PHARMACOTHERAPEUTICS FOR ADVANCED PRACTICE

Chapter 1: Cardiovascular Pharmacology Q1. A 58-year-old man with hypertension and type 2 diabetes presents with a BP of 155/95 mmHg. He has microalbuminuria. Which antihypertensive class is MOST appropriate as first-line therapy? A. Thiazide diuretic B. ACE inhibitor C. Beta-blocker D. Calcium channel blocker E. Alpha-1 antagonist Answer: B. ACE inhibitors (e.g., lisinopril, enalapril) are first-line in diabetics with microalbuminuria due to nephroprotective effects by reducing intraglomerular pressure. Q2. A patient on hydrochlorothiazide develops a serum potassium of 3.1 mEq/L. Which combination is MOST appropriate to add? A. Amlodipine B. Metoprolol C. Spironolactone D. Hydralazine E. Clonidine Answer: C. Spironolactone is a potassium-sparing diuretic (aldosterone antagonist) that corrects hypokalemia caused by thiazide diuretics while providing additional BP control. Q3. A 65-year-old with HFrEF (EF 30%) and sinus rhythm is on lisinopril and furosemide. What additional agent improves mortality? A. Amlodipine B. Digoxin C. Carvedilol D. Hydralazine E. Nifedipine Answer: C. Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) reduce mortality in HFrEF. Carvedilol has additional alpha-blocking vasodilatory properties. Q4. Sacubitril/valsartan (Entresto) works by which mechanism? A. ACE inhibition + beta-blockade B. Neprilysin inhibition + ARB C. Aldosterone antagonism + ACE inhibition D. Direct renin inhibition + ARB E. ACE inhibition + aldosterone antagonism Answer: B. Sacubitril inhibits neprilysin (preventing breakdown of natriuretic peptides), while valsartan blocks AT1 receptors. Together they reduce cardiac remodeling in HFrEF. Q5. A patient with atrial fibrillation and CrCl 45 mL/min is started on dabigatran. What monitoring is MOST important? A. PT/INR weekly B. aPTT monthly C. Renal function every 6 months D. Platelet count monthly E. Anti-Xa levels quarterly Answer: C. Dabigatran is renally cleared (~80%). Renal function must be monitored regularly; deterioration increases bleeding risk and may require dose adjustment or drug change. Q6. Which statin has the greatest reduction in LDL cholesterol at maximum doses? A. Pravastatin 40 mg B. Simvastatin 40 mg C. Atorvastatin 80 mg D. Fluvastatin 80 mg E. Lovastatin 40 mg Answer: C. High-intensity statins (atorvastatin 40–80 mg, rosuvastatin 20–40 mg) reduce LDL by ≥50%. Atorvastatin 80 mg is the most commonly used high-intensity agent. Q7. A 45-year-old develops myopathy 3 weeks after starting simvastatin 80 mg. What is the FIRST action? A. Reduce dose to 40 mg B. Add CoQ10 supplement C. Discontinue simvastatin immediately D. Switch to pravastatin E. Check CK level only Answer: C. Statin-induced myopathy with elevated CK requires immediate discontinuation. Rhabdomyolysis risk with renal failure is life-threatening. Lower-potency statins can be trialed after resolution. Q8. Which antiarrhythmic drug is classified as a Class III agent and prolongs the QT interval? A. Lidocaine B. Metoprolol C. Amiodarone D. Verapamil E. Adenosine Answer: C. Amiodarone is primarily a Class III agent (K+ channel blocker) that prolongs repolarization and QT interval. It also has Class I, II, and IV properties. Q9. A patient with paroxysmal SVT requires IV termination. What is the drug of choice? A. Amiodarone B. Lidocaine C. Adenosine D. Verapamil E. Digoxin Answer: C. Adenosine transiently blocks AV node conduction and terminates re-entrant SVT. It has a half-life of 10 seconds and is first-line for acute SVT termination. Q10. Which drug is contraindicated in patients with hypertrophic obstructive cardiomyopathy (HOCM)? A. Metoprolol B. Verapamil C. Digoxin D. Disopyramide E. Nadolol Answer: C. Digoxin increases contractility and heart rate, worsening the outflow obstruction in HOCM. Beta-blockers and verapamil are preferred to slow HR and reduce obstruction. Q11. A patient taking warfarin has a supratherapeutic INR of 8.0 with minor bleeding. What is the BEST management? A. Hold warfarin and give vitamin K 10 mg IV B. Hold warfarin, give vitamin K 1–2.5 mg oral C. Give FFP immediately D. Give 4-factor PCC immediately E. Continue warfarin and recheck INR in 48h Answer: B. For INR 8 with minor bleeding, hold warfarin and give oral vitamin K 1–2.5 mg. IV vitamin K risks anaphylaxis; FFP/PCC are reserved for life-threatening bleeding. Q12. Ezetimibe lowers LDL by which mechanism? A. Inhibiting HMG-CoA reductase B. Inhibiting PCSK9 C. Blocking intestinal cholesterol absorption D. Increasing HDL via PPAR-alpha E. Activating LDL receptors Answer: C. Ezetimibe inhibits the Niemann-Pick C1-Like 1 (NPC1L1) transporter in the small intestine, reducing dietary and biliary cholesterol absorption by ~50%. Q13. Which loop diuretic has the highest bioavailability when given orally? A. Furosemide B. Bumetanide C. Torsemide D. Ethacrynic acid E. Chlorothiazide Answer: C. Torsemide has ~80% oral bioavailability compared to furosemide's variable 10–100% (avg ~50%). Torsemide is preferred in patients with poor GI absorption. Q14. A patient on lisinopril develops a dry persistent cough. What is the BEST alternative? A. Enalapril B. Benazepril C. Losartan D. Captopril E. Ramipril Answer: C. ACE inhibitor cough is a class effect from bradykinin accumulation. ARBs (losartan, valsartan, irbesartan) block AT1 receptors without affecting bradykinin and are well tolerated. Q15. What is the loading dose of amiodarone for hemodynamically stable VT? A. 150 mg IV over 10 minutes B. 300 mg IV push C. 1 mg/kg IV bolus D. 0.5 mg IV push E. 200 mg oral stat Answer: A. For stable VT, IV amiodarone 150 mg is given over 10 minutes, followed by 1 mg/min infusion for 6 hours, then 0.5 mg/min maintenance. Avoid rapid bolus. Q16. Which beta-blocker is MOST cardioselective and preferred in mild COPD? A. Carvedilol B. Propranolol C. Metoprolol succinate D. Labetalol E. Sotalol Answer: C. Metoprolol succinate has high beta-1 selectivity with minimal beta-2 blockade, making it safer in mild COPD. Carvedilol is non-selective and can worsen bronchoconstriction.   Chapter 2: Pulmonary Pharmacology Q17. A 32-year-old with moderate persistent asthma is on a short-acting beta-agonist (SABA) alone. What should be ADDED as controller therapy? A. Long-acting beta-agonist (LABA) alone B. Theophylline C. Inhaled corticosteroid (ICS) D. Montelukast alone E. Oral prednisone Answer: C. ICS (e.g., fluticasone, budesonide) is the cornerstone controller therapy for persistent asthma at all severity levels due to anti-inflammatory effects on airway mucosa. Q18. Which inhaler technique error is MOST common with a standard MDI (metered dose inhaler)? A. Exhaling too slowly B. Actuating before inhaling C. Not shaking the canister D. Inhaling too rapidly E. Using too large a spacer Answer: C. The most common errors are not shaking the MDI before use and poor coordination. Patients should shake, exhale, then actuate and inhale slowly and deeply.