Older adults, children and women’s health: the BCPS exam’s special populations

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

1. Case 01

   An 84-year-old woman with heart failure, atrial fibrillation, and type 2 diabetes takes 9 scheduled medications. She bathes, dresses, and toilets without help (Katz ADL score 6/6), but her daughter reports missed doses, early refills, and unpaid bills. The team must decide whether she can keep managing her own medications. Which assessment is most appropriate next?

   1. AOption A: Lawton-Brody IADL scale
   2. BOption B: Timed Up and Go test
   3. COption C: Geriatric Depression Scale
   4. DOption D: Repeat Katz ADL index

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Medication management, shopping, and handling finances are instrumental activities of daily living, so the Lawton IADL scale (which scores the ability to take medications correctly) directly answers the question. The Katz index measures basic self-care that she already performs independently, so repeating it adds nothing. The Timed Up and Go test assesses mobility and fall risk, and a depression screen may explain poor adherence but does not measure capacity to manage the regimen.

   A

   Correct: managing medications is an instrumental activity of daily living, and the Lawton-Brody scale scores exactly that ability alongside shopping and finances.

   B

   The Timed Up and Go test screens gait and fall risk; it says nothing about whether she can keep nine medications straight.

   C

   Depression can erode adherence and is worth screening later, but this scale does not measure her capacity to run her own regimen.

   D

   She already scored 6/6 on basic self-care, so repeating the Katz index cannot reveal the higher-level deficit her daughter describes.

2. Case 02

   A Spanish-speaking mother with limited English proficiency picks up amoxicillin 400 mg/5 mL suspension for her 20-kg son with acute otitis media. The prescription is 90 mg/kg/day divided twice daily. Speaking through a professional medical interpreter, which instruction should the pharmacist give and confirm by teach-back?

   1. AOption A: Give 2 teaspoons twice daily using a kitchen spoon
   2. BOption B: Give 22.5 mL once daily using the oral syringe
   3. COption C: Give 5.6 mL twice daily using the oral syringe
   4. DOption D: Give 11.25 mL twice daily using the oral syringe

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   The daily dose is 90 mg/kg × 20 kg = 1,800 mg, or 900 mg twice daily; at 80 mg/mL that is 11.25 mL per dose, measured with an mL-marked oral syringe and confirmed by teach-back through the interpreter. Giving 5.6 mL twice daily delivers only the standard 45 mg/kg/day, which is too low for AOM. Giving the whole daily volume once daily is not the prescribed regimen, and kitchen teaspoons are inaccurate and confusing for a parent with limited English.

   A

   Kitchen spoons vary widely in volume, and 2 teaspoons (about 10 mL) underdoses her son; household measures also confuse families working across languages.

   B

   22.5 mL is the right daily total, but the prescription is divided twice daily, so giving it all at once departs from the ordered regimen.

   C

   5.6 mL twice daily supplies only about 45 mg/kg/day, half the high dose ordered for otitis media.

   D

   Correct: 90 mg/kg × 20 kg = 1,800 mg/day, or 900 mg per dose; at 80 mg/mL that is 11.25 mL twice daily, measured in an mL-marked oral syringe.

3. Case 03

   A 4-year-old boy has wheezing episodes about three times a month that respond to albuterol, nighttime cough twice a month, and two ED visits for wheeze in the past year. He has no other medical problems. According to GINA for children 5 years and younger, which controller is most appropriate?

   1. AOption A: Daily montelukast 4 mg chewable tablet
   2. BOption B: Budesonide-formoterol as maintenance and reliever therapy
   3. COption C: Albuterol as needed, with no controller
   4. DOption D: Daily low-dose ICS by pMDI with spacer and mask

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   For children 5 years and younger with frequent wheeze episodes and exacerbations, GINA’s preferred Step 2 controller is daily low-dose ICS (such as fluticasone), delivered by pMDI with a spacer and face mask at this age. Montelukast is an alternative, but it is less effective than ICS and carries a boxed warning for neuropsychiatric events. Budesonide-formoterol maintenance and reliever therapy is not recommended for children 5 and younger, and albuterol alone leaves the airway inflammation untreated.

   A

   Montelukast is only an alternative controller at this age: it is less effective than an inhaled steroid and carries a boxed warning for neuropsychiatric effects.

   B

   Maintenance-and-reliever budesonide-formoterol is not recommended by GINA for children 5 years and younger.

   C

   With monthly episodes, night cough and two ED visits in a year, reliever-only treatment leaves his airway inflammation untreated.

   D

   Correct: GINA’s preferred Step 2 option under age 6 is daily low-dose ICS, and a pMDI with a valved spacer and face mask suits a 4-year-old.

4. Case 04

   An 82-year-old woman with Alzheimer disease takes donepezil 10 mg nightly. Six weeks ago oxybutynin IR 5 mg three times daily was started for new urge incontinence. Her daughter now reports worsening confusion and constipation. Which change is most appropriate?

   1. AOption A: Increase donepezil to 23 mg daily
   2. BOption B: Add memantine 5 mg daily for the confusion
   3. COption C: Switch oxybutynin to tolterodine ER 4 mg daily
   4. DOption D: Stop oxybutynin and consider mirabegron

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Oxybutynin’s antimuscarinic effect directly opposes the cholinesterase inhibitor and worsens cognition, and the 2023 Beers Criteria advise avoiding strongly anticholinergic drugs in dementia; mirabegron treats urge incontinence without anticholinergic burden. Tolterodine is a tempting swap but is still an antimuscarinic and keeps the same drug–disease interaction. Raising donepezil or adding memantine treats an adverse effect with another drug—a prescribing cascade that began when donepezil itself likely triggered the incontinence.

   A

   Raising donepezil answers a drug-induced problem with more drug, and the 23 mg dose adds GI effects and may worsen the incontinence.

   B

   Adding memantine treats an anticholinergic adverse effect with another medication, a classic prescribing cascade.

   C

   Tolterodine is still an antimuscarinic, so the drug–disease interaction with dementia and the clash with donepezil remain.

   D

   Correct: oxybutynin’s anticholinergic load likely caused the confusion and constipation, and mirabegron treats urge incontinence without that burden (Beers 2023).

5. Case 05

   A 29-year-old woman is 4 days past a vaginal delivery with a second-degree perineal tear and is exclusively breastfeeding her healthy term infant. Scheduled acetaminophen has not fully controlled her pain. She has no history of GI bleeding, asthma, kidney disease, or hypertension. Her discharge prescription is acetaminophen with codeine. Which recommendation is most appropriate?

   1. AOption A: Keep the codeine product but use it for no more than 3 days
   2. BOption B: Add scheduled ibuprofen to acetaminophen instead of codeine
   3. COption C: Change codeine to tramadol, which is less affected by CYP2D6
   4. DOption D: Keep codeine and watch the infant for sleepiness or poor feeding

   Pick an option: the verdict and a note on every option open here.

   Best answer: B.

   In a 2017 Drug Safety Communication, the FDA recommended against codeine and tramadol in breastfeeding women. In mothers who are CYP2D6 ultra-rapid metabolizers, both drugs are converted to more active opioids (morphine and O-desmethyltramadol) that pass into milk. Breastfed infants have had excess sleepiness, trouble feeding, serious breathing problems and death. LactMed calls ibuprofen a preferred analgesic in nursing mothers because milk levels are extremely low and its half-life is short. Adding scheduled ibuprofen to acetaminophen suits her, since she has no NSAID contraindications.

   A

   A short course does not remove the risk: an ultra-rapid CYP2D6 metabolizer can pass dangerous morphine levels to the infant within days.

   B

   Correct. Ibuprofen reaches only very low levels in milk and has a short half-life; LactMed lists it as a preferred analgesic when nursing.

   C

   Tramadol is also activated by CYP2D6, and the FDA recommends against both tramadol and codeine during breastfeeding.

   D

   Monitoring the infant was earlier advice. The FDA now recommends against codeine in breastfeeding women altogether.

6. Case 06

   A 62-year-old man with confirmed symptomatic hypogonadism (two morning total testosterone levels below 250 ng/dL) is starting testosterone gel 1.62%, applied once daily to the shoulders and upper arms. His 4-year-old grandson lives with him. Which counseling point is most important?

   1. AOption A: Cover the site with clothing once the gel has dried
   2. BOption B: Apply the gel at bedtime so it absorbs during sleep
   3. COption C: Shower within 30 minutes to remove residue from the skin
   4. DOption D: Apply the gel to the abdomen so children cannot reach it

   Pick an option: the verdict and a note on every option open here.

   Best answer: A.

   Testosterone gels carry a boxed warning for secondary exposure: children who touch the application site can develop virilization, so the patient should wash his hands, let the gel dry, and keep the site covered with clothing. Moving the application to the abdomen does not prevent skin-to-skin transfer and is not the labeled site for this product. Showering within 30 minutes removes drug before absorption (wait at least 2 hours), and bedtime application does not reduce transfer to family members.

   A

   Correct: the boxed warning is secondary exposure, so once the gel dries the site stays covered with clothing (and hands are washed) to protect the grandson.

   B

   Bedtime application does nothing to stop transfer; skin-to-skin contact with a child can happen at any hour.

   C

   Washing within 30 minutes strips drug before it is absorbed; the label asks patients to wait about 2 hours before showering.

   D

   The 1.62% gel is labeled for the shoulders and upper arms, and an abdominal site can still transfer drug through contact.

7. Case 07

   A 27-year-old woman at 20 weeks of gestation has fatigue. Labs: hemoglobin 9.6 g/dL, MCV 74 fL, ferritin 11 ng/mL. She takes a prenatal vitamin containing 27 mg of iron and has no GI disease or intolerance to oral iron. Which treatment is most appropriate?

   1. AOption A: Ferrous sulfate 325 mg orally three times daily
   2. BOption B: Iron sucrose 200 mg IV for five doses
   3. COption C: Ferrous gluconate 300 mg orally once weekly
   4. DOption D: Ferrous sulfate 325 mg orally once daily

   Pick an option: the verdict and a note on every option open here.

   Best answer: D.

   Ferrous sulfate 325 mg provides 65 mg of elemental iron, and one tablet daily (or every other day) delivers the recommended 60–120 mg/day; each dose raises hepcidin, which blocks absorption for about 24 hours, so more frequent dosing adds GI effects without more absorption. Three tablets a day is the traditional answer but causes more constipation and nausea and reduces adherence. IV iron is reserved for intolerance, malabsorption or severe anemia late in pregnancy, and a weekly dose is far too little.

   A

   Three tablets a day is the traditional answer, but extra doses raise hepcidin, add GI effects and hurt adherence without improving absorption.

   B

   IV iron is reserved for oral intolerance, malabsorption or severe anemia late in pregnancy, none of which applies at 20 weeks.

   C

   A single weekly tablet delivers far too little elemental iron to correct established iron deficiency.

   D

   Correct: one 325 mg tablet (65 mg elemental iron) daily, or every other day, treats the deficiency with fewer GI effects than divided dosing.

8. Case 08

   A 29-year-old woman with polycystic ovary syndrome (BMI 31 kg/m²) has oligo-ovulatory infertility. Her partner’s semen analysis and her tubal patency study are normal. She has tried lifestyle changes for 6 months. Which first-line ovulation induction therapy is most appropriate?

   1. AOption A: Gonadotropin injections daily from cycle day 3
   2. BOption B: Metformin 1,000 mg twice daily alone
   3. COption C: Letrozole 2.5 mg daily on cycle days 3–7
   4. DOption D: Clomiphene 50 mg daily on cycle days 5–9

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   Letrozole, an aromatase inhibitor, is first-line for ovulation induction in PCOS (ASRM/international PCOS guideline) because it produced higher ovulation and live birth rates than clomiphene with fewer multiple pregnancies. Clomiphene is the traditional answer and remains an alternative, but it is less effective in PCOS. Metformin alone is much less effective for live birth, and gonadotropins are second-line because of the risks of ovarian hyperstimulation and multiple gestation.

   A

   Gonadotropins are second-line because they carry higher risks of ovarian hyperstimulation and multiple gestation.

   B

   Metformin alone improves cycles in some women but produces fewer live births than letrozole.

   C

   Correct: in PCOS-related anovulation, letrozole gives higher ovulation and live birth rates than clomiphene and is first-line in the 2023 international PCOS guideline.

   D

   Clomiphene is the older standard and remains an alternative, but it is less effective than letrozole in PCOS.

9. Case 09

   A 31-year-old woman with obstetric antiphospholipid syndrome (persistent lupus anticoagulant and anticardiolipin IgG at high titer, three consecutive losses before 10 weeks, no prior thrombosis) has a positive pregnancy test at 5 weeks. Which regimen is most appropriate during this pregnancy?

   1. AOption A: Aspirin 81 mg daily alone, starting at 12 weeks
   2. BOption B: Warfarin with an INR goal of 2.0–3.0 plus aspirin
   3. COption C: Aspirin 81 mg daily plus prophylactic enoxaparin
   4. DOption D: Therapeutic-dose enoxaparin twice daily, no aspirin

   Pick an option: the verdict and a note on every option open here.

   Best answer: C.

   For obstetric APS without prior thrombosis, low-dose aspirin plus prophylactic-dose LMWH improves live birth rates compared with aspirin alone (ACR 2020/ACOG), and is continued through pregnancy and for 6 weeks postpartum. Aspirin alone is the tempting simpler option, but it is reserved for antiphospholipid antibodies without obstetric APS. Therapeutic-dose LMWH is for patients with prior thrombosis, and warfarin is teratogenic in the first trimester.

   A

   Aspirin alone, started late, suits antiphospholipid antibodies without obstetric APS; with three early losses she needs heparin added.

   B

   Warfarin is teratogenic in the first trimester and is not used during pregnancy for APS.

   C

   Correct: obstetric APS without prior thrombosis calls for low-dose aspirin plus prophylactic heparin, continued through pregnancy and 6 weeks postpartum (ACR 2020).

   D

   Therapeutic-dose LMWH is for patients with a history of thrombosis, and dropping aspirin removes part of the proven regimen.

10. Case 10

    A 52-year-old woman with an intact uterus had her last menstrual period 14 months ago and has 8 to 10 hot flashes a day that disrupt her sleep. She has no history of breast cancer, VTE, stroke, coronary disease, or liver disease, and her BP is 124/78 mm Hg. Two weeks ago her prescriber started a transdermal estradiol patch alone. Which recommendation is most appropriate?

    1. AOption A: Keep the patch and add a progestogen for endometrial protection
    2. BOption B: Keep the patch alone; the transdermal route spares the endometrium
    3. COption C: Replace the patch with low-dose vaginal estradiol cream
    4. DOption D: Stop estradiol and start paroxetine, as hormones are second-line

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    The boxed warning in FDA estrogen labeling states that a woman with a uterus who uses unopposed estrogen has a higher risk of endometrial cancer, and that adding a progestin lowers the risk of endometrial hyperplasia. This applies to systemic estrogen by any route, including a patch. The Menopause Society 2022 hormone therapy position statement calls hormone therapy the most effective treatment for vasomotor symptoms. For women younger than 60 or within 10 years of menopause without contraindications, it says the benefits generally outweigh the risks. Nonhormonal options such as paroxetine are for women who cannot or do not want to use hormones.

    A

    Correct. Systemic estrogen in a woman with a uterus needs a progestogen to prevent endometrial hyperplasia and cancer.

    B

    The route does not change the endometrial risk. Unopposed systemic estrogen by any route stimulates the endometrium.

    C

    Low-dose vaginal estrogen treats genitourinary symptoms, not frequent hot flashes.

    D

    For a healthy woman under 60 within 10 years of menopause, hormone therapy is the most effective treatment for hot flashes.

11. Case 11

    A 66-year-old woman has taken zolpidem 10 mg nightly for 5 years for chronic insomnia. After a nighttime fall she asks to stop it. She sleeps about 6 hours a night and has no depression or sleep apnea. Which plan is most appropriate?

    1. AOption A: Stop zolpidem tonight and start melatonin 5 mg
    2. BOption B: Reduce zolpidem to 5 mg and continue it long term
    3. COption C: Taper zolpidem gradually while starting CBT-I
    4. DOption D: Switch to temazepam 15 mg, then taper it slowly

    Pick an option: the verdict and a note on every option open here.

    Best answer: C.

    Combining a gradual taper with cognitive behavioral therapy for insomnia gives the highest rate of successful hypnotic discontinuation and treats the underlying insomnia. Stopping abruptly after years of nightly use invites rebound insomnia and withdrawal, and melatonin has little effect on chronic insomnia. Switching to a benzodiazepine trades one Beers-listed sedative for another, and continuing 5 mg still leaves her with fall and fracture risk.

    A

    Stopping abruptly after 5 years of nightly use invites rebound insomnia, and melatonin does little for chronic insomnia.

    B

    A lower dose still leaves a Beers-listed hypnotic and the fall risk that prompted her request.

    C

    Correct: a gradual taper paired with CBT-I gives the best odds of staying off the hypnotic and treats the insomnia itself.

    D

    Temazepam swaps one Beers-listed sedative for another and adds a step without lowering her fall risk.

12. Case 12

    A 4-year-old boy has nasal congestion, rhinorrhea and sneezing most days for 3 months, worse in spring, which disturb his sleep. Allergy testing confirms grass and tree pollen sensitization. He has no asthma. Which medication is most appropriate to start?

    1. AOption A: Mometasone nasal spray, 1 spray per nostril daily
    2. BOption B: Pseudoephedrine liquid every 6 hours as needed
    3. COption C: Diphenhydramine liquid 1 mg/kg at bedtime nightly
    4. DOption D: Montelukast 4 mg chewable tablet once daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    Intranasal corticosteroids are the most effective treatment for persistent allergic rhinitis, particularly nasal congestion, and mometasone is approved from age 2 with minimal systemic effects at standard doses. Montelukast is less effective than an intranasal steroid and carries a boxed warning for neuropsychiatric events. First-generation antihistamines such as diphenhydramine sedate, impair learning and can cause paradoxical excitation, and oral decongestants are not recommended in young children because of toxicity.

    A

    Correct: an intranasal corticosteroid is the most effective therapy for persistent allergic rhinitis, and mometasone is labeled from age 2 at 1 spray per nostril daily.

    B

    Oral decongestants are not recommended in young children because of toxicity, and they do not treat the allergic inflammation.

    C

    First-generation antihistamines sedate, impair learning and can cause paradoxical excitation in children.

    D

    Montelukast is less effective than a nasal steroid for rhinitis and carries a boxed warning for neuropsychiatric events.

13. Case 13

    A 47-year-old transgender woman wants to start feminizing hormone therapy. She smokes 1 pack per day and is working on cessation, has a BMI of 31 kg/m², and has no prior VTE. BP is 128/78 mm Hg, K 4.2 mEq/L, and liver enzymes are normal. Which regimen is most appropriate?

    1. AOption A: Conjugated estrogens plus medroxyprogesterone
    2. BOption B: Oral estradiol plus finasteride
    3. COption C: Ethinyl estradiol plus spironolactone
    4. DOption D: Transdermal estradiol plus spironolactone

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    17β-estradiol plus an antiandrogen such as spironolactone is the standard feminizing regimen (Endocrine Society), and the transdermal route is preferred for patients over 45 or with VTE risk factors such as smoking and obesity, because it avoids first-pass hepatic effects on clotting factors. Ethinyl estradiol carries the highest thrombotic risk and is not recommended. Conjugated estrogens cannot be monitored with serum estradiol levels and add a progestin without proven benefit, and finasteride is a weak antiandrogen that does not lower testosterone.

    A

    Conjugated estrogens cannot be tracked with serum estradiol levels, and adding a progestin brings risk without proven feminizing benefit.

    B

    Oral estradiol adds first-pass clotting effects in a smoker over 45, and finasteride does not lower testosterone.

    C

    Ethinyl estradiol carries the highest thrombotic risk of any estrogen and is not used for feminizing therapy.

    D

    Correct: transdermal 17β-estradiol avoids first-pass effects on clotting factors, key with smoking, obesity and age over 45; spironolactone suits her normal potassium.

14. Case 14

    An 8-year-old girl (25 kg, BSA 0.95 m²) has polyarticular juvenile idiopathic arthritis with six active joints despite 8 weeks of naproxen. Liver enzymes and CBC are normal, and she has no risk factors for poor outcome. Which regimen is most appropriate to start?

    1. AOption A: Hydroxychloroquine 100 mg orally once daily
    2. BOption B: Prednisone 2 mg/kg orally once daily for 6 months
    3. COption C: Methotrexate 10 mg orally once daily plus folic acid
    4. DOption D: Methotrexate 10 mg SC once weekly plus folic acid

    Pick an option: the verdict and a note on every option open here.

    Best answer: D.

    Methotrexate at about 10–15 mg/m² once weekly (SC gives more reliable absorption) with folic acid is the first-line DMARD for polyarticular JIA after NSAID failure (ACR 2019). Daily methotrexate is a well-known and potentially fatal dosing error, causing marrow suppression and mucositis, which is why ISMP lists oral methotrexate as a high-alert drug. Hydroxychloroquine is not effective as monotherapy for JIA, and long-term systemic steroids cause growth suppression and are used only as a short bridge.

    A

    Hydroxychloroquine is not effective as monotherapy for polyarticular JIA.

    B

    Months of high-dose prednisone would stunt growth and cause serious toxicity; steroids are only a short bridge in JIA.

    C

    Daily methotrexate is a well-known and potentially fatal dosing error that causes marrow suppression and mucositis.

    D

    Correct: weekly methotrexate (about 10–15 mg/m², SC for reliable absorption) with folic acid is the first-line DMARD after NSAID failure (ACR 2019).

15. Case 15

    A 27-year-old woman with juvenile myoclonic epilepsy has been seizure-free for 3 years on valproic acid 1,000 mg daily. She plans to conceive in about 12 months and currently uses condoms. Which plan is most appropriate?

    1. AOption A: Transition to levetiracetam now and start folic acid daily
    2. BOption B: Continue valproate, then stop it once pregnancy is confirmed
    3. COption C: Switch to topiramate before conception and add folic acid
    4. DOption D: Continue valproate and add high-dose folic acid 4 mg daily

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    Valproate carries the highest risk of major malformations and neurodevelopmental harm, so the AAN/AES 2024 guidance is to transition before conception to a lower-risk agent such as levetiracetam (effective for JME, unlike lamotrigine, which can worsen myoclonus) and give folic acid. Folic acid does not cancel valproate’s teratogenicity. Stopping after pregnancy is confirmed is too late—the neural tube closes by day 28—and risks seizures, and topiramate is linked to oral clefts and small-for-gestational-age infants.

    A

    Correct: valproate is the most teratogenic antiseizure drug, so she should switch well before conception to levetiracetam, which covers JME, and take folic acid.

    B

    Stopping after pregnancy is confirmed is too late: the neural tube closes by day 28, and abrupt withdrawal risks seizures.

    C

    Topiramate is linked to oral clefts and small-for-gestational-age infants, so it is a poor choice for a planned pregnancy.

    D

    High-dose folic acid does not cancel valproate’s malformation and neurodevelopmental risks.

16. Case 16

    A 3-year-old girl (14 kg) with cystic fibrosis and exocrine pancreatic insufficiency is starting pancrelipase delayed-release capsules at 1,000 lipase units/kg/meal. She cannot swallow capsules. Which counseling point for her parents is most appropriate?

    1. AOption A: Sprinkle beads on applesauce as each meal starts
    2. BOption B: Give the full daily dose once at bedtime
    3. COption C: Stir the beads into a glass of milk after meals
    4. DOption D: Crush the beads so they mix evenly into her food

    Pick an option: the verdict and a note on every option open here.

    Best answer: A.

    Pancrelipase beads have an enteric coating that protects the enzymes from gastric acid, so they should be opened onto a small amount of acidic soft food such as applesauce, swallowed without chewing, and given at the start of each meal and snack so the enzymes mix with the food. Crushing or chewing the beads destroys the coating, inactivating the enzymes and irritating the mouth. Milk is not acidic and can dissolve the coating before the stomach, and dosing apart from meals or once daily leaves meals undigested.

    A

    Correct: opening the capsule onto a little acidic soft food such as applesauce at the start of each meal protects the coating and mixes enzyme with food.

    B

    Enzymes act only on food eaten with them, so a bedtime dose leaves every meal undigested.

    C

    Milk is not acidic and can dissolve the coating early, and dosing after the meal misses the food it should digest.

    D

    Crushing the beads destroys the enteric coating, so stomach acid inactivates the enzymes and the mouth gets irritated.