BCPPS Practice Questions Set
Correctly Answered
Which most likely complicates intramuscular drug delivery in neonates?
a. High total body water content.
b. Increased first-pass metabolism.
c. Dose volume.
d. Decreased binding proteins. - Answer- c. Dose volume.
Which best describes renal drug clearance changes that occur through glomerular
filtration rate (GFR) maturation?
a. Most in utero developmental changes in GFR occur between 36 and 40 weeks'
gestation.
b. Changes subject to induction of GFR by exposure to drugs are proximal tubule OAT
(organic anion transporters) or OCT (organic cation transporter) substrates.
c. Renal drug clearance values in children approach those of adults by 2 weeks of age.
d. Maternal creatinine "contaminates" neonatal serum creatinine (SCr), preventing its
use for determining GFR in infants for the first few days of life. - Answer- d. Maternal
creatinine "contaminates" neonatal serum creatinine (SCr), preventing its use for
determining GFR in infants for the first few days of life.
GFR estimates for neonates:
Term: 10-15 mL/min/m2
Preterm: 5-10 mL/min/m2
GFR typically doubles during first 1-2 weeks of life
Many oral drugs metabolized by CYP enzymes require higher milligram per kilogram
doses in 2-year-old toddlers than in adults. Which mechanism best describes this need
for higher doses in toddlers?
a. Reduced drug receptors requiring higher drug concentrations.
b. Increased CYP content per gram of pediatric liver.
c. Reduced first-pass metabolism in toddlers.
d. Larger liver weight/total body weight ratio in toddlers. - Answer- d. Larger liver
weight/total body weight ratio in toddlers.
Which best describes the impact of CYP2D6 polymorphisms on opioid therapy?
a. CYP2D6 genotype is only an important consideration in ultra-metabolizers who need
larger codeine doses.
,b. CYP2D6 genotype has a bigger impact on morphine than on codeine dosing
requirements.
c. Higher morphine concentrations occur in CYP2D6 ultra-metabolizers receiving
codeine.
d. CYP2D6 poor metabolizers have exaggerated opioid effects from codeine. - Answer-
c. Higher morphine concentrations occur in CYP2D6 ultra-metabolizers receiving
codeine.
Which best describes body composition at birth in term newborns?
a. Lower albumin and α1-acid glycoprotein concentrations lead to larger weight
normalized (liters per kilogram) volume of distribution (Vd).
b. Total body water is lower in newborns than older populations.
c. A greater portion of total body water is intracellular.
d. High body fat requires higher loading doses for lipophilic drugs. - Answer- a. Lower
albumin and α1-acid glycoprotein concentrations lead to larger weight normalized (liters
per kilogram) volume of distribution (Vd).
Total body water is higher in newborns. A greater portion of total body water in
newborns is extracellular (70%) than intracellular. Low body fat.
You are caring for a neonate in the neonatal intensive care unit. Which is the most
important consideration for neonates regarding drug absorption?
a. Gastric emptying time is decreased during the first week of life.
b. Transdermal absorption is greater in neonates because hydration is decreased and
skin thickness is increased.
c. Low gastric acid secretion in newborns can impair drug absorption for drugs that
require a low pH for absorption.
d. Intramuscular absorption is predictable and often used because intravenous access
can be limited in neonates. - Answer- c. Low gastric acid secretion in newborns can
impair drug absorption for drugs that require a low pH for absorption.
When determining the correct dose for aminoglycosides, which option best describes
the change you would most likely see in neonates compared with adults?
a. The changes in Vd and clearance have opposite effects on half-life, resulting in
similar halflives in neonates and adults.
b. Vd does not change in neonates, but clearance is higher for neonates than for adults.
c. Clearance is typically lower in neonates because of immature renal function.
d. Clearance varies greatly among individual neonates; therefore, no consistent
comparative differences between adults and neonates can be made. - Answer- c.
Clearance is typically lower in neonates because of immature renal function.
P.D. is a 10-day-old term infant in the neonatal intensive care unit being treated for
seizures. P.D. continues to have seizures despite phenobarbital therapy with a
therapeutic phenobarbital concentration of 28 mcg/ mL. The intern wants to load P.D.
with phenytoin and begin a maintenance dose of phenytoin. Which is the most
appropriate statement regarding phenytoin use in this infant?
,A. Phenytoin should not be used in neonates younger than 2 weeks because of the risk
of kernicterus.
B. Phenytoin is highly protein bound, and with the altered binding in newborns,
monitoring free drug concentrations may be considered.
C. Phenobarbital can induce phenytoin metabolism, so smaller maintenance doses are
usually needed.
D. Genotyping before therapy can predict infants likely to experience phenytoin-induced
liver toxicity. - Answer- B. Phenytoin is highly protein bound, and with the altered
binding in newborns, monitoring free drug concentrations may be considered.
Phenytoin is highly protein bound and does not displace bilirubin. It can be used as
anticonvulsant therapy in newborns. However, high binding and low albumin
concentrations in newborns result in higher free fraction in newborns. Phenobarb can
induce phenytoin metabolism and can require larger phenytoin doses. Some HLA
genotypes have been associated with the development of rash (not hepatotoxicity), but
this is a rare ADR in newborns.
B.G. is a 2-year-old boy (weight 12 kg) with a methicillin-resistant Staphylococcus
aureus (MRSA) pulmonary infection being treated with vancomycin 120 mg
intravenously every 8 hours. His SCr is 0.3 mg/dL. His measured vancomycin trough is
4.0 mcg/mL before the fourth dose. Which is most accurate regarding this toddler's
vancomycin pharmacokinetics?
A. Like most pediatric patients, he has a higher hepatic vancomycin clearance than an
adult and thus requires higher doses.
B. High renal clearance and short half-life of vancomycin in children require more
frequent dosing than in adults to achieve similar troughs.
C. His target therapeutic AUC is lower because of the lower protein binding, and free
(unbound) vancomycin concentrations should be measured before increasing his dose.
D. Because renal function matures by 2 years of age, he should be placed on the adult
equivalent dose of 15 mg/kg every 12 hours. - Answer- B. High renal clearance and
short half-life of vancomycin in children require more frequent dosing than in adults to
achieve similar troughs.
T.G. is a 2-year-old girl receiving valproic acid and phenytoin for treatment of her
seizure disorder. Her SCr is 0.2 mg/dL, albumin 3.4 g/dL and total bilirubin 0.1 mg/dL.
Which statement is most accurate about her anticonvulsant regimen?
A. Liver function tests can be monitored less frequently in children than in adults
because there is a decreased risk of hepatotoxicity in children.
B. Valproate can displace phenytoin from albumin and lead to increased phenytoin free
fraction.
C. Induction of CYP enzymes by valproate will likely lead to lower phenytoin
concentrations.
D. Her CYP2D6 genotype can be used to predict the valproate dose she needs to
achieve therapeutic concentrations. - Answer- B. Valproate can displace phenytoin from
albumin and lead to increased phenytoin free fraction.
, L.A. is a 12-year-old girl (weight 40 kg) with polycystic kidney disease receiving 4-hour
hemodialysis three times weekly. Her most recent SCr is 5.0 mg/dL. Vancomycin is
initiated for a MRSA infection with 600 mg given 2 hours after hemodialysis. Which best
characterizes the vancomycin dosing she will need?
A. She will need intermittent vancomycin dosing, likely twice weekly or less, and her
dosing should be guided by vancomycin drug concentrations because it is difficult to
determine the exact dose in advance.
B. She should receive a standard dose of vancomycin after each dialysis session
because hemodialysis removes most of the vancomycin in her body.
C. All of her vancomycin should be administered during dialysis to minimize her risk of
red man syndrome.
D. Her vancomycin clearance can be determined on the basis of her SCr and the
Schwartz equation. Serum vancomycin concentrations can be measured to fine-tune
dos - Answer- A. She will need intermittent vancomycin dosing, likely twice weekly or
less, and her dosing should be guided by vancomycin drug concentrations because it is
difficult to determine the exact dose in advance.
Vancomycin almost exclusively eliminated renally and only a limited amount is removed
during a standard hemodialysis session
M.C. is an 8-year-old boy (weight 30 kg) who is initiated on phenytoin after a head
injury. After 1 week of therapy, his initial steady-state phenytoin concentration is 22
mg/L on an oral dose of 100 mg once daily. He has had no seizures, but he is
experiencing nystagmus. His dose is reduced to 50 mg once daily. Which is the most
likely result of this dosage change?
A. His phenytoin concentration will decrease but by less than the dose reduction (50%)
because the current concentration is higher than the typical Km value of 4 mcg/mL.
B. His phenytoin concentration will stay the same because phenytoin is an auto-
inhibitor, and its clearance decreases with time.
C. His high initial phenytoin concentration for his dose suggests that he has a CYP2C9
poor or intermediate metabolizer genotype.
D. His high phenytoin concentration is likely a result of transient protein binding changes
seen in patients with head injury. Altho - Answer- C. His high initial phenytoin
concentration for his dose suggests that he has a CYP2C9 poor or intermediate
metabolizer genotype.
W.M. is a 3-day-old boy (height 0.39 inches, weight 1000 g) born at 26 weeks'
gestation. His SCr is 1.4 and blood urea nitrogen is 39 mg/dL. He is given a single dose
of vancomycin 15 mg intravenously. Assuming a vancomycin Vd of 0.6 L/kg, if his first
vancomycin level obtained 24 hours post-dose is 6.25 mcg/mL, which best depicts the
half-life?
A. 4 hours.
B. 6 hours.
C. 8 hours.
D. 12 hours. - Answer- D. 12 hours.
Correctly Answered
Which most likely complicates intramuscular drug delivery in neonates?
a. High total body water content.
b. Increased first-pass metabolism.
c. Dose volume.
d. Decreased binding proteins. - Answer- c. Dose volume.
Which best describes renal drug clearance changes that occur through glomerular
filtration rate (GFR) maturation?
a. Most in utero developmental changes in GFR occur between 36 and 40 weeks'
gestation.
b. Changes subject to induction of GFR by exposure to drugs are proximal tubule OAT
(organic anion transporters) or OCT (organic cation transporter) substrates.
c. Renal drug clearance values in children approach those of adults by 2 weeks of age.
d. Maternal creatinine "contaminates" neonatal serum creatinine (SCr), preventing its
use for determining GFR in infants for the first few days of life. - Answer- d. Maternal
creatinine "contaminates" neonatal serum creatinine (SCr), preventing its use for
determining GFR in infants for the first few days of life.
GFR estimates for neonates:
Term: 10-15 mL/min/m2
Preterm: 5-10 mL/min/m2
GFR typically doubles during first 1-2 weeks of life
Many oral drugs metabolized by CYP enzymes require higher milligram per kilogram
doses in 2-year-old toddlers than in adults. Which mechanism best describes this need
for higher doses in toddlers?
a. Reduced drug receptors requiring higher drug concentrations.
b. Increased CYP content per gram of pediatric liver.
c. Reduced first-pass metabolism in toddlers.
d. Larger liver weight/total body weight ratio in toddlers. - Answer- d. Larger liver
weight/total body weight ratio in toddlers.
Which best describes the impact of CYP2D6 polymorphisms on opioid therapy?
a. CYP2D6 genotype is only an important consideration in ultra-metabolizers who need
larger codeine doses.
,b. CYP2D6 genotype has a bigger impact on morphine than on codeine dosing
requirements.
c. Higher morphine concentrations occur in CYP2D6 ultra-metabolizers receiving
codeine.
d. CYP2D6 poor metabolizers have exaggerated opioid effects from codeine. - Answer-
c. Higher morphine concentrations occur in CYP2D6 ultra-metabolizers receiving
codeine.
Which best describes body composition at birth in term newborns?
a. Lower albumin and α1-acid glycoprotein concentrations lead to larger weight
normalized (liters per kilogram) volume of distribution (Vd).
b. Total body water is lower in newborns than older populations.
c. A greater portion of total body water is intracellular.
d. High body fat requires higher loading doses for lipophilic drugs. - Answer- a. Lower
albumin and α1-acid glycoprotein concentrations lead to larger weight normalized (liters
per kilogram) volume of distribution (Vd).
Total body water is higher in newborns. A greater portion of total body water in
newborns is extracellular (70%) than intracellular. Low body fat.
You are caring for a neonate in the neonatal intensive care unit. Which is the most
important consideration for neonates regarding drug absorption?
a. Gastric emptying time is decreased during the first week of life.
b. Transdermal absorption is greater in neonates because hydration is decreased and
skin thickness is increased.
c. Low gastric acid secretion in newborns can impair drug absorption for drugs that
require a low pH for absorption.
d. Intramuscular absorption is predictable and often used because intravenous access
can be limited in neonates. - Answer- c. Low gastric acid secretion in newborns can
impair drug absorption for drugs that require a low pH for absorption.
When determining the correct dose for aminoglycosides, which option best describes
the change you would most likely see in neonates compared with adults?
a. The changes in Vd and clearance have opposite effects on half-life, resulting in
similar halflives in neonates and adults.
b. Vd does not change in neonates, but clearance is higher for neonates than for adults.
c. Clearance is typically lower in neonates because of immature renal function.
d. Clearance varies greatly among individual neonates; therefore, no consistent
comparative differences between adults and neonates can be made. - Answer- c.
Clearance is typically lower in neonates because of immature renal function.
P.D. is a 10-day-old term infant in the neonatal intensive care unit being treated for
seizures. P.D. continues to have seizures despite phenobarbital therapy with a
therapeutic phenobarbital concentration of 28 mcg/ mL. The intern wants to load P.D.
with phenytoin and begin a maintenance dose of phenytoin. Which is the most
appropriate statement regarding phenytoin use in this infant?
,A. Phenytoin should not be used in neonates younger than 2 weeks because of the risk
of kernicterus.
B. Phenytoin is highly protein bound, and with the altered binding in newborns,
monitoring free drug concentrations may be considered.
C. Phenobarbital can induce phenytoin metabolism, so smaller maintenance doses are
usually needed.
D. Genotyping before therapy can predict infants likely to experience phenytoin-induced
liver toxicity. - Answer- B. Phenytoin is highly protein bound, and with the altered
binding in newborns, monitoring free drug concentrations may be considered.
Phenytoin is highly protein bound and does not displace bilirubin. It can be used as
anticonvulsant therapy in newborns. However, high binding and low albumin
concentrations in newborns result in higher free fraction in newborns. Phenobarb can
induce phenytoin metabolism and can require larger phenytoin doses. Some HLA
genotypes have been associated with the development of rash (not hepatotoxicity), but
this is a rare ADR in newborns.
B.G. is a 2-year-old boy (weight 12 kg) with a methicillin-resistant Staphylococcus
aureus (MRSA) pulmonary infection being treated with vancomycin 120 mg
intravenously every 8 hours. His SCr is 0.3 mg/dL. His measured vancomycin trough is
4.0 mcg/mL before the fourth dose. Which is most accurate regarding this toddler's
vancomycin pharmacokinetics?
A. Like most pediatric patients, he has a higher hepatic vancomycin clearance than an
adult and thus requires higher doses.
B. High renal clearance and short half-life of vancomycin in children require more
frequent dosing than in adults to achieve similar troughs.
C. His target therapeutic AUC is lower because of the lower protein binding, and free
(unbound) vancomycin concentrations should be measured before increasing his dose.
D. Because renal function matures by 2 years of age, he should be placed on the adult
equivalent dose of 15 mg/kg every 12 hours. - Answer- B. High renal clearance and
short half-life of vancomycin in children require more frequent dosing than in adults to
achieve similar troughs.
T.G. is a 2-year-old girl receiving valproic acid and phenytoin for treatment of her
seizure disorder. Her SCr is 0.2 mg/dL, albumin 3.4 g/dL and total bilirubin 0.1 mg/dL.
Which statement is most accurate about her anticonvulsant regimen?
A. Liver function tests can be monitored less frequently in children than in adults
because there is a decreased risk of hepatotoxicity in children.
B. Valproate can displace phenytoin from albumin and lead to increased phenytoin free
fraction.
C. Induction of CYP enzymes by valproate will likely lead to lower phenytoin
concentrations.
D. Her CYP2D6 genotype can be used to predict the valproate dose she needs to
achieve therapeutic concentrations. - Answer- B. Valproate can displace phenytoin from
albumin and lead to increased phenytoin free fraction.
, L.A. is a 12-year-old girl (weight 40 kg) with polycystic kidney disease receiving 4-hour
hemodialysis three times weekly. Her most recent SCr is 5.0 mg/dL. Vancomycin is
initiated for a MRSA infection with 600 mg given 2 hours after hemodialysis. Which best
characterizes the vancomycin dosing she will need?
A. She will need intermittent vancomycin dosing, likely twice weekly or less, and her
dosing should be guided by vancomycin drug concentrations because it is difficult to
determine the exact dose in advance.
B. She should receive a standard dose of vancomycin after each dialysis session
because hemodialysis removes most of the vancomycin in her body.
C. All of her vancomycin should be administered during dialysis to minimize her risk of
red man syndrome.
D. Her vancomycin clearance can be determined on the basis of her SCr and the
Schwartz equation. Serum vancomycin concentrations can be measured to fine-tune
dos - Answer- A. She will need intermittent vancomycin dosing, likely twice weekly or
less, and her dosing should be guided by vancomycin drug concentrations because it is
difficult to determine the exact dose in advance.
Vancomycin almost exclusively eliminated renally and only a limited amount is removed
during a standard hemodialysis session
M.C. is an 8-year-old boy (weight 30 kg) who is initiated on phenytoin after a head
injury. After 1 week of therapy, his initial steady-state phenytoin concentration is 22
mg/L on an oral dose of 100 mg once daily. He has had no seizures, but he is
experiencing nystagmus. His dose is reduced to 50 mg once daily. Which is the most
likely result of this dosage change?
A. His phenytoin concentration will decrease but by less than the dose reduction (50%)
because the current concentration is higher than the typical Km value of 4 mcg/mL.
B. His phenytoin concentration will stay the same because phenytoin is an auto-
inhibitor, and its clearance decreases with time.
C. His high initial phenytoin concentration for his dose suggests that he has a CYP2C9
poor or intermediate metabolizer genotype.
D. His high phenytoin concentration is likely a result of transient protein binding changes
seen in patients with head injury. Altho - Answer- C. His high initial phenytoin
concentration for his dose suggests that he has a CYP2C9 poor or intermediate
metabolizer genotype.
W.M. is a 3-day-old boy (height 0.39 inches, weight 1000 g) born at 26 weeks'
gestation. His SCr is 1.4 and blood urea nitrogen is 39 mg/dL. He is given a single dose
of vancomycin 15 mg intravenously. Assuming a vancomycin Vd of 0.6 L/kg, if his first
vancomycin level obtained 24 hours post-dose is 6.25 mcg/mL, which best depicts the
half-life?
A. 4 hours.
B. 6 hours.
C. 8 hours.
D. 12 hours. - Answer- D. 12 hours.
