NR566 / NR 566 Final Exam 2026/2027 Update | Advanced Pharmacology | Chamberlain University | Verified Questions & Correct Answers with Detailed Rationales | Grade A | APRN Pharmacology & Board Prep PDF

INSTANT PDF DOWNLOAD — This is the comprehensive final exam preparation guide for NR566 / NR 566 - Advanced Pharmacology (2026 Update) at Chamberlain University, featuring verified questions and correct answers with detailed rationales. Designed for advanced practice nursing students (FNP, AGACNP, PMHNP, PNP, CNM), this resource consolidates the critical pharmacologic principles required to master the NR566 final exam and excel in advanced pharmacology coursework and APRN certification. The guide is meticulously aligned with Chamberlain University curriculum, AANP, ANCC, AACN certification blueprints, and current evidence-based pharmacotherapy guidelines. This verified resource provides comprehensive coverage of key NR566 Advanced Pharmacology exam topics, including: Pharmacokinetics and Pharmacodynamics (absorption (bioavailability, first-pass effect, enteral vs parenteral), distribution (volume of distribution, protein binding, blood-brain barrier, pregnancy (placental transfer), lactation (milk-to-plasma ratio), metabolism (phase I (CYP450—oxidation, reduction, hydrolysis), phase II (conjugation—glucuronidation, acetylation, sulfation), CYP450 inducers (rifampin, carbamazepine, phenytoin, phenobarbital, St. John's wort, smoking) and inhibitors (ketoconazole, erythromycin, clarithromycin, grapefruit juice, ciprofloxacin, fluconazole, amiodarone, diltiazem, verapamil, ritonavir), genetic polymorphisms (CYP2D6 (poor metabolizers—codeine ineffective, increased toxicity with some drugs), CYP2C9 (warfarin sensitivity), CYP2C19 (clopidogrel resistance)), elimination (renal (glomerular filtration, tubular secretion, reabsorption, adjust for CrCl), hepatic (hepatobiliary excretion, enterohepatic recirculation), half-life, steady state (4-5 half-lives), loading dose, maintenance dose, therapeutic drug monitoring (vancomycin, aminoglycosides, digoxin, lithium, phenytoin, valproate, carbamazepine, cyclosporine, tacrolimus, methotrexate)); Pharmacotherapy for Special Populations (pregnancy—FDA Pregnancy and Lactation Labeling Rule (PLLR) (replaced ABCD-X categories), teratogenic risk (known human teratogens: isotretinoin (Accutane) (iPLEDGE program), valproate (neural tube defects, developmental delay), warfarin (fetal warfarin syndrome), ACE inhibitors/ARBs (renal dysgenesis, oligohydramnios, neonatal renal failure), lithium (Ebstein's anomaly, risk lower than valproate, monitor levels), methotrexate (aminopterin syndrome), misoprostol (uterine rupture, fetal death), thalidomide (phocomelia), diethylstilbestrol (DES) (clear cell adenocarcinoma in female offspring), phenytoin (fetal hydantoin syndrome), carbamazepine (neural tube defects), topiramate (cleft lip/palate), paroxetine (cardiac defects, first trimester), fluconazole (high dose first trimester (400-800 mg/day)—cleft lip/palate, cardiac defects, limb defects, lower doses (150 mg for vaginitis) likely safe), NSAIDs (third trimester (premature closure of ductus arteriosus, oligohydramnios, neonatal pulmonary hypertension), avoid after 30 weeks, first/second trimester (possible increased risk miscarriage, low risk)), safe in pregnancy (penicillins, cephalosporins, macrolides (except clarithromycin (animal studies adverse, avoid unless necessary)), clindamycin, metronidazole (controversial, generally safe after first trimester), nitrofurantoin (avoid near term (hemolytic anemia in G6PD-deficient newborn)), heparin/LMWH (does not cross placenta, safer than warfarin), insulin (first-line for GDM), levothyroxine (critical for fetal neurodevelopment), ondansetron (first trimester—small increased risk cleft palate (1-2 extra per 10,000), but benefit may outweigh for severe hyperemesis), prednisone (minimal fetal risk, monitor for maternal hyperglycemia, hypertension)), lactation—medications compatible with breastfeeding (most antibiotics (penicillins, cephalosporins, macrolides, clindamycin, metronidazole, nitrofurantoin (avoid if infant G6PD deficiency), fluoroquinolones (avoid due to arthropathy in animal studies but human data limited, use if no alternative), TMP-SMX (avoid in infants 2 months, G6PD deficiency, hyperbilirubinemia), analgesics (acetaminophen (safe), ibuprofen (safe), naproxen (safe but long half-life, possible drowsiness), aspirin (avoid high doses (Reye's syndrome, bleeding), low dose (81 mg) probably safe), opioids (monitor infant for sedation, poor feeding, constipation, neonatal abstinence syndrome (NAS) with chronic use)), psychotropics (SSRIs (sertraline, paroxetine lowest levels), SNRIs (duloxetine low levels), tricyclics (nortriptyline low levels), benzodiazepines (use lowest effective dose, monitor for sedation, poor feeding), antipsychotics (olanzapine, quetiapine, risperidone, haloperidol generally safe, monitor infant for sedation, poor feeding, movement disorders, clozapine (avoid—agranulocytosis risk, infant monitoring CBC))), anticonvulsants (lamotrigine (monitor infant for rash, apnea), levetiracetam (safe), valproate (monitor infant for hepatotoxicity, bleeding (vitamin K), avoid unless necessary), phenytoin (monitor for sedation, poor feeding, methemoglobinemia, vitamin K deficiency bleeding)), anticoagulants (warfarin (safe, no bleeding risk to infant, monitoring INR not needed for infant), heparin/LMWH (safe, does not enter milk)), cardiovascular (beta-blockers (propranolol, metoprolol, labetalol—monitor for bradycardia, hypoglycemia, poor feeding), ACE inhibitors (captopril, enalapril, lisinopril—low levels, monitor for hypotension), calcium channel blockers (nifedipine, verapamil, diltiazem—low levels, monitor for bradycardia)), endocrinology (levothyroxine (safe, essential), methimazole (low levels, risk of neonatal hypothyroidism, monitor thyroid function, use propylthiouracil (PTU) first trimester due to lower risk of congenital anomalies but higher hepatotoxicity, PTU preferred in pregnancy first trimester, then methimazole after), propylthiouracil (PTU) (low levels, hepatotoxicity (fulminant liver failure, Black Box Warning), use only in first trimester then switch to methimazole if possible, monitor LFTs), insulin (safe, does not enter milk), metformin (low levels, generally safe, monitor for GI effects in infant (diarrhea))), pediatrics—off-label prescribing common, weight-based dosing (mg/kg), renal function adjustment (Schwartz formula for CrCl), hepatic immaturity (neonates: reduced phase I, normal phase II), glucuronidation (deficient in neonates (gray baby syndrome with chloramphenicol, avoid), maturation by 6 months), increased volume of distribution (higher water content, higher weight-based dose for hydrophilic drugs), decreased protein binding (higher free drug levels, toxicity risk), decreased renal function (neonates: GFR 10-20 mL/min/1.73m², reaches adult values by 12-24 months, adjust renally cleared drugs), increased BBB permeability (higher CNS drug levels, toxicity risk), safe medications in children (acetaminophen (weight-based, avoid chronic use), ibuprofen (6 months), amoxicillin, cephalosporins, macrolides, TMP-SMX (2 months, not for group A strep pharyngitis due to resistance), oseltamivir (FDA-approved for 2 weeks), ondansetron (for gastroenteritis, age 6 months, FDA-approved), on-label pediatric uses (ADHD medications (methylphenidate, amphetamine, guanfacine, clonidine, atomoxetine—age 6), asthma (ICS, LABA (with ICS), montelukast, omalizumab (6), albuterol (nebulized, MDI with spacer/holding chamber, mask), antibiotics for AOM (amoxicillin 80-90 mg/kg/day, 10 days 6 years, 7 days ≥6 years), streptococcal pharyngitis (penicillin VK or amoxicillin 50 mg/kg/day, 10 days), CAP (amoxicillin first-line, macrolides for atypical, doxycycline 8 years), UTI (TMP-SMX, cephalexin, nitrofurantoin (1 month, not for pyelonephritis)), medication errors (risk higher in children, weight-based dosing errors, decimal errors (leading zero (0.5 mL) correct, trailing zeros (5.0 mL) dangerous), "five rights" (right patient, drug, dose, route, time), high-alert medications in pediatrics (IV opioids, IV insulin, IV heparin, IV potassium, IV magnesium, chemotherapeutic agents, parenteral nutrition, neuromuscular blockers), geriatrics—physiological changes (increased body fat (increased Vd for lipophilic drugs (diazepam, amiodarone, verapamil, haloperidol), prolonged half-life, increased duration of effect), decreased lean body mass, total body water (decreased Vd for hydrophilic drugs (lithium, digoxin, aminoglycosides, ethanol), increased peak concentrations, toxicity risk), decreased albumin (increased free drug levels for highly protein-bound drugs (phenytoin, warfarin, valproate, ceftriaxone, diazepam, furosemide, NSAIDs), toxicity risk, monitor unbound levels if available), decreased CYP450 function (reduced phase I metabolism, increased half-life, reduce doses for hepatically cleared drugs, CYP3A4 (decreased 30-40%), CYP2D6 (decreased), CYP1A2 (decreased), CYP2C9 (decreased—warfarin sensitivity), CYP2C19 (decreased—clopidogrel reduced efficacy? no, still effective, but increased bleeding risk)), decreased renal function (decreased GFR (1 mL/min/year after age 30), reduced renal clearance, calculate CrCl using Cockcroft-Gault (use actual body weight, age, sex), adjust doses for renally cleared drugs (aminoglycosides, vancomycin, lithium, digoxin, metformin, gabapentin, pregabalin, baclofen, many ACE inhibitors (lisinopril, enalapril), ARBs (losartan, valsartan), HCTZ, chlorthalidone, loop diuretics (furosemide, bumetanide), NSAIDs (avoid or reduce dose, increased risk GI bleeding, renal impairment, hypertension, heart failure), opioid-sparing strategies (multimodal analgesia, acetaminophen, NSAIDs (caution), gabapentinoids (reduce dose), topical agents (lidocaine patch, capsaicin), regional anesthesia, non-pharmacologic (ice, heat, TENS, massage, acupuncture, cognitive behavioral therapy, relaxation, guided imagery), avoid Beers Criteria medications (potentially inappropriate medications in older adults (PIMs): anticholinergics (diphenhydramine, hydroxyzine, oxybutynin, tolterodine, amitriptyline, paroxetine (avoid due to falls, confusion, cognitive decline, constipation, urinary retention, dry mouth, blurred vision), benzodiazepines (avoid due to falls, fractures, cognitive impairment, delirium, dependence, withdrawal seizures, increased all-cause mortality, use alternative (SSRI for anxiety, zolpidem/zaleplon/esxopiclone for insomnia (but also use caution, increased falls, cognitive impairment), avoid chronic use 90 days), non-benzodiazepine hypnotics (zolpidem, zaleplon, eszopiclone—avoid chronic use, adverse events (falls, fractures, cognitive impairment, delirium, daytime sedation, motor vehicle crashes), limit to 90 days, low dose (zolpidem 5 mg for women, 5 mg for men (FDA lowered to 5 mg for both due to next-day impairment)), NSAIDs (avoid chronic use (increase GI bleeding, acute kidney injury, hypertension, heart failure exacerbation, especially with high-risk patients (age 75, oral anticoagulants, antiplatelets, corticosteroids, history of PUD or GI bleeding, chronic kidney disease, heart failure, cirrhosis), use lowest dose shortest duration, consider GI prophylaxis (PPI, misoprostol) if necessary), oral sulfonylureas (glyburide, glimepiride, glipizide—long-acting, increased risk severe hypoglycemia (especially glyburide, avoid), use short-acting (glipizide, glimepiride low dose), or safer alternatives (metformin, DPP4 inhibitors (sitagliptin, linagliptin), SGLT2 inhibitors (dapagliflozin, empagliflozin—but increased risk UTI, genital fungal infections, euglycemic DKA, volume depletion), GLP1 agonists (liraglutide, semaglutide—GI side effects, weight loss, pancreatitis, gallbladder disease, medullary thyroid cancer (black box warning), diabetic retinopathy (semaglutide)), insulin (safer, but risk hypoglycemia, dosing complexity)), muscle relaxants (cyclobenzaprine, carisoprodol, methocarbamol, metaxalone, tizanidine, baclofen, orphenadrine—avoid due to anticholinergic effects, sedation, falls, fractures, limited efficacy, use non-pharmacologic (physical therapy, heat, ice, massage, acupuncture, stretching) or consider gabapentin/pregabalin (dose adjust renal function) for neuropathic pain, topical agents (lidocaine, capsaicin) for localized musculoskeletal pain), antipsychotics (first-generation (haloperidol, fluphenazine, perphenazine, chlorpromazine, thioridazine) and second-generation (olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, lurasidone, asenapine, paliperidone, iloperidone, clozapine (avoid in dementia-related psychosis (black box warning for increased mortality from cardiovascular events and infections, especially pneumonia, increased risk stroke, falls, cognitive decline), use non-pharmacologic first (behavioral interventions, environmental modifications, treat underlying delirium/depression/pain/sleep disturbance, caregiver support), if antipsychotic needed, use lowest effective dose, shortest duration, monitor for adverse effects (metabolic (weight gain, diabetes, dyslipidemia), EPS/tardive dyskinesia, orthostatic hypotension, sedation, cognitive impairment, QT prolongation, anticholinergic effects, prolactin elevation), regular monitoring (weight, BMI, waist circumference, fasting glucose/HbA1c, lipid panel, BP, HR, ECG if QT prolonging drug, AIMS for tardive dyskinesia), avoid antipsychotics for insomnia, mild agitation, behavioral and psychological symptoms of dementia (BPSD) without safety risk to patient or others, use alternative (SSRI for depression/anxiety, trazodone for insomnia (low dose 25-50 mg), melatonin, valproate or carbamazepine for agitation in dementia (limited evidence, monitor adverse effects)), H2-receptor antagonists (cimetidine, famotidine, nizatidine—cimetidine (many drug interactions (CYP450 inhibitor), avoid, famotidine safer but risk delirium, acute kidney injury, avoid chronic use), PPIs (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, dexlansoprazole—avoid long-term use without indication (8 weeks for GERD, indefinite for Barrett's esophagus, high-risk NSAID users, pathological hypersecretory conditions), risks (C. difficile infection (increased risk, especially with concurrent antibiotics, hospitalization, age 65, PPIs higher risk than H2RA), community-acquired pneumonia, osteoporosis-related fractures (hip, wrist, spine, especially with long-term high-dose use), vitamin B12 deficiency (malabsorption), hypomagnesemia (severe, arrhythmias, seizures, tetany, monitor Mg++ with prolonged use), acute interstitial nephritis (rare but serious, can progress to chronic kidney disease, discontinue, corticosteroids if severe), dementia (controversial, association not proven), use lowest effective dose, shortest duration, step down to H2RA or antacids when possible, deprescribe if no longer indicated)), adverse drug reactions (ADRs) in elderly (increased risk (polypharmacy (average 5+ medications), drug-drug interactions, drug-disease interactions, altered pharmacokinetics/pharmacodynamics, prescribing cascade (e.g., metoclopramide for GERD → EPS → benztropine for EPS → anticholinergic side effects (constipation, urinary retention, confusion) → laxatives, urinary catheterization, antipsychotics → adverse events, falls, delirium, hospitalization, death), potentially inappropriate medications (PIMs) (Beers Criteria, STOPP criteria (Screening Tool of Older Persons' Prescriptions), START criteria (Screening Tool to Alert to Right Treatment)), deprescribing (systematic process of discontinuing medications when harms outweigh benefits, consider (no current indication, limited life expectancy, adverse effects, drug interactions, falls risk, cognitive impairment, polypharmacy, patient preference), prioritize (medications without clear indication, high-risk medications (anticholinergics, benzodiazepines, sulfonylureas, NSAIDs, antihypertensives (hypotension, falls), statins (primary prevention in limited life expectancy), PPIs (long-term without indication), bisphosphonates (after 5 years, consider drug holiday), vitamin D/calcium (if no osteoporosis, adequate dietary intake, no deficiency), monitor after deprescribing (symptoms of withdrawal, disease recurrence, adverse effects, patient satisfaction)); Pharmacotherapy for Common Chronic Conditions (hypertension (JNC 8, ACC/AHA 2017 guidelines, goal BP 130/80 for most adults (diabetes, CKD, ASCVD, age 65, high CV risk), 140/90 for low-risk, first-line agents (thiazide diuretics (chlorthalidone, HCTZ), ACE inhibitors, ARBs, CCBs (dihydropyridine (amlodipine), non-dihydropyridine (verapamil, diltiazem) (avoid in HFrEF)), beta-blockers (not first-line unless compelling indication (heart failure post-MI, angina, atrial fibrillation, migraine prophylaxis)), combination therapy (initial monotherapy for stage 1 hypertension (BP 160/100) in low-risk patients, initial dual therapy for stage 2 hypertension (BP ≥160/100) or high-risk (ASCVD, CKD, diabetes), single-pill combinations (improve adherence), spironolactone (add-on for resistant hypertension (on 3+ agents including diuretic, doses optimized)), loop diuretics (furosemide, bumetanide, torsemide) if GFR 30 or heart failure with volume overload, monitoring (BP at every visit, home BP monitoring (HBPM) (validate device, measure morning and evening for 7 days, average, white-coat hypertension, masked hypertension), electrolytes (especially with diuretics, ACEi/ARB (hyperkalemia), spironolactone (hyperkalemia, gynecomastia)), renal function (Cr, eGFR, with ACEi/ARB/diuretics, may increase Cr up to 30% from baseline, stable, no need to discontinue unless progressive or hyperkalemia, or acute kidney injury), medication adherence (once-daily dosing preferred, pill burden reduction, side effect management (ACEi cough (switch to ARB), CCB edema (add ACEi/ARB, switch to non-dihydropyridine if no HFrEF, reduce dose), thiazide-induced hyponatremia (monitor, especially elderly, women, low body weight, avoid thiazides, switch to CCB/ACEi/ARB), spironolactone gynecomastia (switch to eplerenone (less gynecomastia, but less potent antihypertensive, contraindicated if CrCl 30, hyperkalemia)), lifestyle modifications (DASH diet (low sodium ( mg/day), high potassium (fruits, vegetables, low-fat dairy), weight loss (BMI 25, waist circumference 40 inches male, 35 inches female), physical activity (150 minutes moderate aerobic per week, or 75 minutes vigorous), moderate alcohol (≤2 drinks/day men, ≤1 drink/day women), smoking cessation, stress reduction), resistant hypertension (BP uncontrolled on ≥3 antihypertensives including diuretic, exclude (non-adherence, white-coat effect, lifestyle factors, secondary causes (primary hyperaldosteronism (aldosterone-to-renin ratio (ARR) screening), renal artery stenosis (doppler ultrasound, CTA, MRA), pheochromocytoma (plasma metanephrines), Cushing's syndrome, thyroid disease, hyperparathyroidism, aortic coarctation, obstructive sleep apnea, medication-induced (NSAIDs, decongestants, stimulants, corticosteroids, oral contraceptives, NSAIDs, cyclosporine, tacrolimus, erythropoietin, licorice, MAOIs with tyramine, sympathomimetics, herbal supplements (ephedra, ma huang, yohimbine, bitter orange, ginseng, licorice))), add spironolactone (first-line for resistant hypertension), refer to hypertension specialist)); Heart Failure with Reduced Ejection Fraction (HFrEF) (EF ≤40%, guideline-directed medical therapy (GDMT): beta-blockers (carvedilol, metoprolol succinate, bisoprolol—start at low dose, titrate to target or maximally tolerated, monitor HR, BP, weight, signs of decompensation, do not stop abruptly), ACE inhibitors (lisinopril, enalapril, captopril, ramipril, trandolapril—start low dose, titrate, monitor Cr, K+, BP) or ARBs (valsartan, candesartan, losartan) if ACEi intolerant, ARNI (sacubitril/valsartan (Entresto)) (replaces ACEi/ARB in patients with HFrEF NYHA class II-III, prior tolerance to ACEi/ARB (stable dose equivalent to enalapril 10 mg daily), monitor for hypotension, angioedema (rare), hyperkalemia, renal impairment, do not give within 36 hours of last ACEi (risk of angioedema), Black Box Warning (fetal toxicity), also contraindicated with ARB (additive risk), aldosterone antagonists (spironolactone, eplerenone) (NYHA class II-IV, EF ≤35%, CrCl 30, K+ 5.0, monitor K+, Cr, avoid NSAIDs, trimethoprim, potassium supplements, potassium-sparing diuretics, risk of hyperkalemia, gynecomastia (spironolactone)), SGLT2 inhibitors (dapagliflozin, empagliflozin) (first-line regardless of diabetes, reduce HF hospitalizations, CV death, monitor for volume depletion, hypotension, euglycemic DKA (especially with fasting, illness, reduced food intake, insulin dose reduction, hold for surgery), UTI, genital fungal infections (candidal balanitis, vulvovaginitis), Fournier's gangrene (rare), weight loss, diuresis (mild)), diuretics (loop (furosemide, bumetanide, torsemide) for volume overload, adjust dose to achieve euvolemia (daily weights, I/O, JVD, edema, orthopnea, dyspnea, rales), avoid thiazides except metolazone (sequential nephron blockade for refractory edema, monitor K+, Mg++, renal function, ototoxicity (with high doses, rapid infusion), torsemide (better bioavailability, more predictable absorption, lower risk ototoxicity, preferred in HF?)), ivabradine (If inhibitor, reduces HR, for stable HFrEF (EF ≤35%, sinus rhythm, HR ≥70 on maximally tolerated beta-blocker, NYHA class II-III), reduces HF hospitalizations, CV death, monitor HR (target 50-60), avoid with AF (risk of bradycardia, heart block), contraindicated with strong CYP3A4 inhibitors (ketoconazole, erythromycin, clarithromycin, itraconazole, ritonavir, nefazodone), drug interactions (CYP3A4 substrates, monitor), side effects (bradycardia, atrial fibrillation (increased risk), phosphenes (brightness in visual field, reversible), hypertension (uncommon)), digoxin (for HFrEF with persistent symptoms despite GDMT, AF with rapid ventricular rate, monitor levels (therapeutic 0.5-0.8 ng/mL for HF, 0.8-2.0 for arrhythmias), toxicity (nausea, vomiting, visual changes (yellow-green halos, blurry vision), bradycardia, arrhythmias (VT, V-fib, heart block, atrial tachycardia with block, bidirectional VT)), hypokalemia, hypomagnesemia, hypercalcemia, hypothyroidism potentiate toxicity, digoxin immune fab (Digibind, DigiFab) for severe toxicity (life-threatening arrhythmias, asystole, bradycardia with hemodynamic compromise, serum potassium 5.0 with toxicity, massive ingestion), hydralazine/isosorbide dinitrate (BiDil) (for HFrEF in self-identified African American patients (NYHA class III-IV, on optimal GDMT with beta-blocker, ACEi/ARB, aldosterone antagonist, diuretic), also for patients with ACEi/ARB intolerance (angioedema, cough, hyperkalemia, renal failure), side effects (headache, dizziness, hypotension, reflex tachycardia (add beta-blocker or rate control), lupus-like syndrome (hydralazine—fever, arthralgias, myalgias, rash, serositis, positive ANA, rarely renal or CNS, treat with NSAIDs, steroids, discontinue hydralazine if severe, reversible)), monitoring (echocardiogram (EF every 1-3 years), BNP/NT-proBNP (trend, response to therapy, prognosis), electrolytes (K+, Mg++), renal function (Cr, eGFR), LFTs (spironolactone, eplerenone, hydralazine), INR (if warfarin for AF), digoxin level (if prescribed), weight (daily, report gain 2-3 lbs in 24 hours or 5 lbs in week), signs of decompensation (increased dyspnea, orthopnea, PND, edema, weight gain, fatigue, exercise intolerance, cough, abdominal bloating, nausea, anorexia), patient education (medication adherence, low sodium diet (2g/day), fluid restriction (1.5-2 L/day if hyponatremia or severe symptoms), daily weight, activity (gradual increase, cardiac rehabilitation), vaccination (influenza, pneumococcal, COVID-19), avoidance (NSAIDs, most antiarrhythmics (except amiodarone, dofetilide), thiazolidinediones (pioglitazone, rosiglitazone) (fluid retention, HF exacerbation), nondihydropyridine CCBs (verapamil, diltiazem) (negative inotropy, HF exacerbation), avoid in HFrEF), prognosis (5-year mortality 50%, worse with advanced age, lower EF, NYHA class III-IV, comorbidities (diabetes, CKD, COPD, anemia, depression), high BNP, hyponatremia, hypotension, poor functional capacity)); Anticoagulation for Atrial Fibrillation (risk stratification (CHA2DS2-VASc score: Congestive heart failure/LV dysfunction (1 point), Hypertension (1), Age ≥75 (2), Diabetes mellitus (1), Stroke/TIA/thromboembolism (2), Vascular disease (prior MI, PAD, aortic plaque) (1), Age 65-74 (1), Sex category female (1)), DOACs first-line (apixaban (Eliquis) (5 mg twice daily (2.5 mg twice daily if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5 mg/dL)), rivaroxaban (Xarelto) (20 mg daily (15 mg daily if CrCl 15-50)), edoxaban (Savaysa) (60 mg daily (30 mg daily if CrCl 15-50, CrCl 95 not recommended—increased ischemic stroke risk compared to warfarin)), dabigatran (Pradaxa) (150 mg twice daily (110 mg twice daily for age ≥80, high bleeding risk, moderate renal impairment CrCl 30-50, concurrent verapamil, amiodarone), all DOACs reduce intracranial hemorrhage risk compared to warfarin, apixaban lowest major bleeding risk, rivaroxaban highest GI bleeding risk, dabigatran dyspepsia, DOACs contraindicated in mechanical heart valves, moderate-severe mitral stenosis, pregnancy, CrCl 15 (dabigatran CrCl 30, rivaroxaban 15, apixaban 25 not studied, use warfarin), CrCl 15-30 (dose adjust, monitor renal function, avoid if unstable), switching between DOACs (stop current, start next at next scheduled dose time), converting from warfarin to DOAC (stop warfarin, start DOAC when INR 2.0 (for apixaban, rivaroxaban, edoxaban) or 2.5 (for dabigatran? check specific drug labeling), converting from DOAC to warfarin (start warfarin, continue DOAC until INR 2.0 on two consecutive measurements (typically 2-3 days for DOACs with longer half-life (dabigatran, apixaban), longer for rivaroxaban (stop DOAC, start warfarin and LMWH bridge until INR therapeutic, as rivaroxaban prolongs INR, unreliable), monitor INR frequently during transition), DOAC reversal agents (idarucizumab (Praxbind) for dabigatran (reverses within minutes, lasts 24 hours, expensive, reserve for life-threatening bleeding or urgent surgery), andexanet alfa (Andexxa) for apixaban, rivaroxaban, edoxaban (reverses within minutes, but incomplete reversal for edoxaban? FDA-approved for apixaban, rivaroxaban, also for edoxaban off-label, expensive, thromboembolic risk 10%, use only for life-threatening/uncontrolled bleeding), PCC (prothrombin complex concentrate (4-factor) (Kcentra) for DOAC-associated bleeding (non-life-threatening, not for reversal of anticoagulation effect for surgery, but may be used for life-threatening if andexanet not available, 50 units/kg, reduces DOAC level but not completely, risk of thromboembolism (1-2%)), no specific reversal agents for edoxaban (andexanet off-label), no reversal for betrixaban, warfarin reversal (vitamin K 5-10 mg IV (slow, risk anaphylaxis) or PO (slow onset 6-24 hours), FFP (fresh frozen plasma) 10-15 mL/kg (rapid, but volume overload, transfusion reaction, infection, no longer first-line), PCC (4-factor) 25-50 units/kg (preferred for life-threatening bleeding or urgent surgery, faster than FFP, lower volume, lower risk of transfusion reaction, more predictable INR correction, monitor INR 30 minutes after infusion, repeat if needed), INR 4.5 without bleeding (hold warfarin, oral vitamin K 1-2.5 mg, monitor INR daily, resume warfarin when INR therapeutic), INR 10 without bleeding (hold warfarin, oral vitamin K 2.5-5 mg, monitor INR daily, consider IV vitamin K if high bleeding risk), major bleeding (hold warfarin, IV vitamin K 5-10 mg, PCC (preferred) or FFP if PCC not available, monitor INR, repeat PCC if needed, consider recombinant factor VIIa (off-label, thrombotic risk high, last resort)), warfarin bridging for perioperative management (for high-risk patients (mechanical heart valve (especially mitral), CHA2DS2-VASc ≥5, recent stroke/TIA (3 months), VTE 3 months), stop warfarin 5 days before surgery, start therapeutic LMWH (enoxaparin 1 mg/kg twice daily or once daily per renal function) when INR 2.0, give last dose LMWH 24 hours before surgery (12 hours for prophylactic dose), resume therapeutic LMWH 24-48 hours after surgery (depending on bleeding risk), restart warfarin same evening or next day, continue LMWH until INR 2.0 on two consecutive measurements, low-risk patients (no bridging needed, restart warfarin post-op when hemostasis adequate, no LMWH), DOAC perioperative management (based on half-life and bleeding risk of procedure, last dose timing (apixaban, rivaroxaban, edoxaban (half-life 12 hours), dabigatran (half-life 12-17 hours, longer if renal impairment), for high bleeding risk surgery (neuraxial, cardiac, intracranial, major orthopedic, urologic (TURP, nephrectomy), GI (polypectomy, EMR, ESD), major dental (extractions 3, implants), last dose 2 days before (apixaban, rivaroxaban, edoxaban), 3-4 days before (dabigatran, if CrCl 30-50, consider 4 days, if CrCl 15-30, 5 days, no DOAC if CrCl 15), for low bleeding risk surgery (cataract, minor dental (1-3 extractions, root canal, crown, filling, cleaning), dermatologic (biopsy, simple excision), endoscopy without polypectomy), last dose 24 hours before, no bridging needed (DOACs short half-life), restart DOAC 24-48 hours after surgery (when hemostasis adequate), if restarting same day, use reduced dose for dabigatran? follow specific drug labeling), left atrial appendage occlusion (Watchman device) for non-valvular AF with contraindication to long-term anticoagulation (prior intracranial hemorrhage, high bleeding risk, fall risk, poor adherence, patient preference), post-procedure antithrombotic regimen (warfarin + aspirin for 45 days then DAPT (aspirin + clopidogrel) for 6 months then aspirin alone, or DOAC + aspirin? evolving, monitor for device-related thrombus (DRT), peridevice leak, pericardial effusion, stroke prevention (non-inferior to warfarin in PROTECT-AF, PREVAIL trials)); Diabetes Mellitus Pharmacotherapy (type 2 diabetes (metformin first-line (unless contraindicated (eGFR 30, metabolic acidosis, severe liver disease, heart failure with hypoperfusion, sepsis, alcoholism, acute MI, hypoxemia, radiocontrast media (hold 48 hours before and after, restart when renal function stable), GI intolerance (titrate slowly, extended-release, take with food, switch to other agent if intolerable), vitamin B12 deficiency (monitor, supplement if deficient, especially with long-term use, peripheral neuropathy risk), lactic acidosis (rare (1 in 30,000 patient-years), but fatal if occurs, risk factors (renal impairment, liver disease, heart failure, sepsis, dehydration, alcoholism, age 80, use of iodinated contrast, hypoxia, hold metformin in acute illness, dehydration, before surgery), not for eGFR 30, use with caution if eGFR 30-45 (reduce dose to 500 mg twice daily, monitor renal function q3-6 months)), after metformin, add-on therapy based on comorbidities (ASCVD, heart failure, CKD, obesity, hypoglycemia risk, cost, patient preference), GLP-1 receptor agonists (liraglutide (Victoza, Saxenda (weight loss)), semaglutide (Ozempic (weekly), Rybelsus (daily oral), Wegovy (weight loss, higher dose)), dulaglutide (Trulicity weekly), exenatide (Byetta (twice daily), Bydureon (weekly)), lixisenatide (Adlyxin daily), oral semaglutide (Rybelsus, take on empty stomach with 4 oz water, wait 30 minutes before eating/drinking/other oral meds), cardiovascular benefit (reduce MACE (major adverse cardiovascular events), non-fatal MI, non-fatal stroke, cardiovascular death) (liraglutide (LEADER trial), semaglutide (SUSTAIN-6),