NR575 AGACNP Gastroenterology Certification Review 2025 with
RATIONALES || Advanced Practice GI Topics, Evidence-Based
Treatment, Clinical Practice Prep | Chamberlain University Study
Guide for Nurse Practitioner Board Exam TESTBANK
1. A 50-year-old Asian American patient presents to the hospital with a 1-month history of burning
epigastric pain with difficulties in swallowing. The pain is not relieved by eating, and he tried famotidine
20 mg/day tablets when symptoms occur, but there is a minimal relief. The patient's medication is
lisinopril 5 mg/day for hypertension. Which is the best action for this patient?
1. Initiate calcium carbonate 500-mg tablet.
2. Refer for endoscopic evaluation.
3. Change Lisinopril to amlodipine.
4. Initiate omeprazole 20 mg twice daily.
2. Refer for endoscopic evaluation.
Rationale: This patient complained of signs of dysphagia, an alarming symptom associated with more
complicated gastroesophageal reflux disease (GERD). The patient has tried a histamine 2 receptor antagonist
with minimal relief. The patient is older than 45 years old, which increases his risk of developing gastric ulcers,
so he should be referred for endoscopic evaluation. This will be not effective; therefore answer 1 is incorrect.
Amlodipine (answer 3) reduce lower esophageal sphincter tone; therefore it is an appropriate recommendation
for reducing GERD symptoms. This should be considered after invasive testing is performed. However, using
proton-pump inhibitors (answer 4) will be appropriate after the evaluation. A twice daily dose is not as essential
as initial dosing.
2. A 59-year-old woman (height 65 inches, weight 77 kg) with a history of heart failure and myocardial
infarction is admitted to the intensive care unit with severe community-acquired pneumonia. Five hours
after admission she develops acute respiratory failure, hypotension, and acute kidney injury from sepsis.
Mechanical ventilation is implanted, and a nasogastric (NG) tube is placed. She currently takes ramipril
10 mg/day, carvedilol 12.5 mg/twice daily, levothyroxine 125 mcg/day, and aspirin 75 mg. Her white blood
cell count is 25 × 103 cells/mm3, platelet count is 170,000/mm3, serum creatinine is 3.7 mg/dL (baseline
1.27 mg/dL), potassium is 4.5 mEq/L, international normalized ratio is 1.1, aspartate aminotransferase is
30 international units/mL, and alanine aminotransferase is 45 international units/mL. Which approach is
the most appropriate for preventing stress-related mucosal disease in this patient?
1. Pantop
1. Pantoprazole 40 mg intravenous (IV) once daily.
Rationale: The patient complained of stress-related mucosal disease (SRMD), which has developed in critically
ill patients and could lead to upper gastrointestinal bleeding. Therapy initiation to prevent SRMD is based on
the presence of risk factors. The patient's risk factors are mechanical ventilation and coagulopathy; therefore
she would meet the criteria for initiation of pharmacological therapy. Pantoprazole (answer 1) would be the
best choice because it does not require renal adjustment. Cimetidine (answer 2) is suitable for SRMD
prevention because it carries the U.S. Food and Drug Administration–approved indication, but the dosing
provided is incorrect. The approved dose of cimetidine is 50 mg/hr. Cimetidine would be dose adjusted for the
,patient's creatinine clearance. Sucralfate (answer 3) is not the best choice because of the need for multiple
dosing daily and the risk of aluminum accumulation for patients suffering from kidney disease. Magnesium
hydroxide (answer 4) is not as effective as histamine 2 receptor antagonists and proton-pump inhibitors. Also, it
can lead to electrolyte accumulation in a patient with a kidney injury.
3. A 45-year-old woman complains of severe pain related to the swelling of three metacarpophalangeal
joints on her right hand. She has suffered for 2 weeks and cannot perform her usual household activities.
Radiograms reveal bone decalcifications and erosions. A serum rheumatoid factor is obtained that is
elevated. Her medical history includes hypertension and dyslipidemia. Her medication is ramipril 10
mg/day, aspirin 81 mg/day, and atorvastatin 40 mg/day. The physician would like to initiate systemic
antiinflammatory drugs for her rheumatoid arthritis with high-dose nonsteroidal antiinflammatory
therapy; however, the physician is worried about potential gastrointestinal toxicity. What is the best
recommended regimen for treating the patient's pain?
1. Indomethacin 75 mg/day.
2. Piroxicam 20 mg/day plus misoprostol 600 mcg three times daily.
3. Naproxen 500 mg twice daily plus omeprazole 20 mg/day.
4. Celecoxib 400
3. Naproxen 500 mg twice daily plus omeprazole 20 mg/day.
Rationale: Patients on long-term nonsteroidal antiinflammatory drug therapy may development of
gastrointestinal (GI) toxicity; therefore assessment of patients and drug-related factors are necessary. This
patient is considered to be at high risk of a cardiovascular event because she uses a low-dose aspirin. A GI
agent should be included at the lowest effective therapeutic dose to avoid GI toxicity. Because of this,
indomethacin (answer 1), piroxicam (answer 2) and celecoxib (answer 4) are not recommended. Indomethacin
and piroxicam actually may increase the GI complication. Misoprostol is effective, but it is associated with a
high incidence of diarrhea and abdominal pain.
4. The patient is a 79-year-old man with a history of type 2 diabetes, anemia, and chronic low back pain
admitted to the hospital for abdominal pain lasting 3 days. His last bowel movement was 4 days ago. The
physician examined him and found moderate left upper quadrant tenderness. An abdominal radiograph
reveals a large amount of stool in the colon with no signs of obstruction. His current medications are
glipizide 5 mg twice daily, iron supplement, acetaminophen 500 mg four times daily, and
oxycodone/acetaminophen 5/375 mg as needed for pain. His serum creatinine is 1.8 mg/dL. Which
therapy would be the best management for the patient's constipation?
1. Bisacodyl suppositories.
2. Methylnaltrexone injection.
3. Psyllium or inulin.
4. Linaclotide.
1. Bisacodyl suppositories.
Rationale: This patient presents with acute constipation, and the contributing factors include the use of iron
supplement and oxycodone without using a drug regimen for constipation prevention. Therapy should be
instituted to provide a quick onset to initiate bowel movement and provide symptomatic relief. Bisacodyl
suppositories (answer 1) can provide a rapid stimulation of the lower intestine tract without the risk of
electrolyte absorption. The patient's creatinine clearance is low, so it will be the best choice for this case.
Methylnaltrexone (answer 2) is indicated for opioid-induced constipation, and it would generally not be used as
,a first-line agent. The added cost for methylnaltrexone injection is higher than the traditional laxatives;
therefore it is not the best drug regimen. Psyllium or inulin (answer 3) is a bulk-forming laxative that would not
treat acute constipation. Linaclotide (answer 4) is approved by the U.S. Food and Drug Administration for
inflammatory bowel syndrome treatment; therefore this answer is not suitable for this patient.
5. A 63-year-old African American woman is assessed in the emergency department for a 48-hour history
of black stool, dizziness, confusion, and vomiting a substance resembling coffee grounds. Her medical
history is myocardial infarction, hypertension, and seasonal allergies. She has taken naproxen 500 mg
twice daily for 3 years, lisinopril 20 mg/day, aspirin 325 mg/day, and loratadine 10 mg/day. Nasogastric
aspiration (NG) is positive for blood, and endoscopic evaluation reveals a 2.5-cm antral ulcer. A rapid
urease test is negative for Helicobacter pylori. What recommendation is best for this patient?
1. Pantoprazole 80 mg intravenous (IV) bolus followed by an 8-mg/hr infusion.
2. IV famotidine 20 mg/hr for 5 days.
3. Oral lansoprazole 15 mg/day by NG tube.
4. Magnesium hydroxide 30 mL daily by NG tube.
1. Pantoprazole 80 mg intravenous (IV) bolus followed by an 8-mg/hr infusion.
Rationale: The patient presents with signs and symptoms of nonsteroidal antiinflammatory drug (NSAID)-
induced upper gastrointestinal (GI) bleeding. She has several factors for NSAID-induced upper GI bleeding
including age older than 60 years old, use of high-dose aspirin, and long duration of naproxen use. According
to the recommendations of nonvariceal bleeding, the patient should receive intravenous proton-pump inhibitors
(PPIs) by bolus, then subsequent continuous infusion for 72 hours; therefore answer 1 is the best
recommendation for this patient. A histamine 2 receptor antagonist (answer 2) is less efficacious for the
treatment and prevention of rebleeding for NSAID-induced ulcers. Oral PPIs (answer 3) are effective in
preventing and healing NSAID-induced ulcer; however, the dose of lansoprazole is inadequate for the treatment
of this patient. Oral PPIs should be used at an appropriate dose after finishing intravenous therapy for at least
8 weeks. Antacids (answer 4) are not effective for treatment of NSAID-induced ulcer.
6. The patient is a 43-year-old man with a history of bipolar disorder for 3 years, chronic angina, and
recurrent urinary tract infection, and he is admitted to the emergency department with severe nausea,
vomiting, fever, and back pain. On exam, he has a dry mucous membrane and right-sided costovertebral
tenderness. A urinalysis is obtained and is positive for leukocyte esterase. His serum creatinine is 1.2
mg/dL and blood urea nitrogen is 30 mg/dL. His current medications are risperidone 6 mg twice daily
and sertraline 100 mg/day. He reports that he has an allergy to sulfamethazine/trimethoprim. Which
drug would be the best treatment for the patient's vomiting?
1. Diphenhydramine 50 mg intravenously (IV) three times daily.
2. Ondansetron 4 mg IV three times daily.
3. Haloperidol 5 mg IV once daily.
4. Prochlorperazine10 mg tablet orally twice daily.
2. Ondansetron 4 mg IV three times daily.
Rationale: This patient complains of pyelonephritis symptoms associated with nausea and vomiting. The nurse
practitioner will prescribe the appropriate antibiotic therapy to treat the infection. However, the patient will
need symptomatic relief until the antibiotics take effect. Diphenhydramine (answer 1) is effective for nausea
associated with motion sickness, but it has no effect on severe vomiting cases. Ondansetron (answer 2) is a
serotonin antagonist that is effective in the treatment of vomiting and nausea caused by a variety of medical
, conditions. Despite its effect on serotonin, it does not cause any drug interaction with the patient's sertraline
dose. Haloperidol (answer 3) is not appropriate for this patient because of his cardiovascular history.
Haloperidol can increase the risk of QTc prolongation and extrapyramidal adverse effect. Prochlorperazine
(answer 4) is commonly used to treat vomiting symptoms, but the oral doses are not appropriate for a patient
who suffers from severe vomiting. Moreover, prochlorperazine is a dopamine antagonist, and the patient is
receiving a high dose of risperidone. Therefore the combination can lead to the development of extrapyramidal
symptoms and QTc prolongation.
7. The patient is a 35-year-old Hispanic woman admitted to the hospital who complains of new-onset
abdominal pain for 9 weeks together with two to three bloody stools per day and weight loss. She reports
an allergy to "sulfa-containing medication." Colonoscopy reveals diffuse superficial colonic inflammation
consistent with ulcerative colitis. The inflammation is continuous and extends to the hepatic flexure.
Which is the best drug regimen for this patient?
1. Infliximab 5 mg/kg as a single dose.
2. Hydrocortisone enema 100 mg every day.
3. Mesalamine 1.6 g orally three times daily.
4. Sulfasalazine extended-release tablet 1 g orally three times daily.
3. Mesalamine 1.6 g orally three times daily.
Rationale: The patient's symptoms can be classified in the mild to moderate active disease category.
Mesalamine (answer 3) is the first-line therapy for an active extensive disease at a dose equivalent of 4.8 g/day.
Infliximab (answer 1) is not appropriate for this patient; using biological agents is required for moderate to
severe active diseases. Moreover, infliximab has a long-term action, which that is why it can be used in a
maintenance drug regimen. Hydrocortisone enema (answer 2) would be appropriate for patients with disease
distal to the splenic flexure. Sulfasalazine tablets (answer 4) would be appropriate for this case, but the patient
has reported an allergy to “sulfa-containing medication”; therefore sulfasalazine is incorrect.
8. A 25-year-old white woman with a history of Crohn disease comes in the clinic with a chief concern of
mucopurulent drainage from an erythematous region on her abdomen. On exam, colonoscopy reveals a
moderate-sized enterocutaneous fistula in the right upper abdomen area. Her medications are
mesalamine 1.6 mg orally three times daily and azathioprine tablet 75 mg twice daily. Her physician
wants to prescribe infliximab. What is the best recommendation before the initiation of therapy?
1. Rule out tuberculosis by purified protein derivative or QuantiFERON-TB test.
2. Obtain an echocardiogram to assess cardiac function.
3. Administer a test dose before the initial infusion.
4. Obtain liver function tests before the initial infusion.
1. Rule out tuberculosis by purified protein derivative or QuantiFERON-TB test.
Rationale: Infliximab is an appropriate agent for treatment of fistulizing Crohn disease. Tumor necrosis factor
agents can reactivate latent infections such as tuberculosis. Therefore patients should perform the purified
protein derivative or QuantiFERON-TB test to rule out underlying tuberculosis infection before drug initiation.
However, infliximab is associated with exacerbation of underlying heart failure and is contraindicated in
patients with New York Heart Association class III or IV disease. A baseline echocardiogram is not necessary to
assess the cardiac function for a healthy patient who does not complain of any clinical signs of the heart failure.
Therefore, answer 2 is incorrect. Although infliximab therapy is associated with infusion-related reaction,
RATIONALES || Advanced Practice GI Topics, Evidence-Based
Treatment, Clinical Practice Prep | Chamberlain University Study
Guide for Nurse Practitioner Board Exam TESTBANK
1. A 50-year-old Asian American patient presents to the hospital with a 1-month history of burning
epigastric pain with difficulties in swallowing. The pain is not relieved by eating, and he tried famotidine
20 mg/day tablets when symptoms occur, but there is a minimal relief. The patient's medication is
lisinopril 5 mg/day for hypertension. Which is the best action for this patient?
1. Initiate calcium carbonate 500-mg tablet.
2. Refer for endoscopic evaluation.
3. Change Lisinopril to amlodipine.
4. Initiate omeprazole 20 mg twice daily.
2. Refer for endoscopic evaluation.
Rationale: This patient complained of signs of dysphagia, an alarming symptom associated with more
complicated gastroesophageal reflux disease (GERD). The patient has tried a histamine 2 receptor antagonist
with minimal relief. The patient is older than 45 years old, which increases his risk of developing gastric ulcers,
so he should be referred for endoscopic evaluation. This will be not effective; therefore answer 1 is incorrect.
Amlodipine (answer 3) reduce lower esophageal sphincter tone; therefore it is an appropriate recommendation
for reducing GERD symptoms. This should be considered after invasive testing is performed. However, using
proton-pump inhibitors (answer 4) will be appropriate after the evaluation. A twice daily dose is not as essential
as initial dosing.
2. A 59-year-old woman (height 65 inches, weight 77 kg) with a history of heart failure and myocardial
infarction is admitted to the intensive care unit with severe community-acquired pneumonia. Five hours
after admission she develops acute respiratory failure, hypotension, and acute kidney injury from sepsis.
Mechanical ventilation is implanted, and a nasogastric (NG) tube is placed. She currently takes ramipril
10 mg/day, carvedilol 12.5 mg/twice daily, levothyroxine 125 mcg/day, and aspirin 75 mg. Her white blood
cell count is 25 × 103 cells/mm3, platelet count is 170,000/mm3, serum creatinine is 3.7 mg/dL (baseline
1.27 mg/dL), potassium is 4.5 mEq/L, international normalized ratio is 1.1, aspartate aminotransferase is
30 international units/mL, and alanine aminotransferase is 45 international units/mL. Which approach is
the most appropriate for preventing stress-related mucosal disease in this patient?
1. Pantop
1. Pantoprazole 40 mg intravenous (IV) once daily.
Rationale: The patient complained of stress-related mucosal disease (SRMD), which has developed in critically
ill patients and could lead to upper gastrointestinal bleeding. Therapy initiation to prevent SRMD is based on
the presence of risk factors. The patient's risk factors are mechanical ventilation and coagulopathy; therefore
she would meet the criteria for initiation of pharmacological therapy. Pantoprazole (answer 1) would be the
best choice because it does not require renal adjustment. Cimetidine (answer 2) is suitable for SRMD
prevention because it carries the U.S. Food and Drug Administration–approved indication, but the dosing
provided is incorrect. The approved dose of cimetidine is 50 mg/hr. Cimetidine would be dose adjusted for the
,patient's creatinine clearance. Sucralfate (answer 3) is not the best choice because of the need for multiple
dosing daily and the risk of aluminum accumulation for patients suffering from kidney disease. Magnesium
hydroxide (answer 4) is not as effective as histamine 2 receptor antagonists and proton-pump inhibitors. Also, it
can lead to electrolyte accumulation in a patient with a kidney injury.
3. A 45-year-old woman complains of severe pain related to the swelling of three metacarpophalangeal
joints on her right hand. She has suffered for 2 weeks and cannot perform her usual household activities.
Radiograms reveal bone decalcifications and erosions. A serum rheumatoid factor is obtained that is
elevated. Her medical history includes hypertension and dyslipidemia. Her medication is ramipril 10
mg/day, aspirin 81 mg/day, and atorvastatin 40 mg/day. The physician would like to initiate systemic
antiinflammatory drugs for her rheumatoid arthritis with high-dose nonsteroidal antiinflammatory
therapy; however, the physician is worried about potential gastrointestinal toxicity. What is the best
recommended regimen for treating the patient's pain?
1. Indomethacin 75 mg/day.
2. Piroxicam 20 mg/day plus misoprostol 600 mcg three times daily.
3. Naproxen 500 mg twice daily plus omeprazole 20 mg/day.
4. Celecoxib 400
3. Naproxen 500 mg twice daily plus omeprazole 20 mg/day.
Rationale: Patients on long-term nonsteroidal antiinflammatory drug therapy may development of
gastrointestinal (GI) toxicity; therefore assessment of patients and drug-related factors are necessary. This
patient is considered to be at high risk of a cardiovascular event because she uses a low-dose aspirin. A GI
agent should be included at the lowest effective therapeutic dose to avoid GI toxicity. Because of this,
indomethacin (answer 1), piroxicam (answer 2) and celecoxib (answer 4) are not recommended. Indomethacin
and piroxicam actually may increase the GI complication. Misoprostol is effective, but it is associated with a
high incidence of diarrhea and abdominal pain.
4. The patient is a 79-year-old man with a history of type 2 diabetes, anemia, and chronic low back pain
admitted to the hospital for abdominal pain lasting 3 days. His last bowel movement was 4 days ago. The
physician examined him and found moderate left upper quadrant tenderness. An abdominal radiograph
reveals a large amount of stool in the colon with no signs of obstruction. His current medications are
glipizide 5 mg twice daily, iron supplement, acetaminophen 500 mg four times daily, and
oxycodone/acetaminophen 5/375 mg as needed for pain. His serum creatinine is 1.8 mg/dL. Which
therapy would be the best management for the patient's constipation?
1. Bisacodyl suppositories.
2. Methylnaltrexone injection.
3. Psyllium or inulin.
4. Linaclotide.
1. Bisacodyl suppositories.
Rationale: This patient presents with acute constipation, and the contributing factors include the use of iron
supplement and oxycodone without using a drug regimen for constipation prevention. Therapy should be
instituted to provide a quick onset to initiate bowel movement and provide symptomatic relief. Bisacodyl
suppositories (answer 1) can provide a rapid stimulation of the lower intestine tract without the risk of
electrolyte absorption. The patient's creatinine clearance is low, so it will be the best choice for this case.
Methylnaltrexone (answer 2) is indicated for opioid-induced constipation, and it would generally not be used as
,a first-line agent. The added cost for methylnaltrexone injection is higher than the traditional laxatives;
therefore it is not the best drug regimen. Psyllium or inulin (answer 3) is a bulk-forming laxative that would not
treat acute constipation. Linaclotide (answer 4) is approved by the U.S. Food and Drug Administration for
inflammatory bowel syndrome treatment; therefore this answer is not suitable for this patient.
5. A 63-year-old African American woman is assessed in the emergency department for a 48-hour history
of black stool, dizziness, confusion, and vomiting a substance resembling coffee grounds. Her medical
history is myocardial infarction, hypertension, and seasonal allergies. She has taken naproxen 500 mg
twice daily for 3 years, lisinopril 20 mg/day, aspirin 325 mg/day, and loratadine 10 mg/day. Nasogastric
aspiration (NG) is positive for blood, and endoscopic evaluation reveals a 2.5-cm antral ulcer. A rapid
urease test is negative for Helicobacter pylori. What recommendation is best for this patient?
1. Pantoprazole 80 mg intravenous (IV) bolus followed by an 8-mg/hr infusion.
2. IV famotidine 20 mg/hr for 5 days.
3. Oral lansoprazole 15 mg/day by NG tube.
4. Magnesium hydroxide 30 mL daily by NG tube.
1. Pantoprazole 80 mg intravenous (IV) bolus followed by an 8-mg/hr infusion.
Rationale: The patient presents with signs and symptoms of nonsteroidal antiinflammatory drug (NSAID)-
induced upper gastrointestinal (GI) bleeding. She has several factors for NSAID-induced upper GI bleeding
including age older than 60 years old, use of high-dose aspirin, and long duration of naproxen use. According
to the recommendations of nonvariceal bleeding, the patient should receive intravenous proton-pump inhibitors
(PPIs) by bolus, then subsequent continuous infusion for 72 hours; therefore answer 1 is the best
recommendation for this patient. A histamine 2 receptor antagonist (answer 2) is less efficacious for the
treatment and prevention of rebleeding for NSAID-induced ulcers. Oral PPIs (answer 3) are effective in
preventing and healing NSAID-induced ulcer; however, the dose of lansoprazole is inadequate for the treatment
of this patient. Oral PPIs should be used at an appropriate dose after finishing intravenous therapy for at least
8 weeks. Antacids (answer 4) are not effective for treatment of NSAID-induced ulcer.
6. The patient is a 43-year-old man with a history of bipolar disorder for 3 years, chronic angina, and
recurrent urinary tract infection, and he is admitted to the emergency department with severe nausea,
vomiting, fever, and back pain. On exam, he has a dry mucous membrane and right-sided costovertebral
tenderness. A urinalysis is obtained and is positive for leukocyte esterase. His serum creatinine is 1.2
mg/dL and blood urea nitrogen is 30 mg/dL. His current medications are risperidone 6 mg twice daily
and sertraline 100 mg/day. He reports that he has an allergy to sulfamethazine/trimethoprim. Which
drug would be the best treatment for the patient's vomiting?
1. Diphenhydramine 50 mg intravenously (IV) three times daily.
2. Ondansetron 4 mg IV three times daily.
3. Haloperidol 5 mg IV once daily.
4. Prochlorperazine10 mg tablet orally twice daily.
2. Ondansetron 4 mg IV three times daily.
Rationale: This patient complains of pyelonephritis symptoms associated with nausea and vomiting. The nurse
practitioner will prescribe the appropriate antibiotic therapy to treat the infection. However, the patient will
need symptomatic relief until the antibiotics take effect. Diphenhydramine (answer 1) is effective for nausea
associated with motion sickness, but it has no effect on severe vomiting cases. Ondansetron (answer 2) is a
serotonin antagonist that is effective in the treatment of vomiting and nausea caused by a variety of medical
, conditions. Despite its effect on serotonin, it does not cause any drug interaction with the patient's sertraline
dose. Haloperidol (answer 3) is not appropriate for this patient because of his cardiovascular history.
Haloperidol can increase the risk of QTc prolongation and extrapyramidal adverse effect. Prochlorperazine
(answer 4) is commonly used to treat vomiting symptoms, but the oral doses are not appropriate for a patient
who suffers from severe vomiting. Moreover, prochlorperazine is a dopamine antagonist, and the patient is
receiving a high dose of risperidone. Therefore the combination can lead to the development of extrapyramidal
symptoms and QTc prolongation.
7. The patient is a 35-year-old Hispanic woman admitted to the hospital who complains of new-onset
abdominal pain for 9 weeks together with two to three bloody stools per day and weight loss. She reports
an allergy to "sulfa-containing medication." Colonoscopy reveals diffuse superficial colonic inflammation
consistent with ulcerative colitis. The inflammation is continuous and extends to the hepatic flexure.
Which is the best drug regimen for this patient?
1. Infliximab 5 mg/kg as a single dose.
2. Hydrocortisone enema 100 mg every day.
3. Mesalamine 1.6 g orally three times daily.
4. Sulfasalazine extended-release tablet 1 g orally three times daily.
3. Mesalamine 1.6 g orally three times daily.
Rationale: The patient's symptoms can be classified in the mild to moderate active disease category.
Mesalamine (answer 3) is the first-line therapy for an active extensive disease at a dose equivalent of 4.8 g/day.
Infliximab (answer 1) is not appropriate for this patient; using biological agents is required for moderate to
severe active diseases. Moreover, infliximab has a long-term action, which that is why it can be used in a
maintenance drug regimen. Hydrocortisone enema (answer 2) would be appropriate for patients with disease
distal to the splenic flexure. Sulfasalazine tablets (answer 4) would be appropriate for this case, but the patient
has reported an allergy to “sulfa-containing medication”; therefore sulfasalazine is incorrect.
8. A 25-year-old white woman with a history of Crohn disease comes in the clinic with a chief concern of
mucopurulent drainage from an erythematous region on her abdomen. On exam, colonoscopy reveals a
moderate-sized enterocutaneous fistula in the right upper abdomen area. Her medications are
mesalamine 1.6 mg orally three times daily and azathioprine tablet 75 mg twice daily. Her physician
wants to prescribe infliximab. What is the best recommendation before the initiation of therapy?
1. Rule out tuberculosis by purified protein derivative or QuantiFERON-TB test.
2. Obtain an echocardiogram to assess cardiac function.
3. Administer a test dose before the initial infusion.
4. Obtain liver function tests before the initial infusion.
1. Rule out tuberculosis by purified protein derivative or QuantiFERON-TB test.
Rationale: Infliximab is an appropriate agent for treatment of fistulizing Crohn disease. Tumor necrosis factor
agents can reactivate latent infections such as tuberculosis. Therefore patients should perform the purified
protein derivative or QuantiFERON-TB test to rule out underlying tuberculosis infection before drug initiation.
However, infliximab is associated with exacerbation of underlying heart failure and is contraindicated in
patients with New York Heart Association class III or IV disease. A baseline echocardiogram is not necessary to
assess the cardiac function for a healthy patient who does not complain of any clinical signs of the heart failure.
Therefore, answer 2 is incorrect. Although infliximab therapy is associated with infusion-related reaction,
