NAPLEX - Osteoarthritis McGraw Hill

KT is a 73-year-old woman with osteoarthritis (OA) of the hand. Her medication list includes: salsalate 500 mg twice daily, Lantus 10 U at bedtime, hydrochlorothiazide 25 mg daily, and ibuprofen 400 mg as needed that was recently increased to 800 mg twice daily as needed because of pain. What recommendation(s) do you give to the physician during rounds? Select all that apply.

A

KT should not be on more than one nonsteroidal anti-inflammatory drug (NSAID) at a time.

B

Ibuprofen should not be given as needed for OA osteoarthritis.

C

Ibuprofen should be dosed 3 to 4 times daily.

D

Salsalate has a longer platelet effect than ibuprofen

ABC

NSAIDs should not be used together as the anticoagulant effect is enhanced. The risk of bleeding increases. NOTE: Patients may be on a baby aspirin for the antiplatelet effect and receive an NSAID for OA.

Answer b is correct. Agents being used to treat OA should be given round the clock. A drug will never be fully effective if used as needed.

Answer c is correct. The duration of ibuprofen is 4 to 6 hours. Its half-life is 2 to 4 hours in adults. Dosing this drug twice daily leaves 6 or more hours at which the patient is not experiencing any pain relief from the drug.

Answer d is incorrect.Salsalate is a nonacetylated salicylate and does not affect platelets like acetylated salicylates (aspirin) or NSAIDs.

PD is a 63-year-old woman with osteoarthritis of the hip. She presents to today for injection of triamcinolone. The patient asks "How does this medication work?" An appropriate response to her question could include which of the following?

A

Repair of damaged nerves around the affected joint.

B

Desensitization of the central nervous system.

C

Reduction in inflammation leading to less swelling and tenderness.

D

Decreases production of uric acid in the affected joint.

C

Steroids likely do not repair damaged nerves. Additionally, osteoarthritis is more closely associated with joint damage, mechanical stress, and loss of articular cartilage as opposed to nerve damage.

Answer b is incorrect. Steroids are not known to be associated with desensitization of the central nervous system.

Answer c is correct. Anti-inflammatory properties of steroids lead to less swelling and tenderness which can lead to a reduction in pain and improved mobility of joints.

Answer d is incorrect. Steroids are not known to decrease production of uric acid. Additionally, high uric acid levels are more closely associated with gout instead of osteoarthritis.

Which of the following are important counseling points regarding handling of Flector? Select all that apply.

A

Do not cover with occlusive bandages.

B

Do not wear during bathing or showering.

C

Keep out of reach of children or pets.

D

Wash hands after applying.

ABCD

If Flector begins to peel-off it should not be covered with an occlusive bandage. Instead a mesh netting sleeve can be used to overlay the patch.

Answer b is correct. Flector should be removed before bathing or showering. According to the package insert, bathing should occur between patch removal and application.

Answer c is correct. Flector should be discarded out of reach of children or pets to avoid harm. If ingested by child or pet, seek medical help immediately.

Answer d is correct. Patients should wash hands immediately after applying the patch

Which of the following is a sign or symptom of a patient with clinical presentation of osteoarthritis?

A

Joint stiffness with rest

B

Normal range of motion with joint

C

Joint stability

D

Joint stiffness with movement

E

Frictionless joint movement

A

Patients will experience a stiffening of the joint at rest and improved mobility with increased movement.

Answer b is incorrect. Patients have a limited range of motion because of abnormal joint structure.

Answer c is incorrect. Patients will experience joint instability secondary to pathophysiological changes leading to abnormal anatomy.

Answer d is incorrect. Osteoarthritis patients will experience relief of stiffness with movement (gelling phenomenon) of the joint. Stiffness worsens with rest.

Answer e is incorrect. Osteoarthritis patients experience friction with movement as bone may move against bone secondary to cartilage destruction.

Which of the following are goals of osteoarthritis management? Select all that apply.

A

Teaching patient about the disease state

B

Curing osteoarthritis

C

Providing pain relief

D

Improving musculoskeletal movement

E

Maintaining ability to perform activities of daily living

ACDE

Patient education is a goal for osteoarthritis treatment.

Answer b is incorrect. At present, there is no cure for osteoarthritis.

Answer c is correct. Pain relief is the primary goal for osteoarthritis.

Answer d is correct. Improvement in musculoskeletal movement is a goal for osteoarthritis treatment.

Answer e is correct. Patients should be able to perform activities of daily living even with osteoarthritis.

SL is a 62-year-old obese man with a history of degenerative joint disease in his left knee. Past medical history is significant for dyslipidemia treated with gemfibrozil and diabetes with NPH 10 units bid and glipizide 10 mg bid. Blood sugar readings are not at goal with HgA1c of 8.5%. Current blood pressure is 130/80 mm Hg. He receives his second injection of 40 mg of Kenalog in his left knee today. Which side effect could cause a drug-disease state interaction in this patient?

A

Skin depigmentation

B

Adrenal insufficiency

C

Joint infection

D

Hyperglycemia

D

Patient is a diabetic. Glucocorticoid use is associated with carbohydrate intolerance and hyperglycemia. This would necessitate closer monitoring of his diabetes.

Answer a is incorrect. Skin depigmentation may occur with corticosteroids. However, this is not a disease-drug state interaction this patient is at risk for. Increased pigmentation can be a sign associated with adrenal insufficiency.

Answer b is incorrect. Patient is not manifesting signs of hypotension, fever or symptoms of weakness, anorexia, or myalgia associated with adrenal insufficiency. Adrenal insufficiency is a life-threatening situation.

Answer c is incorrect. He does not report any joint infection with symptoms of painful joint and abnormal white blood cell count.

EM is a 63-year-old obese man with a history of increasing pain in his left knee. He presently cares for his 85-year-old mother who has had bilateral knee replacements secondary to osteoarthritis. During his college years, he played on the intramural football team and suffered several knee injuries. During his career as a radio announcer for sports, he maintained a sedentary lifestyle and does not presently exercise. Which of the following are risk factors for the development of osteoarthritis in EM? Select all that apply.

A

Age

B

Genetics

C

Joint injury

D

Obesity

ABCD

Osteoarthritis mainly affects adults >50 years old. This patient is over the age of 50.

Answer b is correct. Osteoarthritis can be inherited. This patient has a mother with a history of knee replacements secondary to osteoarthritis.

Answer c is correct. Acute joint injury can place a patient at risk for osteoarthritis. Tears of the meniscus as well as articular surface injury increases joint instability. This patient has a history of acute joint injury during his college years with sports participation which placed him at risk for injury.

Answer d is correct. Weight gain predisposes patients to development of osteoarthritis secondary to overload of the knee. This patient is stated as being obese.

Which of the following medications is contraindicated in patients with documented sulfa allergy?

A

Ultram

B

Toradol

C

Celebrex

D

Aspirin

E

Hyaluronic acid

C

An allergy to sulfa is a contraindication to celecoxib.

Answer a is incorrect.Tramadol may be taken in patients with a history of sulfa allergy.

Answer b is incorrect. Toradol may be taken in patients with a history of sulfa allergy.

Answer d is incorrect.Aspirin is not contraindicated in patients with a sulfa allergy.

Answer e is incorrect. Hyaluronic acid is not contraindicated in patients with a sulfa allergy.

CJ is a 56-year-old man with confirmed osteoarthritis. He has previously failed acetaminophen. His physician would like to start him on the lowest strength tablet available of celecoxib. What recommendation will you present to the physician?

A

50 mg tablet

B

100 mg tablet

C

200 mg tablet

D

400 mg tablet.

A

The lowest tablet strength available for celecoxib is 50 mg. This strength is available under brand name Celebrex or as a generic.

Answer b is incorrect. The lowest tablet strength available for celecoxib is 50 mg.

Answer c is incorrect. The lowest tablet strength available for celecoxib is 50 mg.

Answer d is incorrect. The lowest tablet strength available for celecoxib is 50 mg.

Which of the following are preventative measures for osteoarthritis? Select all that apply.

A

Resistance exercise

B

Maintaining a healthy weight

C

Surgery

D

Joint rehabilitation

ABCD

Building muscle strength with resistance exercise is a strategy for strengthening muscles, which could possibly prevent risk of osteoarthritis later in life.

Answer b is correct. Avoiding obesity can decrease risk of osteoarthritis development. Increased weight can increase load on joints and predispose them to damage.

Answer c is correct. Surgery may be needed for joint injuries to restore normal function. Surgery may assist with prevention of later life development of osteoarthritis.

Answer d is correct. Rehabilitation of the joint may involve different types of exercise and regimen of rest to improve flexibility and proprioception (unconscious movement of the body with spatial awareness).

RT is a construction worker that presents to your clinic for knee pain. He is diagnosed with osteoarthritis (OA). He is currently obese and cannot take time off from work because of providing for his family. Additionally, he has a family history of OA. He would like to try nonpharmacologic therapy before starting a medication. Which of the following are preventable risk factors for developing OA?

A

Genetics

B

Joint trauma history

C

Repetitive movement

D

Obesity

D

Weight loss is the most preventable risk factor for development of OA. Decrease of load on joints can prevent damage and possible malalignment.

Answer a is incorrect. Genetics is not modifiable.

Answer b is incorrect. History of joint trauma is not modifiable since it occurred in the past. Appropriate therapy at the time of trauma may assist to decrease development of future OA.

Answer c is incorrect. Repetitive movement is a risk factor for development of joint damage. Certain occupations may be associated with repetitive movements. This may not be easily modified unless measures are taken to address it.

Which of the following help reduce nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) toxicity? Select all that apply.

A

Nonacetylated salicylates

B

Cyclooxygenase (COX)-2 inhibitors

C

Addition of misoprostol

D

Addition of proton pump inhibitor

ABCD

Nonacetylated salicylates are associated with decrease in GI toxicity.

Answer b is correct.Celecoxib demonstrated fewer GI ulcers when compared to traditional NSAIDs.

Answer c is correct.Misoprostol is protective for ulcers and potential GI complications.

Answer d is correct. Proton pump inhibitors reduce risk for GI ulcer development.

DP is a 55-year-old man who has hypertension and a positive family history of early cardiovascular (CV) disease. His medications include aspirin 81 mg daily and metoprolol 25 mg bid. DP's osteoarthritis is no longer controlled with acetaminophen 650 mg every 6 hours. The physician wants to begin DP on a regimen including an nonsteroidal anti-inflammatory (NSAID). Which treatment do you recommend?

A

Naproxen 250 mg bid

B

Naproxen 250 mg tid

C

Naproxen 500 mg bid

D

Naproxen 500 mg tid

A

NSAIDs as a class are probably not the best option for a patient with high CV risk. In this situation, the physician will prescribe an NSAID regardless, so you should provide the option that will cause the least harm. Most nonselective NSAIDs have not been studied in regards to CV risk. But of those studied, naproxen seems to have less CV risk than others. The lowest effective dose should be used to reduce risk.

Answer b is incorrect. The frequency of naproxen is bid, not tid.

Answer c is incorrect. CV risk with NSAID use is believed to be dose-dependent. The lowest effective dose should be used to minimize CV risk.

Answer d is incorrect. The frequency of naproxen is bid, not tid. Also, CV risk with NSAID use is believed to be dose-dependent. The lowest effective dose should be used to minimize CV risk.

A 44-year-old woman with a history of gastrointestinal (GI) bleed presents to your community pharmacy. She tells you her pregnancy test from last night was positive. She presents refill bottles for her prescription of ibuprofen 400 mg every 8 hours and Cytotec 200 µg bid and asks if these are okay for her to keep taking. You respond:

A

Stop taking Cytotec. It is ok to continue ibuprofen.

B

Stop taking ibuprofen. It is ok to continue Cytotec.

C

Continue taking both medications. Call your physician as soon as you can.

D

Continue taking both medications. Your pregnancy test may not be accurate.

E

Stop taking both prescriptions. Let us call your physician together now to discuss your situation.

E

The patient should stop taking the medications immediately until the physician can be reached to assess pain control and pregnancy plans. NOTE: Misoprostol is a gastroprotective agent that prevents nonsteroidal anti-inflammatory drug (NSAID) gastrointestinal (GI) ulceration. However, it is a prostaglandin analog and is contraindicated in pregnancy and women of child-bearing potential (unless a woman is capable of complying with effective contraception measures).

Answer a is incorrect.Ibuprofen has a C/D pregnancy rating. It has caused deformities and miscarriages in some cases.

Answer b is incorrect.Misoprostol has a pregnancy rating of X. It is an abortifacient.

Answer c is incorrect. Both medications should be stopped immediately if any chance of pregnancy exists. Then the physician should be called to prescribe alternative agents.

Answer d is incorrect. Pregnancy tests can have false-positives, but you should not take the risk of counseling the patient to continue an abortifacient.

After initiation of ibuprofen, when is steady-state concentrations likely to be achieved.

A

1 to 2 hours

B

4 to 6 hours

C

6 to10 hours

D

12 to 18 hours

C

.Ibuprofen has a half-life of approximately 2 hours. Stead-state concentrations can be reached after roughly 3 to 5 times the half-life. Therefore, ibuprofen is likely to reach stead-state concentrations around 6 to 10 hours after initiation of treatment.

Answer a is incorrect.Ibuprofen is not likely to reach stead-state concentrations in 1 to 2 hours after initiation of treatment.

Answer b is incorrect.Ibuprofen is not likely to reach stead-state concentrations in 4 to 6 hours after initiation of treatment.

Answer d is incorrect.Ibuprofen is likely to reach stead-state concentrations before 12 to 18 hours after initiation of treatment.

AZ is a 72-year-old woman with a history of atrial fibrillation treated with warfarin. Her height is 5 ft 2 in, weight is 198 lb, blood pressure is 116/76 mm Hg, and serum creatinine (SCr) is 1.1. AZ is now complaining of pain and stiffness in her left knee. X-ray shows joint space narrowing and osteophytes at the joint. Which treatment should be initiated at this point? Select all that apply.

A

Weight reduction

B

Tylenol

C

Celebrex

D

Tramadol

AB

Initiation of weight loss may assist with decreased load for the joint and possible symptom relief.

Answer b is correct.Acetaminophen is a first-line treatment for osteoarthritis. Acetaminophen can potentiate the anticoagulant effect of warfarin therapy, but is an appropriate choice with monitoring of the patient.

Answer c is incorrect.Celecoxib is third-line treatment for osteoarthritis and has demonstrated an increase in the anticoagulant effect of warfarin.

Answer d is incorrect.Tramadol is used for patients with contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) or have failed previous drug trials.

AM is a 52-year-old woman whose medications include acetaminophen 500 mg four times per day, gabapentin 300 mg three times per day, gemfibrozil 600 mg twice daily, and fluoxetine 20 mg daily. At the direction of her physician, AM added ibuprofen 800 mg twice daily and capsaicin cream 0.025% three times per day as needed to her regimen. While putting on her contacts this morning she experienced an immediate burning pain in her eyes. She immediately takes out her contacts, flushes her eyes, and calls you, her pharmacist. Which of the following is most likely causing her eye pain?

A

Capsaicin cream

B

Acetaminophen

C

Drug interaction between acetaminophen and gemfibrozil

D

Drug interaction between acetaminophen and gabapentin

A

Contact with the eyes should be avoided when using capsaicin because it causes a burning sensation and irritation. AM either did not wash her hands after applying the cream or did not wash the cream completely off of her hands before touching her contacts to her eyes.

Answer b is incorrect. Eye pain is not a side effect of acetaminophen.

Answer c is incorrect. There are no drug interactions between acetaminophen and gemfibrozil.

Answer d is incorrect. There are no drug interactions between acetaminophen and gabapentin.

PJ is a 80-year-old man who presents to your clinic due to osteoarthritis (OA) in his right hand. Past medical history is significant for dyslipidemia treated with rosuvastatin 20 gm daily and hypertension with lisinopril 5 mg daily. Which of the following medications should considered a first-line treatment for this patient?

A

Acetaminophen

B

Oral naproxen

C

Topical naproxen

D

Hydrocodone

C

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are preferred first-line agents for patients 75 years of age or older. Alternative first-line agents can include topical capsaicin and/or tramadol.

Answer a is incorrect.Acetaminophen is not a recommended first-line option for OA of the hand.

Answer b is incorrect. Use of oral NSAIDs should be avoided in patients 75 years of age or older due to increased risk for gastrointestinal bleed. Topical NSAIDs can be considered as an alternative.

Answer d is incorrect. Use of opioids for OA should be avoided when possible, especially in elderly patients.

TM is a 67-year-old woman who presents to your pharmacy with a new prescription for tramadol for her osteoarthritis. She has a past medical history (PMH) of hypertension, dyslipidemia, diabetes, and depression. The medications which have been dispensed by your pharmacy are as follows: amlodipine 10 mg daily; hydrochlorothiazide 25 mg daily; pravastatin 20 mg daily; metformin 500 mg bid; and paroxetine 20 mg daily. Which of the patient's medications can increase the risk for serious adverse events including seizures and serotonin syndrome with the use of tramadol?

A

Amlodipine

B

Hydrochlorothiazide

C

Pravastatin

D

Metformin

E

Paroxetine

E

.Tramadol use with concomitant administration of CYP2D6 and/or CYP3A4 inhibitors, such as paroxetine, can increase the risk of serious adverse effects including seizure and serotonin syndrome due to reduced metabolic clearance of tramadol.

Answer a is incorrect.Tramadol use with amlodipine is not likely to cause serious adverse effects.

Answer b is incorrect.Tramadol use with hydrochlorothiazide is not likely to cause serious adverse effects.

Answer c is incorrect.Tramadol use with pravastatin is not likely to cause serious adverse effects.

Answer d is incorrect.Tramadol use with metformin is not likely to cause serious adverse effects.

AM is a 62-year-old woman who has a recent diagnosis of osteoarthritis in her hands and knees. Her medications include simvastatin 20 mg daily and metformin 500 mg bid. AM is contraindicated for use of acetaminophen due to prior allergy. She was recently prescribed Voltaren 1% gel. Which of the following describes correct administration of Voltaren gel? Select all that apply.

A

Apply 4 grams to each hand.

B

Apply to the affected areas 4 times daily.

C

Do not apply more than 16 grams daily to any one affected joint of the lower extremities.

D

Total daily dose should not exceed 32 grams per day over all affected joints.

BCD

Recommended use of Voltaren is four times daily. The lowest effective dosage for the shortest duration should be used based on patient treatment goals.

Answer c is correct. According to the package insert, the maximum recommended dose for lower extremities is 16 grams daily to any one affected joint. Voltaren gel should be measured on the dosing card to ensure proper dosage.

Answer d is correct. The total daily dose of Voltaren should not exceed 32 grams per day. This includes all affected joints. Voltaren gel should be measured on the dosing card to ensure proper dosage.

Answer a is incorrect. According to the package insert, 2 grams of gel should be applied to the affected area for upper extremities. However, 4 grams can be applied to each joint on lower extremities. Voltaren gel should be measured on the dosing card to ensure proper dosage.

GM is an 81-year-old woman with history of bilateral knee osteoarthritis for 25 years. She has contraindications to surgery and has received one injection of hyaluronic acid (Synvisc One). She calls your clinic 2 days after the intra-articular injection and states that she has not felt any pain relief. You explain:

A

She will not experience pain relief at this point.

B

She may need concomitant administration of intra-articular glucocorticoid.

C

She should take glucosamine and chondroitin in addition to the use of hyaluronic acid.

D

She should stop nonsteroidal anti-inflammatory drug (NSAID) therapy while Hyalgan is administered.

A

Hyaluronic acid has a slow onset of action; therefore, the results of the medication are not evident immediately.

Answer b is incorrect. Patients should receive intra-articular corticosteroids for acute exacerbations and not as treatment for chronic inflammation.

Answer c is incorrect. Use of glucosamine and chondroitin in addition to hyaluronic acid will not improve patient response.

Answer d is incorrect. Patient should continue current NSAID treatment if she is receiving it. This will continue to decrease pain and inflammation for the patient.

BY is a 65-year-old man with confirmed osteoarthritis (OA). He has been pain-free on his current regimen of acetaminophen 650 mg every 6 hours for 2 years. Past medical history (PMH) is significant for gastrointestinal (GI) bleed 4 years ago and hypertension (HTN). He now presents to your clinic with pain in his left hip. BY's medication regimen also consists of lisinopril 40 mg daily and hydrochlorothiazide 25 mg daily. What recommendation will you present to the physician?

A

Increase acetaminophen to 1000 mg every 4 hours, reinforce fitness program.

B

Add pantoprazole 40 mg daily to his regimen, reinforce fitness program.

C

Stop acetaminophen, begin ibuprofen 400 mg tid, reinforce fitness program.

D

Stop acetaminophen, begin Anaprox 250 mg bid, Protonix 40 mg daily, reinforce fitness program.

E

Add celecoxib 200 mg daily, reinforce fitness program.

D

Naproxen is a member of the nonselective nonsteroidal anti-inflammatory drug (NSAID) class. Increased cardiovascular disease may be higher in NSAIDs as a class. At this time, naproxen is the only nonselective drug studied that has a lower risk than ibuprofen or diclofenac. BY has a PMH of GI bleed, so a GI protective agent such as pantoprazole should be added to his NSAID regimen. Reinforcing muscle-strengthening and range-of-motion exercises should be part of every OA treatment.

Answer a is incorrect. The maximum dose for acetaminophen is 4000 mg daily. This answer gives a daily dose of 6000 mg daily and increases the patient's risk for developing hepatotoxicity.

Answer b is incorrect. The addition of pantoprazole would provide some GI protection, but would not provide any more pain relief.

Answer c is incorrect. BY has HTN and is at high risk for cardiovascular disease. Though studies are not conclusive and all drugs in the nonselective NSAID class have not been studied, ibuprofen has shown some increased risk of myocardial infarction (MI), stroke, heart failure, and HTN

Answer e is incorrect. Studies have shown that cyclooxygenase (COX)-2 inhibitors have an increased risk of MI, stroke, heart failure, and HTN. Celecoxib would not be an appropriate choice as BY has hypertension and is at high CV risk.

VM is a 55-year-old man who has hypertension and a positive family history of early cardiovascular (CV) disease. His medications include aspirin 81 mg daily and metoprolol 25 mg bid. VM's osteoarthritis is no longer controlled with acetaminophen 650 mg every 6 hours. The physician wants to begin VM on a regimen including a nonsteroidal anti-inflammatory drug (NSAID). She prescribes ibuprofen 800 mg three times per day. Which of the following do you need to counsel VM concerning?

A

Do not take this medication, it might cause you harm.

B

Take ibuprofen at least 30 minutes after aspirin or aspirin 8 hours after ibuprofen. Monitor your BP more often.

C

Stop taking your aspirin. Do not take ibuprofen on an empty stomach.

D

Stop taking your aspirin. Monitor your BP more often.

B

.Ibuprofen may block the antiplatelet effect of aspirin. Ibuprofen may diminish the cardioprotective effect that aspirin is providing this patient. Aspirin may decrease the effect of ibuprofen. To limit the interaction, the two drugs should be administered separately. The minimum time between these two drugs is ibuprofen at least 30 minutes after aspirin or aspirin 8 hours after ibuprofen. BP should be monitored because NSAIDs cause sodium and water retention, therefore, possibly raising BP.

RXprep rec ibu 1h after ASA

Answer a is incorrect. The studies evaluating nonselective NSAIDs as a class are inconclusive. You should counsel the patient to monitor their BP more frequently, keep all appointments with their physician, and call the pharmacist or physician if any side effects are experienced.

Answer c is incorrect. This patient is a high-risk CV patient. Aspirin is being used for cardioprotection and should not be stopped. Ibuprofen should not be taken on an empty stomach.

Answer d is incorrect. BP should be monitored more often, but aspirin should not be discontinued without a physician's consent. The patient has a family history positive for CV disease.

What is the primary objective of pharmacologic therapy for osteoarthritis?

A

Improve mobility

B

Weight loss

C

Pain relief

D

Improve muscle and joint strength

C

Pain relief is the primary objective of pharmacologic treatment.

Answer a is incorrect. Improvement of mobility without relief of pain may assist with increased movement; however, patients will not have improved quality of life. Improved mobility occurs as a result of pain relief.

Answer b is incorrect. Weight loss can improve signs and symptoms but will not provide acute pain relief. However, it is not the primary objective of medication therapy.

Answer d is incorrect. Improvement of muscle and joint strength can assist with support of the joint. However, this will not improve acute pain.

Capsaicin is available in the United States in which of the following dosage forms? Select all that apply.

A

Cream

B

Gel

C

Lotion

D

Patch

E

Tablet

ABCD

Capsaicin is available as a cream under brand names Capzasin-P, Capzix, Sure Result SR Relief, Trixaicin, Trixaicin HP, Zostrix HP, Zostrix Maximum Strength Natural pail Relief, Zostrix Maximum Strength Natural Foot Pain Relief, and Zostrix Original Strength Natural Pain Relief. Generic capsaicin cream is also available.

Answer b is correct.Capsaicin is available as a gel under brand names Capzasin-P.

Answer c is correct.Capsaicin is available as a lotion under brand names DiabetAid Pain and Tingling Relief.

Answer d is correct.Capsaicin is available as a patch under brand names Aflexeril MC, Allevess, Captracin, Flexin, Levatio, MaC Patch, MenCaps, Neuvaxin, Qutenza, Releevia, Releevia MC, Renovo, Sinelee, Salonpas Gel-Patch Hot, and Salonpas Hot.

Answer e is incorrect.Capsaicin is not available as a tablet. Capsaicin is available as topical products only.

Which of the following best describes the mechanism of action of Mobic?

A

Antagonism of serotonin receptors in the central nervous system

B

Inhibition of prostaglandin synthetase in the arachidonic acid cascade

C

Depolarization of neurons via binding of vanilloid receptor subtype 1 (TRPV1)

D

Activation of mu-opioid receptors in the neuron cell membrane

B

According to the package insert, nonsteroidal anti-inflammatory drugs' (NSAIDs) mechanism of action is likely related to prostaglandin synthetase inhibition which is included in the arachidonic acid cascade. This inhibition results in reduced formation of prostaglandins.

Answer a is incorrect. Mobic is not involved in antagonism of serotonin receptors.

Answer c is incorrect. Mobic is not involved in depolarization of neurons.

Answer d is incorrect. Mobic does not activate mu-opioid receptors.

Select the first-line pharmacologic agent for treating osteoarthritis?

A

Acetaminophen

B

Intra-articular corticosteroids

C

Tramadol

D

Ibuprofen

A

recs changed so now APAP is only condt rec, NSAIDs strongest

.Acetaminophen has been shown to be the most appropriate first-line agent to relieve pain and inflammation.

Answer b is incorrect. Intra-articular corticosteroids are appropriate for exacerbations of osteoarthritis for patients who are not candidates for nonsteroidal anti-inflammatory drugs (NSAIDs).

Answer c is incorrect.Tramadol is used for those with contraindications to nonselective NSAIDs and cyclooxygenase (COX)-2 inhibitors with failure on previous drug trials.

Answer d is incorrect. Nonselective NSAIDs is second-line therapy after acetaminophen.

CK is a 58-year-old woman who presents to your pharmacotherapy clinic today with an international normalized ratio (INR) of 4.2 (she was previously stable for 6 months). She has a past medical history (PMH) of diabetes, atrial fibrillation, and hypertension. The list of medications that she gives you from her pharmacy are as follows: metformin 1000 mg and glipizide 10 mg bid; warfarin 5 mg on Monday, Wednesday, and Friday and 2.5 mg on Sunday, Tuesday, Thursday, and Saturday; amlodipine 10 mg daily; potassium chloride 10 mEq daily; and hydrochlorothiazide 25 mg daily. CK has not had a warfarin dosage change in over 1 year. She tells you her right knee has been bothering her much more frequently than usual. Which of the following is the most likely reason for her INR fluctuation?

A

CK took 5 mg warfarin tablets every day in the past week.

B

After questioning CK about over-the-counter (OTC) use, she tells you she has been using Capsaicin-HP on her knee for the past week.

C

After questioning CK about OTC use, she tells you she has been taking acetaminophen 650 mg every 6 hours to relieve her from knee pain for the past week.

D

CK is not telling you about a herbal product she has begun taking.

C

A drug-drug interaction can occur between warfarin and acetaminophen. Acetaminophen may enhance the anticoagulant effect of warfarin. Acetaminophen is available OTC. Many patients do not consider an OTC drug as part of their medication list. Patients should always be asked what OTC medications they are taking.

Answer a is incorrect. Though this is a possibility, CK has been stabilized for 6 months. She is young and has not made this mistake previously.

Answer b is incorrect. Capsaicin-HP is a topical treatment and does not affect INR.

Answer d is incorrect. Though this is a possibility, CK has stated she is having knee pain. A proven drug interaction is seen between warfarin and acetaminophen. CK is most likely taking something for her pain, not a herbal product that is not labeled to help reduce pain.

Which of the following is a contraindication for Kenalog?

A

History of stoke

B

Idiopathic thrombocytopenic purpura

C

Latent tuberculosis

D

Diverticulitis

B

According to the package insert, idiopathic thrombocytopenic purpura is a contraindication for the use of Kenalog when given via intramuscular administration. Caution should be used with intra-articular administration.

Answer a is incorrect. Kenalog is not contraindicated in patients with a history of stroke. Higher risk for stroke is associated with epidural administration of Kenalog.

Answer d is incorrect. Latent tuberculosis in not a contraindication for Kenalog administration; however, monitoring should be completed to evaluate for activation of tuberculosis when using corticosteroids.

Answer e is incorrect. Diverticulitis is not a contraindication for Kenalog administration; however, the risk for perforation can be increased with the use of steroids.

PA is a 68-year-old man who presents to your pharmacy today. He has been started on Lodine for treatment of his osteoarthritis. Which of the following is an important counseling point regarding his new prescription?

A

Lodine should be stored in original container until ready to use.

B

Lodine should be added to a pill box to help improve adherence.

C

Lodine should be stored in the fridge to maintain a temperature ≤68°F.

D

Lodine should be shaken well before each use.

A (Etodolac)

Lodine should be stored in the original container until ready to use.

Answer b is incorrect. Lodine should not be added to a pill box due to the requirement of storage in the original container until ready to use.

Answer c is incorrect. Lodine should be maintained room temperature of 68°F to 77°F.

Answer d is incorrect. Lodine does not need to be shaken before use.

A 59-year-old man with history of 2 months of joint pain in his knees with movement decides to treat with glucosamine chondroitin. He reports an allergy to shellfish. He asks for your recommendation. Which of the following counseling points do you discuss with the patient? Select all that apply.

A

No significant benefit is seen with use of glucosamine chondroitin as monotherapy.

B

Glucosamine chondroitin could be considered as an adjunct to other forms of therapy.

C

Glucosamine chondroitin is contraindicated in those with shellfish allergies.

D

Gastrointestinal symptoms of gas, bloating, and cramps may occur with use of glucosamine chondroitin.

all

Use of these agents as monotherapy did not show superiority to placebo.

Answer b is correct. Glucosamine chondroitin is not recommended and should not be used as monotherapy. It can be considered as an adjunct therapy for patients taking additional therapies.

Answer c is correct. Glucosamine is contraindicated with shellfish allergies.

Answer d is correct. Gastrointestinal symptoms are mild but may include gas, bloating, or cramps.