Trivia+Q&A

Make sure to check back on this page every day! I will be posting some trivia and case questions for you guys to answer periodically. Make sure that you have a reference for your answer.

Wiki #1 Upon initiation of lisinopril in your patient TL, his SCr increases from 1.1 to 1.6. What specific abnormality (disease) would you be concerned about in this patient and should the lisinopril be continued? Include current contraindications for ACEI use.

Under the given circumstances, we should be on the look out for signs of renal artery stenosis. Lisinopril use has been reported to cause acute renal failure in these patients because it blocks arteriolar vasoconstriction (causes efferent arteriole vasodilation), preventing these patients from maintaining glomerular filtration. If this patient does in fact have renal artery stenosis, particulary bilateral RAS, then discontinuation of lisinopril would be strongly advised. An increase in the patients SCr by 30% within the first 2 weeks of therapy is reason for concern, and increase of 50% warrents discontinuation of the ACEI. Other contraindications to the use of lisinopril include past episodes of angioedema related to the use of ACE inhibitors, a history of ideopathic or hereditray angioedema, hypersensitivity to the components of this medication, and pregnancy. Since this patient, TL had a >30% increase in his SCr, and and jump of 0.5 (considered acute renal failure), then it would be advised to discontinue his lisinopril and evaluate for RAS.

1. Kumar A, Asim M, Davison AM. Taking precautions with ACE inhibitors. Brit Med J. 1998;316:1921. 2. Zestril [package insert]. Wilmington, DE: AstraZeneca; November 2009.

Wiki #2 JB is a 69 year old female with PMH significant for systolic heart failure x 10 years, with a recent LVEF of 15%. The patient’s current medications are as follows: Lisinopril 40 mg daily, carvedilol 12.5 mg BID, furosemide 60 mg BID, spironolactone 25 mg daily, aspirin 81 mg daily. JB is admitted to the internal medicine service with positive JVD and 2+ pitting edema with physical exam positive for lung crackles. JB says she has been taking all of her medications as directed and she only uses Ms.Dash to season her food. Upon administering the furosemide it is noticed that JB’s urine output is not increased significantly. JB appears to be suffering from diuretic resistance. What recommendation should be made on how to manage JB’s medications (what to add/change/discontinue).

Addition of a thiazide or thiazide-like diuretic will improve diuretic resistance by decreasing sodium reabsorption in the distal tubule. 5-10% of all sodium is reabsorbed in the distal tubule and when loop diuretics are not working adequately, then addition of metolazone 5mg daily 30 minutes prior to furosemide will increase the sodium removal. NSAIDs should be avoided and salt and fluid intake should be restricted. Switching to IV furosemide and shortening the interval may provide some benefit with the max dose of 250mg (little benefit seen when >160mg).

1.De Bruyne L. Mechanisms and management of diuretic resistance in congestive heart failure. Postgrad Med J. 2003;79:268-271. 2. Felker G, Volz E. How to use diuretics in heart failure. Curr Treat Options Cardiovacs Med. 2009; 6:426-32.

Wiki #3 PP is a 27 year old male admitted to the medicine team for a diagnosis of left lower extremity cellulitis. In addition to his antibiotics, he is started on pantoprazole 40 mg daily for stress ulcer prophylaxis. What are the indications for stress ulcer prophylaxis and what are the possible adverse effects (short and long term) associated with inappropriate use on proton pump inhibitors?

Indications for stress ulcer prophylaxis include patients who are on mechanical ventilation, have renal failure or sepsis, are on high doses of corticosteroids (250 mg/day), have brain or spinal cord injuries, are suffering from major burns, or have a high risk of coagulopathy. Adverse effects of inappropriate PPI use include neoplasias, C. diff, pneumonias, nutritional deficiencies, osteoporosism, renal effects, and hepatobiliary effects.

1. Nealis T, Howden C. Is There a Dark Side to Long-term Proton Pump Inhibitor Therapy?. Am J Th. 2008:15;536-542.  2. Guillamondegui OL, Gunter OD, Bonadies JA, et al. Practice management guidelines for stress ulcer prophylaxis.,

Wiki #4 What test result may return as positive in a patient taking selegiline? Describe this drug's mechanism of action and the indication.

A patient taking selegiline would likely have a positive result on an amphetamine/methamphetamine drug screening since two of it's metabolites are L-enantiomers of methamphetamine. Selegiline itself is a selective MAO-B inhibitor that prevents the metabolism of dopamine at normal doses. It is most commonly used to slow the progression of Parkinson's disease(in combination with levodopa), but can also treat major depressive disorder.

Wiki #5 A patient is taking digoxin 0.125 mg daily and furosemide 20 mg daily. What electrolyte abnormalities can potentiate digoxin toxicity and how? What are the signs of digoxin toxicity?

Furosemide increases the excretion of potassium and magnesium, which can cause hypokalemia and/or hypomagnesaemia. Depletion of these electrolytes can make the myocardium more sensitive to the toxic effects of digoxin. Diuretic-induced electrolyte imbalance appears to be a major predisposing factor for digitalis overall. Since digoxin's mechanism of action is to compete with potassium at the sodium-potassium ATpase pump, hypokalemia leaves digoxin nothing to compete against. In this absence of potassium, digoxin binds preferentially to the pump. Digoxin's narrow therapeutic window coupled with this increase in binding time results in increased digoxin toxicity.

Signs and symptoms of digoxin toxicity are more frequently seen with levels > 2ng/mL. Cardiac abnormalities are often seen. These include various types of arrhythmias- 1st, 2nd , & 3rd degree block, atrial tachycardia, AV dissociation, unifocal and multiform ventricular premature contractions, ventricular tachycardia, and ventricular fibrillation. PR prolongation and ST segment depression have also been reported. Gastrointestinal signs and symptoms (nausea, vomiting, diarrhea, and anorexia) are associated with digoxin toxicity. Neurologic disturbances such as confusion and dizziness are common. Patients can experience visual changes including: yellow/green color discrimination, blurred vision, double vision, and blind spots. Muscle weakness, headaches, and fatigue may also be seen.


 * 1) <span style="background-color: transparent; color: #000000; display: block; font-family: 'times new roman'; font-size: 16px; text-align: left; text-decoration: none;">Facts & Comparisons. Facts & Comparisons Web site. http://online.factsandcomparisons.com.ezproxy.samford.edu/. <span style="font-family: Arial,Helvetica,sans-serif;">Accessed May 23, 2011.
 * 2) <span style="background-color: transparent; color: #000000; display: block; font-family: arial,helvetica,sans-serif; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #000000; font-size: 16px; text-decoration: none; vertical-align: auto;">Lanoxin [package insert]. GlaxoSmithKline, Greenville, NC; August 2009. <span style="background-color: transparent; color: #800080; font-size: 16px; text-align: left; vertical-align: auto;">__[]__ <span style="background-color: transparent; color: #000000; font-size: 16px; text-decoration: none; vertical-align: auto;">. Accessed May 23, 2011.

<span style="background-color: transparent; color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-decoration: none; vertical-align: auto;">Wiki #6

<span style="background-color: transparent; color: #000000; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-decoration: none; vertical-align: auto;">JK is and AA male with and past history significant for DMII with CKD, epilepsy since childhood, and HTN. He is being treated with lisinopril 20 mg daily, aspirin 325 mg daily, simvastatin 20 mg daily, phenytoin 100 mg TID, and carvedilol 6.25 mg BID. On admission he is ataxic with some AMS. His labs are reported below. <span style="font-family: Arial,Helvetica,sans-serif;">Ca = 7.8 <span style="font-family: Arial,Helvetica,sans-serif;">Mg = 1.9 <span style="font-family: Arial,Helvetica,sans-serif;">Albumin = 2.1 <span style="font-family: Arial,Helvetica,sans-serif;">Phenytoin = 13 mg/dL <span style="font-family: Arial,Helvetica,sans-serif;">What medication change(s) should be made based on these results? And why?
 * <span style="font-family: Arial,Helvetica,sans-serif;">Na 142 || <span style="font-family: Arial,Helvetica,sans-serif;">Cl 103 || <span style="font-family: Arial,Helvetica,sans-serif;">BUN 22 ||
 * <span style="font-family: Arial,Helvetica,sans-serif;">K 3.9 || <span style="font-family: Arial,Helvetica,sans-serif;">CO 2 24 || <span style="font-family: Arial,Helvetica,sans-serif;">SCr 1.9 ||

JK currently has hypoalbuminemia, as the normal range is 3.4-5.4g/dl. Phenytion is greatly affected by this, as it his highly bound to albumin. In cases of hypoalbuminemia such as this, it is necessary to correct for the low albumin level with the equation:

Adjusted concentration = measured total concentration / [(0.2 x albumin) + 0.1]

This will give the real concentration, which is 25mcg/ml. This is the reason for his ataxia and AMS, as patients can experience adverse effects from phenytoin in levels higher than 20mcg/ml. Also, he is on a daily dose of 325mg which is much higher than necessary. A dose of 81mg every day will provide JK with the benefits of stroke prevention without causing NSAID related side effects.


 * 1) Uptodate. Up-to-date Web site. http://ezproxy.ulm.edu:2054/contents/search. Accessed June 1, 2011.

Wiki #7

A patient is in the hospital for pain management related to chronic cancer pain. Currently they are receiving morphine 5 mg IV Q4 hours. The physicians want to transition this patient to either oral oxycodone or a fentanyl patch. Please make recommendations for the equianalgesic doses for both of the options and include and additional information you would provide for initiating the patch.

TDD of morphine 5 mg IV q 4 hrs= 30 mg/day

IV morphine x3=oral morphine 30 mg/d (IV) X 3=90 mg/day oral morphine

Oral morphine /1.5=oral oxycodone 90mg/day oral morphine/ 1.5= 60 mg oral oxycodone

Oral morphine X 100= µg transdermal fentanyl TDD oral morphine: 90mg/day TDD oral morphine/100=equivalent fentanyl dose in 24 hours 90/100=0.9 mg/day 0.9 mg X 1000=900 µg/day Fentanyl dose/day ÷ 24 hrs=µg/hr 900 µg/day ÷24 hrs=37.5 µg/hr Choose closest dose available= 25 µg/hr patch

Can give a breakthrough dose to control the pain when switching from IV to the patch (Breakthrough dose=10% X TDD given every hour as needed) 90 X .10=9 mg q hr prn pain

Patch counseling:
 * Want to start at the lowest dose of the patch then increase accordingly
 * Can increase dose q 3 days
 * Apply patch to clean, hairless (if there is hair: clip the hair, but do NOT shave the area), intact/non -irritated skin
 * Clean skin with water ONLY (no soap)
 * When applying patch: press firmly for 30 seconds over the patch
 * If the edges start to fold upward, you can tape the edges of the patch. Do not apply a complete bandage/patch/tape over the whole patch.
 * Change patch every 72 hours and apply new patch to a different spot on the skin
 * However, some patients may need a patch change q 48 hours
 * If patch falls off: fold patch in half and flush down the toilet & place a new patch on the skin at a different site
 * May need a short acting analgesic or immediate release morphine when first switching to fentanyl patch to cover for breakthrough pain
 * Do not apply direct heat over the patch because it will increase the absorption and increase the toxic effects of fentanyl
 * Common toxic effects include: hypoventilation and bradycardia
 * Therapeutic blood levels are not reached for the 1st 13-24 hours after application and it continues to release into blood for 24 hours after removal
 * Opioid withdrawal symptoms can occur during doing conversions (minimize this by treating with breakthrough opioids)

Wiki #8

A patient is intolerant to Bactrim for PCP prophylaxis and is going to be started on Dapsone. What specific genetic test should be completed prior to starting therapy? What is the risk if the patient is positive and given Dapsone? What other drugs require this test prior to use?

Patients should be tested for glucose-6-phosphate dehydrogenase deficiency (G6PD) before taking Dapsone. If the patient is positive for G6PD they are more likely to suffer from hemolytic anemia, a major side effect of this medication. Dapsone should be given with caution to these patients or if the patient is exposed to other agents or conditions such as infection or diabetic ketosis capable of producing hemolysis. Other drugs that require this test prior to their use are:
 * Antimalarial drugs
 * Aspirin
 * Nitrofurantoin
 * Nonsteroidal anti-inflammatory drugs (NSAIDs)
 * Quinidine
 * Quinine
 * Sulfa drugs

1. Uptodate. Up-to-date Web site. http://ezproxy.ulm.edu:2054/contents/search. Accessed June 1, 2011.

Wiki #9

<span style="font-family: 'Arial','sans-serif'; font-size: 12px;">KP is a 48 year old female taking lisinopril 40 mg daily for hypertension. On initiation of lisinopril KP’s Scr=0.9 and K=3.2. KP was also prescribed potassium supplements in the past when she was on HCTZ for her blood pressure. Her physician continued these supplements when he switched her medication last month. KP comes in for her followup appointement feeling weak and groggy. Her heart rate is found to be 42bpm and EKG shows peaked T waves. Her BMP on arrival shows K=6.7. What is the appropriate management for KP? Include all possible treatment options for hyperkalemia.

Hyperkalemia is defined as serum potassium plasma concentration of more than 5 mEq/L. Elevations are classified as follows: (1) mild elevation, 5 to 6 mEq/L, (2) moderate elevation, 6 to 7 mEq/L, and (3) severe elevation, greater than 7 mEq/L. Therefore, the patient is classified as moderate elevation.

Treatment of moderate hyperkalemia:

Stabilize the myocardium

-IV calcium (chloride or gluconate)- 1g IV over 1 minute

Shift potassium intracellularly

-IV insulin (10 units) and dextrose (50 grams)- moves K from ECF to ICF

-Dextrose 25 g (50 mL of D50) and regular insulin 10 units IV over 15 to 30 minutes- moves K

from ECG to ICF

-Sodium bicarbonate (500-100 mEq IV over 5 minutes)- moves K from ECF to ICF but only use if patient is in an acidotic state

-Beta2 agonist (albuterol 10 to 20mg via inhalation over 15 minutes)- watch cardiac side effects

Enhance potassium excretion

-Sodium polystyrene sulfonate (Kayxelate) (15 to 50 g in sorbitol orally or rectally)- cation ion

exchange resin that exchange Na+ for K+ in GI then binds K to excrete from body

-SPS 15 g PO x 1 dose (can also be give as enema)- each gram removes 0.5-1 mmol of potassium-

takes 1-2 hours to work (produces bowel movement)

-Furosemide Adults: 40 to 80 mg IV ( increases H+ and K excretion)

Long-term treatment

Dietary potassium restriction

D/C potassium supplements

Avoid salt substitutes

Consider decreasing dose of offending agent

Wiki #10

What are the differences between systemic steroid agents? Include equivalent doses, anti-inflammatory potency, mineralocorticoid activity and half-life.


 * || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Approximate equivalent dose, mg || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Relative anti-inflammatory activity || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Relative mineralocorticoid activity || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Duration of action, hours ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Cortisol || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">20 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">8-12 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Cortisone acetate || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">25 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.8 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.8 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">8-12 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Hydrocortisone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">20 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">8-12 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Prednisone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.8 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12-36 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Prednisolone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.8 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12-36 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Methylprednisolone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.5 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12-36 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Triamcinolone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12-36 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Fludrocortisone ||  || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">10 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">125 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12-36 ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Dexamethasone || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0.75 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">30 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">0 || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">36-72 ||

Schimmer, BP, Parker, KL; Adrenocorticotropic hormone; adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormones; Chap 59 Pharmacological basis of therapeutics; 11th ed Brunton, LL et al eds. 2006 McGraw Hill, New York, NY

Wiki #10

KP is a 53 year old CKD patient being treated for VRE bacteremia with linezolid 600 mg PO BID. KP has a PMH significant for CKD, depression, DM-2, and osteoarthritis. Home meds include: fluoxetine 20 mg daily, glipizide 10 mg BID, lisinopril 10 mg daily, and acetaminophen 500 mg QID. Which of the patient's home meds should you caution the medical team on while patient is taking linezolid? What is the result of the interaction and what should you recommend to the team? Are there any significant drug-food interactions that the patient should be made aware of while on linezolid?

Fluoxetine, an SSRI, should not be administered with linezolid. Linezolid has some mild monoamine oxidase inhibitor properties and can enhance the effect of an SSRI. This can lead to serotonin syndrome. Serotonin syndrome manifests itself as restlessness, confusion, shivering, tachycardia, diarrhea, muscle twitches/ rigidity, fever, seizures, loss of consciousness and death. Because of fluoxetine’s long half-life, the FDA recommends stopping fluoxetine for 5 weeks before starting linezolid therapy. Patient’s can start linezolid therapy if the benefits outweigh the risks and the patient is closely monitored for signs and symptoms of serotonin syndrome.

Patient should avoid eating large amounts of foods containing tyramine. Examples of tyramine containing foods are aged cheese, cured meats (like sausage and salami), fava beans, tap and draft beers, wine, sauerkraut, soy sauce and other soybean condiments.


 * 1) Sanders-Bush E, Hazelwood L. Chapter 13. 5-Hydroxytryptamine (Serotonin) and Dopamine. In: Sanders-Bush E, Hazelwood L, eds. //Goodman & Gilman's The Pharmacological Basis of Therapeutics//. 12nd ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=16662305. Accessed January 10, 2012.
 * 2) Lexi-Comp (Lexi-Drugs) [computer program]. Lexi-Comp; Ver: 1.7.3.(151).
 * 3) Gever J. FDA Warns About Methylene Blue, Linezolid with SSRIs. Medpage Today. http://www.medpagetoday.com/ProductAlert/Prescriptions/27748. July 26, 2011. Accessed January 10, 2012.