Therapeutics and patient management: the PK and counseling domain

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

   A 7-year-old with persistent asthma is prescribed fluticasone HFA 44 mcg, 2 puffs twice daily, through a valved holding chamber with a mouthpiece. Which instruction should the pharmacist give the child and parent?

   1. AOption A: Wait about 5 minutes after releasing the puff before inhaling
   2. BOption B: Inhale as fast and hard as possible, as with a dry powder inhaler
   3. COption C: Release both puffs into the chamber at once, then inhale deeply
   4. DOption D: Release one puff into the chamber, then take 5–6 slow breaths

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

   Best answer: D.

   Each actuation should be inhaled separately: one puff into the chamber, followed promptly by slow tidal breaths (or one slow deep breath with a hold), then repeat for the second puff and rinse the mouth after the ICS. Firing two puffs at once increases particle impaction and electrostatic loss, so less drug reaches the lungs. Delaying inhalation lets the aerosol settle in the chamber, and the forceful inhalation used for dry powder inhalers drives HFA particles into the throat.

   A

   Waiting minutes lets the aerosol settle on the chamber walls, so little drug is left to inhale.

   B

   Forceful inhalation suits dry powder devices; with an HFA inhaler it drives particles into the throat.

   C

   Two puffs at once increase particle collision and electrostatic loss in the chamber, cutting the lung dose.

   D

   Correct: one actuation into the chamber followed by slow tidal breaths, repeated for the second puff, then a mouth rinse after the steroid.

2. Case 02

   A 31-year-old nonsmoker has episodic wheeze and nighttime cough. Spirometry: pre-bronchodilator FEV1 2.10 L (72% predicted), FEV1/FVC 0.68; 15 minutes after albuterol, FEV1 is 2.45 L. Which interpretation is correct?

   1. AOption A: Normal spirometry; symptoms likely due to postnasal drip
   2. BOption B: Obstruction without significant reversibility, consistent with COPD
   3. COption C: Restrictive pattern requiring lung volumes for confirmation
   4. DOption D: Obstruction with significant reversibility, consistent with asthma

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

   Best answer: D.

   An FEV1/FVC below 0.70 shows airflow obstruction, and FEV1 rose by 0.35 L, or about 17% (0.35 ÷ 2.10), which meets the reversibility criterion of at least 12% and 200 mL—supporting asthma. Calling it fixed obstruction misreads the post-bronchodilator change, and COPD is unlikely in a young nonsmoker. A restrictive pattern requires a normal or high FEV1/FVC with low FVC, and spirometry here is clearly not normal.

   A

   An FEV1/FVC of 0.68 is below 0.70, so this spirometry is clearly abnormal.

   B

   FEV1 rose 350 mL after albuterol, so the obstruction is reversible, and COPD is unlikely in a 31-year-old nonsmoker.

   C

   Restriction shows a normal or high FEV1/FVC with a low FVC, the opposite of this low ratio.

   D

   Correct: the ratio below 0.70 shows obstruction, and a 0.35 L (about 17%) rise exceeds the 12% and 200 mL reversibility threshold, supporting asthma.

3. Case 03

   A 55-year-old man with rheumatoid arthritis well controlled on etanercept 50 mg weekly and methotrexate 15 mg weekly is admitted with community-acquired pneumonia requiring IV antibiotics. His RA is quiet. Which plan for etanercept is most appropriate?

   1. AOption A: Switch to adalimumab during the admission
   2. BOption B: Double the methotrexate while etanercept is held
   3. COption C: Hold etanercept until the infection has resolved
   4. DOption D: Continue etanercept to prevent an RA flare

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

   Best answer: C.

   TNF inhibitors impair host defense, and their labels advise holding the biologic during a serious infection and restarting once the infection has resolved and antibiotics are complete; a short interruption rarely causes a flare. Continuing etanercept risks worse infection. Adalimumab is another TNF inhibitor with the same risk, and doubling methotrexate adds immunosuppression and toxicity during an acute infection.

   A

   Adalimumab is another TNF inhibitor with the same infection risk, so switching changes nothing.

   B

   Doubling methotrexate adds immunosuppression and toxicity in the middle of an acute infection.

   C

   Correct: TNF inhibitor labels advise holding therapy during a serious infection and restarting once it resolves; a brief pause rarely triggers a flare.

   D

   Continuing a TNF inhibitor through pneumonia that needs IV antibiotics risks a worse infection.

4. Case 04

   A 52-year-old man is 3 weeks past a kidney transplant and takes tacrolimus 4 mg twice daily (8 AM and 8 PM), mycophenolate mofetil 1,000 mg twice daily, and prednisone 5 mg daily. Tacrolimus trough levels are drawn in clinic at 8 AM. Which counseling point about tacrolimus is correct?

   1. AOption A: Take St. John’s wort if low mood occurs
   2. BOption B: Take the morning dose just before the blood draw
   3. COption C: Take the morning dose after the blood draw
   4. DOption D: Drink grapefruit juice on days the level is low

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

   Best answer: C.

   A trough must be drawn just before the next scheduled dose (about 12 hours after the last), so the morning dose is taken after the blood draw; dosing first falsely elevates the level and can lead to underdosing and rejection. Grapefruit inhibits CYP3A4 and P-glycoprotein and makes tacrolimus levels unpredictable. St. John’s wort induces CYP3A4 and can drop tacrolimus levels enough to cause rejection.

   A

   St. John’s wort induces CYP3A4 and can drop tacrolimus levels enough to cause rejection.

   B

   Dosing before the draw falsely raises the trough, which can lead to underdosing and rejection.

   C

   Correct: a trough is drawn just before the next dose, about 12 hours after the last, so the morning dose follows the blood draw.

   D

   Grapefruit inhibits CYP3A4 and P-glycoprotein, making tacrolimus exposure unpredictable rather than correcting a low level.

5. Case 05

   A 67-year-old man with newly diagnosed type 2 diabetes will start an insulin glargine pen, 10 units at bedtime. When asked ‘How confident are you filling out medical forms by yourself?’ he answers ‘not at all,’ and he often asks his daughter to read his mail. Which education approach is most appropriate?

   1. AOption A: Refer him to the manufacturer’s online video series
   2. BOption B: Give him the manufacturer’s detailed patient leaflet
   3. COption C: Ask his daughter to read him the package insert
   4. DOption D: Demonstrate the pen, then have him show it back

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

   Best answer: D.

   His answer to the validated single-item screener suggests limited health literacy, so education should use plain language and teach-back (show-back), which confirms that he can actually prime, dial, and inject the dose. Detailed written leaflets are usually above the reading level of such patients, and having a family member read the insert transfers words, not verified skill. Online videos may help as reinforcement but give no confirmation that he can perform the technique.

   A

   Videos can reinforce teaching later, but they give no proof that he can prime, dial and inject the dose.

   B

   Detailed leaflets are usually written above the reading level of a patient with limited health literacy.

   C

   Having his daughter read the insert passes along words, not a verified skill he can perform alone.

   D

   Correct: his answer flags limited health literacy, so a demonstration followed by show-back confirms he can actually use the pen.

6. Case 06

   A 66-year-old woman with triple-positive antiphospholipid syndrome and a new DVT is being transferred to a skilled nursing facility on day 3 of enoxaparin 1 mg/kg every 12 hours overlapping with warfarin 5 mg daily. Today’s INR is 1.4. Which item in the transfer communication is most important to prevent a medication error?

   1. AOption A: The brand names of each generic medication she receives
   2. BOption B: Enoxaparin stop rule: ≥5 days and INR ≥2 for 24 hours
   3. COption C: Her preferred community pharmacy for future refills
   4. DOption D: The time her last acetaminophen dose was given

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

   Best answer: B.

   Warfarin is required in triple-positive APS (DOACs are avoided), and the overlap is the high-risk step: enoxaparin must continue for at least 5 days and until the INR is ≥2 for 24 hours, so the receiving facility needs that explicit stop rule to avoid stopping too early (clot) or never stopping (bleeding). Brand names add confusion rather than safety. The pharmacy preference and the last acetaminophen dose matter far less than defining when a high-alert anticoagulant ends.

   A

   Listing brand names adds a second name for each drug and invites confusion rather than safety.

   B

   Correct: the overlap is the high-risk step, so the facility needs the explicit rule to stop enoxaparin only after 5 days and an INR of 2 or more for 24 hours.

   C

   Her preferred pharmacy matters for refills later but does not prevent an anticoagulation error at transfer.

   D

   The last acetaminophen dose is minor information next to defining when a high-alert anticoagulant ends.

7. Case 07

   An 80-year-old man with HFrEF and mild cognitive impairment (MoCA 21/30) lives alone. He takes carvedilol, sacubitril/valsartan, spironolactone, dapagliflozin, and furosemide, and has had two HF admissions in 6 months linked to missed and doubled doses. His daughter visits daily. Which intervention is most appropriate?

   1. AOption A: Pharmacy adherence packaging, checked daily by his daughter
   2. BOption B: A written schedule and a 7-day organizer that he fills himself
   3. COption C: Donepezil to improve his ability to manage his medications
   4. DOption D: A sliding-scale furosemide plan that he adjusts by daily weights

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

   Best answer: A.

   His cognitive impairment explains the dosing errors, so the plan should remove the steps he cannot reliably perform: pharmacy-filled blister packaging plus a caregiver check addresses both adherence and safety. A self-filled organizer and written schedule still depend on the memory and executive function he has lost. A self-titrated diuretic plan adds complexity, and cholinesterase inhibitors have no proven benefit in MCI and add bradycardia risk with a beta-blocker.

   A

   Correct: pharmacy-filled blister packs checked daily by his daughter remove the steps his memory can no longer handle.

   B

   A self-filled organizer still depends on the memory and planning skills his cognitive impairment has eroded.

   C

   Cholinesterase inhibitors have no proven benefit in MCI and add bradycardia risk alongside carvedilol.

   D

   A self-adjusted diuretic plan adds decisions for a man who is already doubling and missing doses.

8. Case 08

   A 70-year-old woman with type 2 diabetes and rheumatoid arthritis has hand deformities and macular degeneration. She needs basal insulin and cannot reliably draw up NPH from a vial or read the syringe markings. She lives alone. Which delivery option is most appropriate?

   1. AOption A: Insulin glargine vial with low-dose syringes and a magnifier
   2. BOption B: Inhaled insulin as her once-daily basal insulin
   3. COption C: U-500 regular insulin vial to reduce injection volume
   4. DOption D: Insulin glargine prefilled pen with an audible dose dial

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

   Best answer: D.

   A prefilled pen removes the drawing-up step and lets her count dose clicks by sound, matching her dexterity and vision limits while giving the predictable basal insulin she needs. Vials with a magnifier still require fine motor skill she lacks. Inhaled insulin is a rapid-acting prandial product, not a basal insulin, and concentrated U-500 insulin is a high-alert product prone to severe dosing errors in this setting.

   A

   A magnifier helps with markings, but drawing up from a vial still needs the fine motor control her hands lack.

   B

   Inhaled insulin is a rapid-acting mealtime product and cannot serve as basal insulin.

   C

   U-500 concentrated insulin is a high-alert product prone to severe dosing errors, especially with poor vision.

   D

   Correct: a prefilled glargine pen removes the drawing-up step, and the audible clicks let her count the dose despite poor vision.

9. Case 09

   A 79-year-old man is admitted with confusion and an INR of 5.8. He says he takes ‘a blood thinner, a water pill, and a heart pill’ and has visited two clinics and an urgent care center in the past month. His wife fills his pill organizer. Which approach is most appropriate to obtain his medication history?

   1. AOption A: Interview him and his wife and verify with pharmacy fill data
   2. BOption B: Use the primary care EHR medication list as the single source
   3. COption C: Rely on his own recall, since he reports managing his medications
   4. DOption D: Copy the medication list from his discharge summary 6 months ago

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

   Best answer: A.

   A best possible medication history uses a structured interview plus at least one other independent source; his wife fills the organizer and fill records reveal recent new prescriptions (such as an interacting antibiotic) that could explain the high INR. A 6-month-old discharge list misses recent changes from multiple prescribers. His confusion makes his own recall unreliable, and a single clinic’s EHR list will not show what urgent care or the other clinic prescribed.

   A

   Correct: a best possible medication history pairs a structured interview with an independent source; his wife and fill records can reveal recent interacting prescriptions.

   B

   A single clinic’s EHR list misses what urgent care and the second clinic prescribed this month.

   C

   He is confused and cannot name his drugs, so his own recall is the least reliable source here.

   D

   A list from 6 months ago misses every recent change from his several prescribers.

10. Case 10

    A 50-year-old woman with autoimmune hepatitis is stable on azathioprine 100 mg daily and prednisone 5 mg daily. She develops recurrent gout, and her physician orders allopurinol 100 mg daily. CBC and renal function are normal. Allopurinol is considered necessary. Which plan is most appropriate?

    1. AOption A: Use febuxostat instead to avoid the interaction
    2. BOption B: Add colchicine prophylaxis and continue both unchanged
    3. COption C: Continue both drugs unchanged and check a CBC monthly
    4. DOption D: Reduce azathioprine to 25–33% of the dose; monitor CBC

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

    Best answer: D.

    Allopurinol inhibits xanthine oxidase, the enzyme that inactivates 6-mercaptopurine, so standard azathioprine doses can cause life-threatening myelosuppression; if the combination is used, the azathioprine dose must be cut to about one-quarter to one-third with close CBC monitoring. Febuxostat is also a xanthine oxidase inhibitor and is contraindicated with azathioprine. Continuing full doses with monthly CBCs or adding colchicine leaves the interaction in place.

    A

    Febuxostat also inhibits xanthine oxidase and is contraindicated with azathioprine, so it does not avoid the interaction.

    B

    Colchicine prevents gout flares but leaves the dangerous azathioprine interaction untouched.

    C

    Monthly CBCs at the full azathioprine dose would detect, not prevent, the marrow suppression this combination causes.

    D

    Correct: allopurinol blocks xanthine oxidase, which inactivates 6-mercaptopurine, so azathioprine is cut to about a quarter to a third with close CBC checks.

11. Case 11

    A 72-year-old woman is improving on IV levofloxacin 750 mg every 24 hours for community-acquired pneumonia (CrCl 70 mL/min) and will finish therapy orally at home. She takes calcium carbonate and ferrous sulfate every morning. Which oral levofloxacin regimen and instruction are most appropriate?

    1. AOption A: 500 mg daily, since oral absorption exceeds IV
    2. BOption B: 750 mg daily, taken together with the supplements
    3. COption C: 1,500 mg daily to offset lower oral absorption
    4. DOption D: 750 mg daily, 2 hours apart from the supplements

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

    Best answer: D.

    Oral levofloxacin is almost completely absorbed, so the IV dose converts 1:1 to 750 mg orally; the key risk at home is chelation by calcium and iron, which can sharply reduce absorption, so the dose should be separated from the supplements by at least 2 hours. Lowering to 500 mg or doubling to 1,500 mg misreads its near-100% bioavailability. Taking it together with the supplements is the common error that leads to treatment failure.

    A

    Oral levofloxacin is nearly 100% bioavailable, so the IV dose converts 1:1 and no reduction is needed.

    B

    Calcium and iron chelate levofloxacin and can sharply reduce absorption when taken together.

    C

    Doubling the dose misreads levofloxacin’s near-complete oral absorption and adds toxicity.

    D

    Correct: the 750 mg dose converts 1:1 from IV, and spacing it at least 2 hours from calcium and iron prevents chelation.

12. Case 12

    A 70-year-old woman with atrial fibrillation takes apixaban 5 mg twice daily at 8 AM and 8 PM. She calls at 2 PM because she forgot her morning dose. Which instruction is most appropriate?

    1. AOption A: Skip the missed dose and take only the 8 PM dose
    2. BOption B: Take 10 mg now and skip the 8 PM dose tonight
    3. COption C: Take the missed dose now, then the 8 PM dose
    4. DOption D: Skip the missed dose and take 10 mg at 8 PM

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

    Best answer: C.

    Apixaban’s label advises taking a missed dose as soon as possible on the same day and then resuming twice-daily dosing; with a half-life of about 12 hours, skipping a dose leaves a gap in stroke protection. Doubling the dose (at 8 PM or now) raises peak levels and bleeding risk without adding benefit. Simply skipping the dose is the tempting conservative choice, but it leaves her unprotected for 24 hours.

    A

    Skipping looks cautious, but with a half-life near 12 hours it leaves a long gap in stroke protection.

    B

    Taking a double dose raises the peak level and bleeding risk without adding benefit.

    C

    Correct: apixaban’s label says to take a missed dose as soon as possible the same day and then resume twice-daily dosing.

    D

    Doubling the evening dose raises bleeding risk and still leaves the daytime gap.

13. Case 13

    A 61-year-old woman with colon cancer takes capecitabine 1,000 mg/m² twice daily on days 1–14 of a 21-day cycle. On day 6 she calls to report 5 loose stools a day more than her usual, without fever or bleeding. Which instruction is most appropriate?

    1. AOption A: Continue capecitabine and take loperamide only
    2. BOption B: Double tomorrow’s dose to make up for any missed doses
    3. COption C: Stop capecitabine and contact the oncology team today
    4. DOption D: Continue capecitabine and report it at the next cycle visit

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

    Best answer: C.

    An increase of 4–6 stools per day over baseline is grade 2 diarrhea, and capecitabine labeling calls for interrupting therapy until it resolves to grade 0–1, then resuming (with dose reduction for recurrences); loperamide and hydration are added, and the team must assess her. Continuing capecitabine with loperamide alone allows progression to dehydration and grade 3–4 toxicity. Missed oral chemotherapy doses are never made up, and waiting until the next cycle is unsafe.

    A

    Loperamide alone while capecitabine continues lets grade 2 diarrhea progress to dehydration and grade 3–4 toxicity.

    B

    Missed oral chemotherapy doses are never made up, and doubling invites serious toxicity.

    C

    Correct: 4–6 extra stools a day is grade 2, and capecitabine labeling calls for interrupting it until resolved to grade 0–1, with same-day assessment.

    D

    Waiting until the next cycle visit ignores a toxicity that needs action today.

14. Case 14

    A 54-year-old woman with primary hypothyroidism has been stable on levothyroxine 88 mcg daily for 3 years. She started biotin 10 mg daily for hair thinning 2 months ago. She feels well, with no palpitations or weight loss, but today’s labs show TSH 0.05 mIU/L and free T4 2.8 ng/dL. Which is the most appropriate next step?

    1. AOption A: Reduce levothyroxine to 50 mcg daily and recheck in 6 weeks
    2. BOption B: Hold biotin for 2 or more days, then repeat the tests
    3. COption C: Order a radioactive iodine uptake scan
    4. DOption D: Start methimazole 5 mg daily for new hyperthyroidism

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

    Best answer: B.

    High-dose biotin interferes with streptavidin–biotin immunoassays, producing falsely low TSH and falsely high free T4 that mimic hyperthyroidism; the FDA has issued a safety warning about this interference. Holding biotin for at least 2 days before repeating the tests (longer after very high doses) unmasks the true values, and her lack of symptoms supports interference. Reducing levothyroxine or starting methimazole would treat a lab artifact and make her truly hypothyroid. An uptake scan is unnecessary until the results are confirmed without biotin.

    A

    Cutting levothyroxine would treat a lab artifact and could leave her truly hypothyroid.

    B

    Correct: high-dose biotin skews streptavidin–biotin immunoassays toward a false hyperthyroid pattern, so tests are repeated after holding it for at least 2 days.

    C

    An uptake scan is premature before the results are confirmed without biotin interference.

    D

    Methimazole would treat lab interference as disease and push her into hypothyroidism.

15. Case 15

    A 66-year-old man with a new PEG tube receives continuous enteral nutrition at 70 mL/hr. He takes phenytoin suspension 100 mg via the tube three times daily. His total phenytoin level fell from 14 mcg/mL before feeding began to 6 mcg/mL; albumin is 3.9 g/dL. Which intervention is most appropriate?

    1. AOption A: Open phenytoin ER capsules and flush the contents down the tube
    2. BOption B: Mix the phenytoin suspension directly into the feeding bag
    3. COption C: Hold feeds 1–2 hours before and after each phenytoin dose
    4. DOption D: Switch to IV fosphenytoin for the rest of his tube feeding

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

    Best answer: C.

    Continuous enteral feeding binds phenytoin in the tube and gut and can drop levels by more than 50%; holding feeds around each dose (with the dietitian raising the hourly rate to keep the daily calorie goal) restores absorption, and the level is then rechecked. Adding drugs to the feeding bag is unsafe and gives erratic delivery. Opening ER capsules destroys their release mechanism and clogs tubes, and long-term IV therapy is unnecessary when the enteral interaction can be managed.

    A

    Phenytoin ER capsules should not be opened for tube use; the contents clog tubes and lose their release mechanism.

    B

    Adding any drug to the feeding bag is unsafe and makes delivery erratic.

    C

    Correct: continuous feeds bind phenytoin; holding them 1–2 hours before and after each dose restores absorption, with the feed rate raised to keep calories.

    D

    Long-term IV therapy is unnecessary when the enteral interaction can be managed at the bedside.

16. Case 16

    A 66-year-old man has taken metformin 1,000 mg twice daily for 9 years. He reports 2 months of numbness and tingling in both feet. A1c is 6.9%, eGFR 72 mL/min/1.73 m², hemoglobin 11.8 g/dL, and MCV 104 fL. Which step is most appropriate?

    1. AOption A: Measure a vitamin B12 level and replace it if low
    2. BOption B: Stop metformin and start glipizide 5 mg daily
    3. COption C: Start folic acid 1 mg daily for the macrocytosis
    4. DOption D: Start gabapentin for diabetic peripheral neuropathy

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

    Best answer: A.

    Long-term metformin reduces vitamin B12 absorption, and ADA Standards recommend periodic B12 measurement, especially with neuropathy; macrocytic anemia plus neuropathy makes deficiency likely and reversible with replacement. Starting gabapentin labels the symptoms as diabetic neuropathy without excluding a treatable cause. Stopping effective metformin is unnecessary, and folic acid can correct the anemia while B12-related nerve damage progresses.

    A

    Correct: long-term metformin lowers B12 absorption, and macrocytic anemia with neuropathy makes a reversible deficiency likely; ADA advises periodic B12 checks.

    B

    Metformin is working and need not be stopped, and glipizide adds hypoglycemia risk in an older adult.

    C

    Folic acid can correct the anemia while B12-related nerve damage keeps progressing.

    D

    Gabapentin labels the symptoms diabetic neuropathy before a treatable cause has been ruled out.

17. Case 17

    A 56-year-old man with severe persistent asthma remains uncontrolled on high-dose fluticasone/salmeterol by metered-dose inhaler despite good refill adherence. When asked to demonstrate, he actuates the inhaler before starting to breathe in and exhales immediately afterward. Peak inspiratory flow is adequate, and he has no cognitive or motor impairment. Which step should be taken first?

    1. AOption A: Refer him for biologic therapy such as dupilumab now
    2. BOption B: Add tiotropium soft-mist inhaler to his current MDI regimen
    3. COption C: Retrain technique by demonstration and add a valved spacer
    4. DOption D: Switch the inhaler to nebulized budesonide twice daily at home

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

    Best answer: C.

    GINA advises checking and correcting inhaler technique and adherence before calling asthma ‘severe’ or stepping up; his poor hand–breath coordination is the reason the ICS/LABA is not reaching the lungs, and hands-on retraining plus a valved spacer fixes it. Adding tiotropium or a biologic escalates therapy for what may be a delivery problem, adding cost and adverse effects. Home nebulizers are less convenient and are not needed when a spacer can overcome the coordination error.

    A

    A biologic escalates therapy for what is really a delivery problem, adding cost before the basics are fixed.

    B

    Adding tiotropium steps up treatment while the current inhaler still fails to reach his lungs.

    C

    Correct: GINA calls for checking technique before labeling asthma severe; retraining plus a valved spacer fixes his hand–breath mismatch.

    D

    A home nebulizer is less convenient and unnecessary when a spacer can overcome the coordination error.

18. Case 18

    A 45-year-old woman with rheumatoid arthritis has moderate disease activity despite methotrexate 25 mg weekly. Her rheumatologist plans to add adalimumab 40 mg SC every 2 weeks, and she is anxious about starting injections. Which step must be completed before the first dose?

    1. AOption A: Live attenuated intranasal influenza vaccine
    2. BOption B: Interferon-gamma release assay for latent TB
    3. COption C: Anti-CCP antibody titer to set the starting dose
    4. DOption D: Baseline adalimumab trough concentration

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

    Best answer: B.

    TNF inhibitors can reactivate latent tuberculosis, so every patient needs TB screening (IGRA or skin test, plus hepatitis B testing) before the first dose, and latent infection is treated first; teach-back injection training then addresses her anxiety. Live vaccines should be given at least 4 weeks before, not with, immunosuppressive biologic therapy, and inactivated influenza vaccine is used instead. Drug levels have no meaning before exposure, and anti-CCP supports the diagnosis and prognosis but does not determine dosing.

    A

    Live vaccines are avoided with immunosuppressive biologics; she should receive inactivated influenza vaccine instead.

    B

    Correct: TNF inhibitors can reactivate latent tuberculosis, so TB screening (with hepatitis B testing) must precede the first dose.

    C

    Anti-CCP supports diagnosis and prognosis in RA but plays no role in choosing the adalimumab dose.

    D

    A drug level means nothing before the first dose; there is no exposure to measure yet.

19. Case 19

    A 59-year-old man with type 2 diabetes has limited health literacy and has been taking his metformin 500 mg twice-daily prescription only once a day. The pharmacy is revising its prescription label instructions. Which label wording is most appropriate for him?

    1. AOption A: Take 1 tablet in the morning and 1 tablet in the evening
    2. BOption B: Take 1 tablet by mouth twice daily with meals as directed
    3. COption C: Take 1 tablet every 12 hours with or without food
    4. DOption D: Take 1 tablet b.i.d. with breakfast and dinner as directed

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

    Best answer: A.

    Explicit-timing instructions based on the Universal Medication Schedule (morning, noon, evening, bedtime) are understood far more reliably by patients with limited health literacy than frequency terms; ‘twice daily’ is commonly misread as a single daily dose. ‘Every 12 hours’ requires the patient to work out clock times, and ‘b.i.d.’ is a Latin abbreviation most patients cannot decode. Confirming understanding with teach-back completes the intervention.

    A

    Correct: explicit times of day, as in the Universal Medication Schedule, are understood more reliably than frequency terms by patients with limited literacy.

    B

    ‘Twice daily’ is exactly the wording he misread as once a day, and ‘as directed’ adds nothing he can act on.

    C

    ‘Every 12 hours’ makes him work out clock times, an extra step that trips up patients with limited health literacy.

    D

    ‘b.i.d.’ is a Latin abbreviation most patients cannot decode, and it does not belong on a patient label.

20. Case 20

    A 70-year-old man with HFrEF, type 2 diabetes, and COPD lives 60 miles from the nearest pharmacy. He takes seven chronic medications with different refill dates, makes four or five trips a month, and has run out of carvedilol twice in the last 3 months. Which intervention is most appropriate?

    1. AOption A: Ask him to fill a weekly pill organizer from the bottles
    2. BOption B: Synchronize refills to one date with 90-day mail supplies
    3. COption C: Switch carvedilol to an as-needed dose when he runs out
    4. DOption D: Ask his prescribers for early refills whenever he runs low

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

    Best answer: B.

    Medication synchronization aligns all refills to a single date, and 90-day mail-order supplies cut his travel to almost nothing, directly removing the access barrier that causes gaps in therapy. Ad hoc early refills keep the staggered dates and the frequent trips. Beta-blockers must not be used as needed—intermittent use risks rebound tachycardia and worsening HF—and a pill organizer helps with organization, not with running out.

    A

    An organizer helps with sorting doses but does nothing about running out or the long drives to refill.

    B

    Correct: synchronizing refills to one date with 90-day mail supplies removes the trips and the gaps behind his missed carvedilol.

    C

    Beta-blockers must not be used as needed; intermittent use risks rebound tachycardia and worsening heart failure.

    D

    Ad hoc early refills keep the staggered dates and the four or five trips a month.