Black Box & Beyond
This combination carries a black box warning that ticagrelor should not be used with aspirin doses above this threshold, as higher doses reduce its effectiveness.
What is 100 mg/day? (ticagrelor should be used with aspirin ≤100 mg/day)
A patient presents to the ED with new-onset atrial fibrillation and rapid ventricular response (RVR) with HR 160 bpm and BP 140/85. Name the two first-line medication classes for rate control in hemodynamically stable patients.
What are beta-blockers or non-dihydropyridine calcium channel blockers (e.g., metoprolol, diltiazem)?
A 58-year-old male with decompensated cirrhosis presents with confusion and asterixis. His ammonia level is elevated. This agent is first-line treatment to reduce ammonia levels in hepatic encephalopathy.
What is lactulose?
A 61-year-old patient develops diarrhea after a 10-day course of clindamycin. Stool toxin is positive for C. difficile. This antibiotic is recommended first-line for non-severe C. difficile infection.
What is oral vancomycin (or fidaxomicin)?
A 68-year-old female with type 2 diabetes and CKD stage 4 (eGFR 25 mL/min/1.73m²) is taking metformin 1000 mg twice daily. What modifications should be made to her current therapy?
This medication should be discontinued or avoided in patients with eGFR <30 mL/min/1.73m²
This adjustment should be made to prasugrel maintenance dosing in patients ≥75 years of age or weighing <60 kg to reduce bleeding risk.
What is a reduced maintenance dose of 5 mg daily instead of the standard 10 mg daily?
A 74-year-old female with hypertension and diabetes presents with AFib. You calculate her CHA₂DS₂-VASc score to assess her need for this type of therapy.
What is anticoagulation for stroke prevention?
This is recommended diuretic combo regimen for managing ascites and edema in patients with cirrhosis. Provide drug names and dose ratio.
What is spironolactone and furosemide maintaining a 100:40 ratio?
A 40-year-old male presents with a painful, red abscess on his thigh. He has a history of MRSA infection. The abscess is incised and drained. Name 3 oral antibiotics that are an appropriate empiric treatment for MRSA coverage following I&D of a skin abscess (purulant).
What is trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, or clindamycin? Also linezolid or minocycline.
A 85-year-old male with atrial fibrillation weighs 75 kgs and has a serum creatinine of 2.1 mg/dL. He’s prescribed apixaban 5 mg twice daily.
Is the current apixaban dose appropriate?
For a fib indications in a patient meeting two of the following—age ≥80, weight ≤60 kg, or SCr ≥1.5 mg/dL—this dose adjustment should be made.
What is reducing apixaban to 2.5 mg twice daily?
This antiarrhythmic carries black box warnings for pulmonary toxicity, hepatotoxicity, and proarrhythmic effects.
What is amiodarone?
A patient presents with AFib and RVR but has systolic heart failure with EF 30%. This commonly used rate control medication should be avoided due to its negative inotropic effect.
What is diltiazem (or verapamil)?
This blood test that measures how long it takes for your blood to clot can be elevated in liver disease.
What is INR?
A 58-year-old hospitalized patient with pneumonia has a nasal PCR positive for MRSA. Name two IV antibiotics that could be added empirically for MRSA coverage.
What is vancomycin (or linezolid)?
A 70-year-old male has an estimated CrCl of 25 mL/min. He’s started on levofloxacin for PNA treatment. This adjustment should be made to levofloxacin dosing in a patient with CrCl <50 mL/min.
What is extending the dosing interval (750 mg every 48 hours or 500 mg every 48 hours)?
A 45-year-old female with a history of a recent deep vein thrombosis is seeking therapy for vasomotor symptoms of menopause. She asks about oral contraceptives or hormone replacement therapy. What is your recommendation?
estrogen-containing medications (e.g., combined oral contraceptives, estrogen replacement therapy) carry a black box warning for increased risk of venous thromboembolism and should generally be avoided in patients with active or recent blood clots.
A patient is started on amiodarone for rhythm control of AFib. As the pharmacist, you should monitor for these two major organ toxicities associated with long-term use.
What are pulmonary toxicity and thyroid dysfunction (or hepatic toxicity)?
A 62-year-old male with a history of hepatic encephalopathy controlled on lactulose is hospitalized again with worsening confusion. The team wants to add a medication to reduce recurrence.This non-absorbable antibiotic is added to lactulose to prevent recurrent episodes of hepatic encephalopathy.
What is rifaximin?
A 67-year-old female presents with left lower quadrant abdominal pain and fever. CT confirms uncomplicated diverticulitis. She has no drug allergies and can tolerate oral medications. This oral antibiotic regimen provides both gram-negative and anaerobic coverage appropriate for uncomplicated diverticulitis.
What is ciprofloxacin (or levaquin) plus metronidazole?
This IV third generation cephalosporin agent does not require any renal dose adjustments.
What is ceftriaxone (rocephin)?
This class of medications used to treat anemia in CKD carries a black box warning for increased risk of cardiovascular events, stroke, and tumor progression when hemoglobin targets are exceeded.
What are erythropoiesis-stimulating agents (ESAs)?
A patient is found to be in AFib for more than 48 hours and is scheduled for cardioversion. You recommend anticoagulation for at least this duration before the procedure unless a TEE shows no thrombus.
What is at least 3 weeks?
A 63 year old female with alcoholic cirrhosis and portal hypertension presents with increasing abdominal distension and shortness of breath. She's currently on furosemide 40 mg daily and spironolactone 100 mg daily. Her potassium is 5.4 mEq/L. In a cirrhotic patient with hyperkalemia and ascites, this adjustment should be made to her diuretic regimen.
What is decreasing or discontinuing spironolactone while continuing furosemide?
A 72-year-old patient in the ICU develops fever and purulent sputum after being intubated for 5 days. Sputum culture grows Pseudomonas aeruginosa. Name 2 broad-spectrum beta-lactam antibiotics that are a common empiric choice for ventilator-associated pneumonia when Pseudomonas is suspected.
What is piperacillin-tazobactam or cefepime (or meropenem)?
This commonly used antibiotic for uncomplicated UTIs should be avoided when CrCl is below 30 mL/min due to decreased urinary concentrations (efficacy) and risk of toxicity.
What is nitrofurantoin?