adult Liver Disease

37. Which of the following hepatic markers can help tell the severity of liver disease? A – ALT/AST B – Tbili C – INR D - AlkPhos

38. HT presents as a 16beer/day drinker. It is determined he has severe ALD. He has AMS (indicative of hepatic encephalopathy – increased NH3 levels on lab report) and his MDF score is 42. Which of the following therapies would be appropriate at this time? A – no therapy indicated since severe dz B – Lactulose enema til AMS resolves C – Prednisone 40mg/day for 28 days, then taper D – Pentoxifylline 400mg TID

39. HG has portal hypertension and a history of variceal bleeding as a result of his cirrhosis. Which of the following would be appropriate prophylaxis for repeat bleeding? A – Nadolol 40mg BID, goal HR 55-60 B – Propranolol 10mg TID, goal HR 55-60 C – Nadolol 20mg daily, goal HR 65-70 D – Propranolol 20mg TID, goal HR 65-70

40. HG does not take your recommendation for prophylaxis for bleeding and is admitted to your ICU for bleeding of his varices. The attending asks if there is anything that should be added to his regimen besides Ocreotide, fluids, and the propranolol he wasn’t taking before. What do you recommend? A – Ciprofloxacin 400mg IV daily for 7 days B – Ceftriaxone 1gm IV daily for 7 days C – Ceftriaxone 1gm IV daily for 14 days D – Norfloxacin 400mg IV BID for 14 days

41. Determine if HG’s ascites is due to portal hypertension. Serum albumin 2.7gm/dL. Ascitic albumin: 1.5gm/dL A – yes, due to portal hypertension B – no, not due to portal hypertension

42. Since HG’s ascites is due to portal hypertension, the attending asks for a recommendation on appropriate diuretics. What do you recommend? A – Use bumetaminde preferrentially as single agent B – Use furosemide in combo with spironalactone; no recommended ratio C – use furosemide in combo with spironalactone; recommended ratio 40:100 D – use thiazides preferentially over loops

43. Despite appropriate treatment with diuretics, HG required a therapeutic paracentesis. The medical student wants to know if he should recommend albumin replacement to the resident. 4.5L of fluid were removed during the procedure. A – no replacement required B – yes, give 30g of 5% albumin C – yes, give 30g of 25% albumin

44. HG is discharged home 1 week later but returns at the end of the month and it is discovered he has developed spontaneous bacterial peritonitis. The PMN count on his recent ascitic fluid was 350. SCR 1.8mg/dL today. Recommend appropriate therapy at this time. A – Start abx – Cefotaxime 1gm IV q8h. B – Start albumin – 1.5g/kg on day 1 + 1g/kg on day 3 C – Start abx – ceftriaxone 1gm IV q12h D – start albumin – 6-8g/L of fluid removed

45. The physician wants to know if there is anything he can to do to prevent HG from getting SBP again. What do you say? A – Bactrim DS TIW B – Cipro 500mg daily C – Bactrim DS daily D – Cipro 750mg weekly

46. Which of the following is the DOC for hepatic encephalopathy? A – neomycin B – rifaximin C – lactulose D – flumazenil

47. Pediatric Liver Disease

48. What is the DOC for treating neonatal jaundice? A – exchange tranfusion B – pentoxifylline C – phototherapy D – exclusive breast feeding

49. Which drug is not known to displace biliribuin from albumin and is considered safe in neonates? A – ceftriaxone B – sulfonamide C – lipid emulsion D – cefotaxime

50. Parenteral Nutrition Associated Liver Disease (PNALD) is common in pediatric patients receiving long term PN. Which of the following medications can be used to treat PNALD? A – increase rate of PN B – remove lipids from PN C – omega-3 fatty acids D – wait to introduce enteral nutrition

51. Acholic stools are most often a sign of what disease when presenting in the pediatric population? A – neonatal jaundice B – biliary atresia C – PNALD D – Alagille’s syndrome

52. Which medication used to treat sclerosing cholangitis in children has not been shown to have efficacy in the same disease state in adults? A – ursodeoxycholic acid B – azathioprine C – prednisone D – CCK

53. What drug can be used to chelate copper in patients with Wilson’s disease? A – ursodiol B – ascorbic acid C – exjade D – penicillamine

54. Drug-Induced Liver Disease

55. Which drug is it important to reduce the dose for renal function to prevent hepatic injury? A – sulfonamides B – allopurinol C – nitrofurantoin D – isoniazid

56. Cytotoxic (hepatocellular) damage is evident by an increase in what hepatic markers? A – INR B – AST C - AST and ALT D – ALT

57. Age over 50 years is a risk factor for hepatic injury when taking which of the following medications? A – allopurinol B – nitrofurantoin C – isoniazid D – acetaminophen

58. Which drug is associated with both chronic and acute hepatic injury? A – nitrofurantoin B – allopurinol C – acetaminophen D – sulfa drugs

59. Acetaminophen overdose results in which of the following? A – significant rise in ALT B – significant rise in AST C – normal AST D – normal ALT, increased INR

60. Inhibition of which enzyme may increase the toxicity of acetaminophen overdose? A – CYP3A4 B – CYP2E1 C – CYP2D6 D – CYP1A2

61. Hepatitis

62. Which hepatic virus is there treatment but no vaccine for? A – Hepatitis A B – Hepatitis B C – Hepatitis C

63. Which of the following serological profiles is that of a patient who is immune to the HBV virus due to natural infection? A – HBsAG negative; antiHBc positive; antiHBs positive B – HBsAg negative; antiHBc negative; antiHBs positive C – HBsAg negative; antiHBc negative; antiHBs negative

64. Which of the following is the serological profile of a patient who is chronically infected with HBV? A – HBsAg – positive; Anti-HBc positive; IgM antiHBc – positive; anti-HBs – negative B - HBsAg – positive; Anti-HBc positive; IgM antiHBc – negative; anti-HBs – negative

65. BF has been stuck by a needle after administering a flu vaccine because he did not follow the proper protocol. It is determined that the patient has HBV. BF is not up to date on his HBV vaccine. What should he receive as post-exposure prophylaxis? A – HBIG alone if no more than 7 days have passed since exposure B – HBV vaccine + HBIG C – HBIG alone D – HBV vaccine alone

66. What is used for treatment of autoimmune hepatitis? A – prednisolone B – prednisone + azathioprine C – ursodiol D – medrol

67. What is the general duration of treatment for HCV if no cirrhosis is present? A – 24 weeks B – 16 weeks C – 12 weeks D – 8 weeks

68. Pancreatitis

69. What is the most common cause of acute pancreatitis? A – alcohol B – medications C – hyperparathyroidism D – gallstones

70. Which of the following causes of pancreatitis (acute) is most likely to progress to chronic pancreatitis? A – alcohol B – medications C – hypertriglyceridemia D – gallstones

71. PK presents to the ED with epigastric pain that he reports is constant. Pancreatitis is suspected and amylase and lipase levels are drawn. His amylase is WNL but his lipase is 300units/L. On CT scan, a collection of fluid is noted outside the pancreas. The attending asks you for a recommendation regarding PK’s condition given the odd lab results. A – Recommend treating for pancreatitis B – Recommend looking for other causes of dx

72. You have correctly chosen to treat PK for pancreatitis. What should you recommend first line? A – Abx (broad spectrum) for his fluid collection B – Fluids for hypovolemia C – enteral nutrition to prevent mortality D – pain medication

73. LT is a chronic alcoholic and presents to the ER with his 5 th case of pancreatitis in the last year. He is diagnosed with chronic pancreatitis. What can be done to manage his pain and discomfort? A – insulin B – pancreatic enzymes C – welchol D – increase fiber in diet

74. IRRITABLE BOWEL SYNDROME BONUS!

75. A patient presents to your clinic with a history of IBS. Today her symptoms include the following: chronic constipation mixed with intermittent diarrhea, pain that is relieved with defecation, and a recent weight loss of 10kg. Current patient weight of 80kg. What should be your course of action? A – consider change in medication to rectify constipation/diarrhea picture B – refer, symptoms not consistent with IBS C – recommend increased fiber intake

76. HG is a patient who has recently been diagnosed with diarrhea predominant IBS. He would like some non-pharmacologic options to try before beginning a medication regimen as he does not have good prescription drug coverage. A – Avoid lactose containing foods B – increase dietary fiber C – avoid gas-producing foods D – consider food allergies

77. The previous pt, HG, has tried nonpharmacologic methods with no success. Which of the follow pharmacologic agents would be a good choice for him? A – Alosetron (Lotronex) B – Loperamide (Imodium) C – Lubiprostone (Amitiza) D – Linactolide (Linzess)

78. JY is a pt with constipation predominant IBS. Which agent should be avoided in his regimen as you design it? A – Linaclotide (Linzess) B – Amitriptyline (Elavil) C – Lubiprostone (Amitiza) D – Tegaserod (Zelnorm)

79. A patient presents to your clinic. She is a 2 nd year pharmacy student who has been experiencing anxiety secondary to working 35 hours a week and going to school full time. She is worried about her grades. She has been experiencing abdominal pain relieved by defecation, intermittent constipation mixed with diarrhea, and overall nausea. Which medication is indicated in this patient? A – loperamide B – alprazolam C – linactolide D – citalopram