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PHARMACOTHERAPEUTICS FOR ADVANCED PRACTICE NURSE
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Chapter 1. An Introduction to Pharmacogenetics Multiple Choice Identify the choice that best completes the statement or answers the question.
- Genetic polymorphisms account for differences in metabolism, including:
- (^) Poor metabolizers, who lack a working enzyme
- (^) Intermediate metabolizers, who have one working, wild-type allele and one mutant
- (^) Extensive metabolizers, with two normally functioning alleles
- (^) All of the above
- Up to 21% of Asians are ultra-rapid 2D6 metabolizers, leading to:
- (^) A need to monitor drugs metabolized by 2D6 for toxicity
- (^) Increased dosages needed of drugs metabolized by 2D6, such as the selective serotoreuptake inhibitors
- (^) Decreased conversion of codeine to morphine by CYP 2D
- (^) The need for lowered dosages of drugs, such as beta blockers
- Rifampin is a nonspecific CYP450 inducer that may:
- Lead to toxic levels of rifampin and must be monitored closely
- (^) Cause toxic levels of drugs, such as oral contraceptives, when coadministered
- Induce the metabolism of drugs, such as oral contraceptives, leading to therapeutic
- Cause nonspecific changes in drug metabolism
- Inhibition of P-glycoprotein by a drug such as quinidine may lead to:
- Decreased therapeutic levels of quinidine
- Increased therapeutic levels of quinidine
- (^) Decreased levels of a coadministered drug, such as digoxin, that requires P-glycoprabsorption and elimination
- Increased levels of a coadministered drug, such as digoxin, that requires P-glycoproabsorption and elimination
- Warfarin resistance may be seen in patients with VCORC1 mutation, leading to:
- (^) Toxic levels of warfarin building up
- Decreased response to warfarin
- (^) Increased risk for significant drug interactions with warfarin
- Less risk of drug interactions with warfarin
- Genetic testing for VCORC1 mutation to assess potential warfarin resistance is requiredprior to prescribing warfarin.
- (^) True
- (^) False
- Pharmacogenetic testing is required by the U.S. Food and Drug Administration prior toprescribing:
- (^) Erythromycin
- (^) Digoxin
- (^) Cetuximab
- (^) Rifampin
- Carbamazepine has a Black Box Warning recommending testing for the HLA- B*1502 allelein patients with Asian ancestry prior to starting therapy due to:
- (^) Decreased effectiveness of carbamazepine in treating seizures in Asian patients wit HLA-B*1502 allele
- (^) Increased risk for drug interactions in Asian patients with the HLA-B*1502 allele
- (^) Increased risk for Stevens-Johnson syndrome in Asian patients with HLA-B*1502 a
- (^) Patients who have the HLA-B*1502 allele being more likely to have a resistance tocarbamazepine
- A genetic variation in how the metabolite of the cancer drug irinotecan SN-38 isinactivated by the body may lead to:
- (^) Decreased effectiveness of irinotecan in the treatment of cancer
- (^) Increased adverse drug reactions, such as neutropenia
- (^) Delayed metabolism of the prodrug irinotecan into the active metabolite SN- 38
- (^) Increased concerns for irinotecan being carcinogenic
- Patients who have a poor metabolism phenotype will have:
- (^) Slowed metabolism of a prodrug into an active drug, leading to accumulation of pr
- (^) Accumulation of inactive metabolites of drugs
- (^) A need for increased dosages of medications
- (^) Increased elimination of an active drug
- Ultra-rapid metabolizers of drugs may have:
- (^) To have dosages of drugs adjusted downward to prevent drug accumulation
- (^) Active drug rapidly metabolized into inactive metabolites, leading to potential therafailure
- (^) Increased elimination of active, nonmetabolized drug
- (^) Slowed metabolism of a prodrug into an active drug, leading to an accumulation of
- A provider may consider testing for CYP2D6 variants prior to starting tamoxifen forbreast cancer to:
- Ensure the patient will not have increased adverse drug reactions to the tamoxifen
- (^) Identify potential drug-drug interactions that may occur with tamoxifen
- (^) Reduce the likelihood of therapeutic failure with tamoxifen treatment
- Identify poor metabolizers of tamoxifen
Chapter 1. An Introduction to PharmacogeneticsAnswer Section MULTIPLE CHOICE
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Chapter 2. Review of the Basic Principles of Pharmacology Multiple Choice Identify the choice that best completes the statement or answers the question.
Drugs that have a significant first-pass effect:
- Must be given by the enteral (oral) route only
- Bypass the hepatic circulation
- Are rapidly metabolized by the liver and may have little if any desired action
- Are converted by the liver to more active and fat-soluble forms
The route of excretion of a volatile drug will likely be the:
Kidneys
- Lungs
- Bile and feces
- Skin
Medroxyprogesterone (Depo Provera) is prescribed intramuscularly (IM) to create astorage reservoir of the drug. Storage reservoirs: 1. Assure that the drug will reach its intended target tissue 2. Are the reason for giving loading doses 3. Increase the length of time a drug is available and active 4. Are most common in collagen tissues
The NP chooses to give cephalexin every 8 hours based on knowledge of the drug’s:
- (^) Propensity to go to the target receptor2.^ Biological half-life
- Pharmacodynamics
- Safety and side effects
Azithromycin dosing requires that the first day’s dosage be twice those of the
other 4 days of theprescription. This is considered a loading dose. A loading dose:
- Rapidly achieves drug levels in the therapeutic range
- Requires four- to five-half-lives to attain
- Is influenced by renal function
- Is directly related to the drug circulating to the target tissues
- The point in time on the drug concentration curve that indicates the first sign of a therapeuticeffect is the:
- Minimum adverse effect level
- Peak of action
- Onset of action
- Therapeutic range
- Phenytoin requires that a trough level be drawn. Peak and trough levels are done:
- When the drug has a wide therapeutic range
- When the drug will be administered for a short time only
- When there is a high correlation between the dose and saturation of receptorsites 4.^ To determine if a drug is in the therapeutic range
- A laboratory result indicates that the peak level for a drug is above the minimum toxic concentration. This means that the:
- Concentration will produce therapeutic effects2. Concentration will produce an adverse response
- Time between doses must be shortened
- Duration of action of the drug is too long
- Drugs that are receptor agonists may demonstrate what property?
- Irreversible binding to the drug receptor site
- Upregulation with chronic use
- Desensitization or downregulation with continuous use
- Inverse relationship between drug concentration and drug action
- Drugs that are receptor antagonists, such as beta blockers, may cause:
- Downregulation of the drug receptor
- An exaggerated response if abruptly discontinued
- Partial blockade of the effects of agonist drugs
- An exaggerated response to competitive drug agonists
- Factors that affect gastric drug absorption include:
- Liver enzyme activity
- Protein-binding properties of the drugmolecule 3. Lipid solubility
of the drug
- Ability to chew and swallow
- Drugs administered via IV:
- Need to be lipid soluble in order to be easily absorbed2. Begin distribution into the body immediately
- Are easily absorbed if they are nonionized
- May use pinocytosis to be absorbed
- When a medication is added to a regimen for a synergistic effect, the combined effect of the drugs is:
- The sum of the effects of each drug individually
- Greater than the sum of the effects of each drug individually
- Less than the effect of each drug individually
- Not predictable, as it varies with each individual
- Which of the following statements about bioavailability is true?
- Bioavailability issues are especially important for drugs with narrowtherapeutic ranges or sustained-release mechanisms.
- All brands of a drug have the same bioavailability.
- Drugs that are administered more than once a day have greater bioavailability than
drugs given once daily.
- Combining an active drug with an inert substance does not affect bioavailability.
- Which of the following statements about the major distribution barriers (blood-brain or fetal-placental) is true?
- Water soluble and ionized drugs cross these barriers rapidly.
- The blood-brain barrier slows the entry of many drugs into and from brain cells.
- The fetal-placental barrier protects the fetus from drugs taken by the mother.
- Lipid-soluble drugs do not pass these barriers and are safe for pregnant women.
- Drugs are metabolized mainly by the liver via phase I or phase II reactions. The purpose of bothof these types of reactions is to:
- Inactivate prodrugs before they can be activated by target tissues
- Change the drugs so they can cross plasma membranes
- Change drug molecules to a form that an excretory organ can excrete
- Make these drugs more ionized and polar to facilitate excretion
- Once they have been metabolized by the liver, the metabolites may be:
- More active than the parent drug
- Less active than the parent drug
- Totally “deactivated” so they are excreted without any effect4.^ All of the above
- All drugs continue to act in the body until they are changed or excreted. The ability of the bodyto excrete drugs via the renal system would be increased by:
- Reduced circulation and perfusion of the kidney
- Chronic renal disease
- Competition for a transport site by another drug
- Unbinding a nonvolatile drug from plasma proteins
- Steady state is:
- (^) The point on the drug concentration curve when absorption exceedsexcretion 2. When the amount of drug in the body remains constant
- When the amount of drug in the body stays below
the minimumtoxic concentration
- All of the above
- Two different pain medications are given together for pain relief. The drug—drug interaction is:
- Synergistic
- Antagonistic
- Potentiati ve4.^ Additive
- Actions taken to reduce drug—drug interaction problems include all of the following EXCEPT:
- Reducing the dosage of one of the drugs
- Scheduling their administration at different times
- Prescribing a third drug to counteract the adverse reaction of the combination
- Reducing the dosage of both drugs
- Phase I oxidative-reductive processes of drug metabolism require certain nutritional elements.
Which of the following would reduce or inhibit this process?
- Protein malnutrition
- Iron-deficiency anemia
- Both 1 and 2 2
- The time required for the amount of drug in the body to decrease by 50% is called:
- Steady state2. Half- life
- Phase II metabolism
- Reduced bioavailability time
- An agonist activates a receptor and stimulates a response. When given frequently overtime, the body may:
- Upregulate the total number of receptors
- Block the receptor with a partial agonist
- Alter the drug’s metabolism
- Downregulate the numbers of that specific receptor
- Drug antagonism is best defined as an effect of a drug that:
- Leads to major physiological and psychological dependence2.^ Is modified by the concurrent administration of another drug
- Cannot be metabolized before another dose is administered
- Leads to a decreased physiological response when combined with another drug
- Instructions to a client regarding self-administration of oral enteric- coated tablets shouldinclude which of the following statements?
- “Avoid any other oral medicines while taking this drug.”
- “If swallowing this tablet is difficult, dissolve it in 3 ounces of orange juice.”
- “The tablet may be crushed if you have any difficulty taking it.”
- “To achieve best effect, take the tablet with at least 8 ounces of fluid.”
- The major reason for not crushing a sustained-release capsule is that, if crushed,
- (^) Neither 1 nor
the coated beadsof the drugs could possibly result in:
- Disintegration
- Toxicity
- Malabsorption
- Deterioration
- Which of the following substances is the most likely to be absorbed in the intestines ratherthan in the stomach?
- Sodium bicarbonate
- Ascorbic acid
- Salicylic acid
- Glucose
- Which of the following variables is a factor in drug absorption?
- (^) The smaller the surface area for absorption, the more rapidly the drug is absorbed.2. A rich blood supply to the area of absorption leads to better absorption.
- The less soluble the drug, the more easily it is absorbed.
- Ionized drugs are easily absorbed across the cell membrane.
- An advantage of prescribing a sublingual medication is that the medicationis: 1.^ Absorbed rapidly
- Excreted rapidly
- Metabolized minimally
- Distributed equally
- Drugs that use CYP 3A4 isoenzymes for metabolism may:
- Induce the metabolism of another drug
- Inhibit the metabolism of anotherdrug 3. Both 1 and 2
- Neither 1 nor 2
- Therapeutic drug levels are drawn when a drug reaches steady state. Drugs reach steady state:
- After the second dose
- After four to five half-lives
- When the patient feels the full effect of the drug
- One hour after IV administration
- Upregulation or hypersensitization may lead to:
- Increased response to a drug
- Decreased response to a drug
- An exaggerated response if the drug is withdrawn
- Refractoriness or complete lack of response
Chapter 2. Review of the Basic Principles of PharmacologyAnswer Section MULTIPLE CHOICE
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Chapter 3. Rational Drug Selection Multiple Choice Identify the choice that best completes the statement or answers the question.
- An NP would prescribe the liquid form of ibuprofen for a 6 - year-old child because:
- Drugs given in liquid form are less irritating to the stomach.2. A 6 - year-old child may have problems swallowing a pill.
- Liquid forms of medication eliminate the concern for first-pass effect.
- Liquid ibuprofen does not have to be dosed as often as the tablet form.
- In deciding which of multiple drugs used to use to treat a condition, the NP chooses Drug Abecause it: 1. Has serious side effects and it is not being used for a life-threatening condition 2. Will be taken twice daily and will be taken at home 3. Is expensive, but covered by health insurance 4. None of these are important in choosing a drug
- A client asks the NP about the differences in drug effects between men and women. What isknown about the differences between the pharmacokinetics of men and women? 1. Body temperature varies between men and women. 2. Muscle mass is greater in women. 3. Percentage of fat differs between genders. 4. Proven subjective factors exist between the genders.
- The first step in the prescribing process according to the World Health Organization is:
- Choosing the treatment
- Educating the patient about the medication 3. Diagnosing the patient’sproblem
- Starting the treatment
- Treatment goals in prescribing should:
- (^) Always be curative 2.^ Be patient-centered
- Be convenient for the provider
- Focus on the cost of therapy
- The therapeutic goals when prescribing include(s):
- Curative
- Palliative
- Preventive
- All of the above
- When determining drug treatment, the NP prescriber should:
- Always use evidence-based guidelines
- Individualize the drug choice for the specific patient
- Rely on his or her experience when prescribing for complex patients
- Use the newest drug on the market for the condition being treated
- Patient education regarding prescribed medication includes:
- Instructions written at the high school reading level2. Discussion of expected adverse drug reactions
- How to store leftover medication such as antibiotics
- Verbal instructions always in English
- Passive monitoring of drug effectiveness includes:
- Therapeutic drug levels
- Adding or subtracting medications from the treatment regimen
- Ongoing provider visits
- Instructing the patient to report if the drug is not effective
- Pharmacokinetic factors that affect prescribing include:
- Therapeutic index
- Minimum effective concentration 3. Bioavailability
- Ease of titration
- Pharmaceutical promotion may affect prescribing. To address the impact of pharmaceuticalpromotion, the following recommendations have been made by the Institute of Medicine:
- (^) Conflicts of interest and financial relationships should be disclosed by thoseproviding education.
- (^) Providers should ban all pharmaceutical representatives from their office setting.
- (^) Drug samples should be used for patients who have the insurance to pay forthem, to ensure the patient can afford the medication.
- (^) Providers should only accept low-value gifts, such as pens and pads of paper,from the pharmaceutical representative.
- Under new U.S. Food and Drug Administration labeling, Pregnancy Categories will be:
- Strengthened with a new coding such as C+ or C- to discern when a drug ismore or less toxic to the fetus
- Changed to incorporate a pregnancy risk summary and clinicalconsiderations on the drug label
- Eliminated, and replaced with a link to the National Library of Medicine TOXNET Web site for in-depth information regarding pregnancy concerns
- Clarified to include information such as safe dosages in eachtrimester of pregnancy
Chapter 3. Rational Drug SelectionAnswer Section MULTIPLE CHOICE
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Chapter 4. Legal and Professional Issues in Prescribing Multiple Choice Identify the choice that best completes the statement or answers the question.
- The U.S. Food and Drug Administration regulates:
- Prescribing of drugs by MDs and NPs
- The official labeling for all prescription and over-the-counter drugs
- Off-label recommendations for prescribing
- Pharmaceutical educational offerings
- The U.S. Food and Drug Administration approval is required for:1. Medical devices, including artificial joints
- Over-the-counter vitamins
- Herbal products, such as St John’s wort
- Dietary supplements, such as Ensure
- An Investigational New Drug is filed with the U.S. Food and Drug Administration:
- When the manufacturer has completed phase III trials
- When a new drug is discovered
- Prior to animal testing of any new drug entity 4.^ Prior to human testing of any new drugentity
- Phase IV clinical trials in the United States are also known as:
- Human bioavailability trials2. Post marketing research
- Human safety and efficacy studies
- The last stage of animal trials before the human trials begin
- Off-label prescribing is:
- Regulated by the U.S. Food and Drug Administration
- Illegal by NPs in all states (provinces)
- Legal if there is scientific evidence for the use
- Regulated by the Drug Enforcement Administration
- The U.S. Drug Enforcement Administration:
- Registers manufacturers and prescribers of controlled substances
- Regulates NP prescribing at the state level
- Sanctions providers who prescribe drugs off-label
- Provides prescribers with a number they can use for insurance billing
- Drugs that are designated Schedule II by the U.S. Drug Enforcement Administration:
- Are known teratogens during pregnancy
- May not be refilled; a new prescription must be written
- Have a low abuse potential
- May be dispensed without a prescription unless regulated by the state
- Precautions that should be taken when prescribing controlled substances include:
- Faxing the prescription for a Schedule II drug directly to the pharmacy
- Using tamper-proof paper for all prescriptions written for controlled drugs
- Keeping any pre-signed prescription pads in a locked drawer in the clinic
- Using only numbers to indicate the amount of drug to be prescribed
- Strategies prescribers can use to prevent misuse of controlled prescription drugs include:
- Use of chemical dependency screening tools
- Firm limit-setting regarding prescribing controlled substances
- Practicing “just say no” to deal with patients who are pushing the providerto prescribe controlled substances
- All of the above
- Behaviors predictive of addiction to controlled substances include:1. Stealing or borrowing another patient’s drugs
- Requiring increasing doses of opiates for pain associated with malignancy
- Receiving refills of a Schedule II prescription on a regular basis
- Requesting that only their own primary care provider prescribe for them
- Medication agreements or “Pain Medication Contracts” are recommended to be used:1. Universally for all prescribing for chronic pain
- For patients who have repeated requests for pain medication
- When you suspect a patient is exhibiting drug-seeking behavior
- For patients with pain associated with malignancy
- A prescription needs to be written for:
- Legend drugs
- Most controlled drugs
- Medical devices4. All of the above