When Guidelines Say Don’t Even Think About It
Which first line hypertension medications are not recommended/should be held when a patient has an AKI?
ACEs and ARBs
A patient is interested in smoking cessation drug therapy options. After asking further questions, you find out that the patient has been smoking 1 pack daily for the last 10 years. Which Nicotine patch strength should the patient be started on?
21mg Patch
What is one reason why we hold metformin in the hospital for patients with HF?
Risk of lactic acidosis
A patient is started on 40 mEq of IV potassium. How much would you expect a patient’s potassium level to increase?
0.4
True/False & Why: According to the STRONG trial with HF, it is recommended to start medications inpatient and do conservative titration, which can be adjusted outpatient with more monitoring.
False - this trial supports starting new medications and aggressive titration during admission to ensure patients reach their appropriate therapeutic targets.
LP has recently been discharged after having an NSTEMI and is now having complaints of headaches and wants an OTC treatment option. Which medication class should they avoid?
NSAIDs
A patient has an AKI and has hypertension. They are currently taking lisinopril and the medical resident wants to know if it is okay to give them their next dose, what is your recommendation?
The patient should not take and ACE inhibitor or an ARB. You could start them on a Calcium channel blocker like amlodipine.
What are the cardinal symptoms that indicate the need for antibiotic therapy in a patient presenting with an acute COPD exacerbation?
dyspnea, increased sputum volume, and sputum purulence
A patient is presenting to the ED with a pulmonary embolism. That is being treated but the patient's congestive heart failure medications need to be corrected. The docotor wants to start metoprolol succinate PO daily and the patient is currently on metoprolol tartrate 50 mg PO BID. What is you're recommendation and why?
The patient should be initiated on metoprolol succinate 100 mg because they are already taking a 100 mg of the tartrate and they are still uncontrolled.
What other medications besides benzodiazepines can you use for alcohol withdrawal
A. Phenobarbital
B. Gabapentin
C. Carbamazepine
D. Valproic acid
E. All of the above
E. All of the above
Patient JH presented to the hospital, presenting with an NSTEMI requiring PCI, prior to the procedure, JH was started on continuous heparin infusion. Following PCI, what should happen to the patient's heparin infusion?
The heparin should be discontinued.
HP presented to the ER and received a new diagnosis of HFrEF and was started on three new medications, but the physician can't remember one medication that should be added. Currently, HP is on Spironolactone, Empagliflozin, and Lisinopril. What medication is missing?
Beta-blocker (Carvedilol, Metoprolol succinate, or Bisoprolol)
List two reasons bisphosphonates like alendronate for Osteoporosis commonly held while inpatient?
- Requires a full glass of water and an empty stomach
- The patient must remain upright for 30–60 minutes to prevent esophagitis/ulceration
- This is a long-term medication that won't show rapid benefits
- GI risk is higher in patients with feeding tubes, intubation, reflux, or stress gastritis.
What is the appropriate Lovenox Dosing following a VTE consideration for a patient with an elevated BMI?
1 mg/kg every 12 hours
A patient is admitted to the general medicine floor. On his second day of admission, he starts to develop hand tremors and visual hallucinations as well as nausea/vomiting. A CIWA score is performed and the patient scores a 14. Which of the following is an appropriate drug therapy for this patient?
A. Cyanocobalamin
B. Pyridoxine
C. Niacin
D. Thiamine
D. Thiamine - Thiamine is an appropriate drug to initiate for a patient undergoing alcohol withdrawal to prevent Wernicke's syndrome.
Patient ML is on ertapenem for a UTI and now has a C.diff infection. Would it be appropriate to stop the ertapenem and only treat with PO fidaxomicin?
No, because ML still needs treatment for the UTI and stopping the ertapenem can make the infection worse.
Patient SS presents to the hospital with SOB and increased RR, which is worsening. All other labs and vitals are WNL, and no signs or symptoms of infection. SS states they currently use Salmeterol (LABA) twice daily, which has improved their COPD, but they still have flare-ups. Eosinophils are less than 100. What is most appropriate for SS's therapy regimen at this time?
Escalate to LABA + LAMA combination therapy
Should you check anti-Xa levels when a patient is on prophylaxis for a DVT?
No, it is appropriate to check anti-Xa levels when giving treatment doses for DVT
A patient is currently on Heparin following a VTE and is ready to get discharged on oral anticoagulation. What are the two requirements for bridge therapy when initiating warfarin?
Continue Heparin for a minimum of 5 days AND until INR is ≥2.0 for 2 consecutive days
Which of the following electrolyte imbalances can albuterol cause?
A. Hypocalcemia
B. Hypomagnesemia
C. Hypokalemia
D. Hypophosphatemia
C. Hypokalemia - Albuterol is a drug that shifts potassium inside the cell, which can cause hypokalemia.
Patient JB is admitted to the hospital, hemorrhaging and with an elevated INR due to a recent warfarin dose adjustment, and is indicated for a reversal agent. The team wants to initiate Kcentra infusion. At last admission, JB was on heparin for a PE, but started experiencing a rash and a significant decrease in platelet count. What should you educate the team on when considering starting Kcentra?
Kcentra contains a little heparin, which makes it contraindicated in patients with a history HIT
HH is experiencing HIT following receiving heparin for a PE, but still requires anticoagulation. The hospital you are working at is experiencing a shortage of Bivalirudin and Argatroban. HH does have good oral intake and is not experiencing any nausea or vomiting. What can you recommend?
DOAC (apixaban or rivaroxaban)
RM is being treated for mild/moderate COVID-19 and was started on Paxlovid. You recommend to the team holding the patients on Atorvastatin while on Paxlovid, but why?
Paxlovid is a strong CYP3A4 inhibitor and can cause an increase in Atorvastatin concentration.
KE is hospitalized for a C. difficile infection and is being treated with Fidaxomicin. They are bed bound and refuse to get up to walk. KE has a PMH of CKD, HFrEF, HTN, and Depression.
Labs include: K+ 3.3, Na+ 130, SCr 1.5, Glucose 106, CrCl 11
Which of the following is an appropriate dose of Enoxaparin for the patient?
A. 1.5 mg/kg Subq daily
B. 1 mg/kg Subq BID
C. 40 mg Subq daily
D. 30 mg Subq daily
D. 30 mg Subq daily
Which of the following medications is NOT appropriate for blood pressure lowering in the presence of a hemorrhagic stroke?
A. Clevidipine
B. Nitroglycerin
C. Labetalol
D. Nicardipine
B. Nitroglycerin - Nitroglycerin is not an appropriate blood pressure in the setting of a hemorrhagic stroke due to the risk of raising intracranial pressure.