Comprehensive Pearson VUE Pharmacy Exam Bullet Notes

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Long-acting choices: naproxen, piroxicam ("peroxicam").
• Contra-indicated late pregnancy → premature ductus arteriosus closure & bleeding risk.
• Aspirin + heparin/warfarin ↑ bleeding; if aspirin not listed choose diclofenac.
• NSAID renal risks → avoid in dehydration, elderly, CKD.
• NSAID-induced ulcer: manage with PPI (omeprazole, pantoprazole) ± amoxicillin + clarithromycin for H. pylori.

Opioids & Antidotes

• Tramadol, morphine OD → naloxone $0.1\,\text{mg kg}^{-1}$ paeds (max 2 mg).
• Persistent respiratory depression after flumazenil suggests antidote given >4\text{ h}, under-dosed, or rapid antidote clearance.
• Neonatal morphine: preferred route IV.
• Withdrawal cramps unresponsive to diazepam ⇒ likely opioid (not cocaine) dependence.

Statins, Fibrates & Myopathy

• Gemfibrozil + statin ↑ myopathy; monitor serum creatine kinase (CK).
• Statin myopathy risk factors: high dose, age >65, hypothyroid, CYP inhibitors.
• Pravastatin/rosuvastatin least grapefruit interaction; simvastatin/lovastatin most.

Diabetes & Endocrine

• HbA1c interpretation: normal <5.6\%, pre-DM $5.7–6.4\%$, DM $\ge 6.5\%$; goal in treated <7\%.
• Poor control: FBG $9.1\,\text{mmol L}^{-1}$ & HbA1c 9 → intensify therapy (add metformin or insulin).
• Metformin FDA-approved ≥10 yrs; first-line GDM drug if insulin unavailable; insulin remains gold standard in pregnancy.
• Sulfonylurea (chlorpropamide) ADRs: prolonged hypoglycaemia, cholestatic jaundice, SIADH-like hyponatraemia.

Hypertension, Heart & CHADS

• Elderly: "start low go slow"—initiate small dose & up-titrate.
• Target BP: general <140/90\,\text{mmHg}; lower for diabetics if tolerated. • CHADS$_2$ score ≥2 indicates anticoagulation: CHF/HTN/age >75/DM =1 pt each, prior stroke/TIA =2 pts. 75-y HTN + DM → $3$.
• Orthostatic HTN on ACEI+thiazide → add amlodipine (not prazosin).

Respiratory

• SABA: albuterol/salbutamol, terbutaline.
• LABA monotherapy ↑ cardiovascular death; combine with inhaled corticosteroid.
• Max prednisolone for acute asthma exacerbation up to $120\,\text{mg day}^{-1}$ (options 80–240 mg).
• Cromolyn safest for long-term asthma in pregnancy.

Vaccines & Infectious Disease

• Chronic lung disease/unvaccinated: give influenza ± pneumococcal vaccines.
• Pregnant admitted for URTI: influenza vaccine is priority.
• H. pylori triple therapy: omeprazole + clarithromycin + amoxicillin (replace with metronidazole if PCN-allergic).
• Syphilis in pregnancy: benzathine penicillin; if PCN-allergic use amoxicillin-clavulanate.
• Pneumocystis, CMV, HSV: acyclovir (HSV); foscarnet if ganciclovir unavailable for CMV.

Psychiatry & Neurology

• Oxcarbazepine rash/tremor: switch to topiramate or lamotrigine; avoid carbamazepine cross-reaction.
• Benzodiazepine safest hypnotic in elderly = zolpidem (if absent choose alprazolam).
• Zolpidem MOA: selectively binds $\omega<em>1$ subtype of $GABA</em>A$ receptor.
• Memantine: uncompetitive $NMDA$ antagonist; used in moderate–severe Alzheimer’s.
• Tardive dyskinesia after 11 yrs antipsychotic → consider clozapine.
• Acute dystonia antidote: benztropine or diphenhydramine.
• Iproniazid (MAOI) can cause postural hypotension due to NE depletion.
• Serotonin syndrome risk MAOI + fluoxetine.
• Buspirone lacks dependency; barbiturate withdrawal causes irritability/agitation.

Obstetrics, Lactation & Paediatrics

• Breast-feeding: avoid lithium, warfarin safe, estrogen ↓ milk, metoclopramide/domperidone ↑ prolactin.
• Finasteride & warfarin teratogenic → stop pre-conception (finasteride ⇢ genital malformation, warfarin ⇢ nasal bone hypoplasia).
• Contra-indicated laxative in pregnancy: castor oil.
• Levocetirizine approved ≥6 months (choose youngest age).
• BMI paediatric percentiles: <5\% under-wt; $85–94\%$ overweight; $\ge95\%$ obese. 85 % wt with normal skin-fold = at risk/overweight.

Pharmacokinetics & Calculations

• $\text{Osmolarity}=2[Na^+]+\frac{\text{Glucose}}{18}+\frac{\text{BUN}}{2.8}$ → example 140,6,6 gives $\approx282\,\text{mOsm kg}^{-1}$.
• Css (IV): $Css=\frac{F\times MD}{CL\times \tau}$; $CL=\frac{0.693\,V<em>d}{t</em>{1/2}}$.
• 99 % elimination needs $6.6\,t<em>{1/2}$. • Dose mis-written .5→5 mg = 10-fold error. • Child dose (BSA): $\text{Child}=\frac{BSA}{1.73}\times\text{Adult}$; eg BSA 0.7 m², adult 250 → $\approx101\,\text{mg}$. • Vancomycin example: Vd $=1\,L kg^{-1}$, $t</em>{1/2}=8\,h$, CL $\approx6.75\,L h^{-1}$, MD 1 g q12 → $Css\approx12\,mg L^{-1}$.

Formulary, Errors & Regulation (Saudi/General)

• Committees: Pharmacy & Therapeutics (P&T) adjusts formulas & rules out drugs; Drug & Therapeutic / Hospital Management review non-formulary requests.
• Error types: dose change by technician = dispensing error; wrong drug filled = mechanical error.
• Narcotics in-patient IV infusion limited 24 h; oral ≥72 h; outpatient ≤30 days; max emergent detox 3 days.
• Controlled prescription validity commonly 30–90 days (local law).
• Investigational drug release authorised by principal investigator + chief pharmacist.
• Look-alike/sound-alike high-alert drugs kept in black/dark bins.
• OTC counselling: pharmacist must verbally warn of ADRs.

Toxicology & Antidotes

• Lead poisoning: Ca-EDTA or penicillamine.
• Lithium toxicity: saline hydration, hemodialysis; seizures → benzodiazepines; sodium bicarbonate for alkalinisation.
• Gasoline fumes risk lead exposure.
• Rhabdomyolysis detection: CK, myoglobin, Ca²⁺, urine dipstick.
• Cyanide burn victim: hydroxycobalamin or sodium thiosulfate.
• Cocaine OD lacks specific antidote; manage with benzodiazepines, cooling.

Miscellaneous Therapeutics

• Amphotericin B for systemic mycoses; acyclovir for HSV.
• Phenobarbital slow metabolism; thiopental ultra-short.
• Metoclopramide: $D<em>2$ antagonist + $5-HT</em>4$ agonist; works on CTZ.
• Mannitol = osmotic diuretic.
• Prazosin = selective $\alpha_1$ blocker.
• Entacapone = COMT inhibitor → ↑ L-dopa.
• Orlistat for obesity; loperamide acts on $\mu$‐opioid gut receptors.

Examples & Mini-Problems

• Aluminum chloride: $20\,\text{mL}\rightarrow5350\,\text{mg}$ ⇒ $5\,\text{mL}$ needs $25\,mEq$ ($1\,mEq=0.0535\,g$).
• Prednisolone 8 mg mL−1; two ×125 mL bottles = 2 000 mg; 100 mg QID (400 mg day−1) covers 5 days.
• Penicillin G 600 000 IU mL−1; four patients ×7.5 M IU = 30 M IU → need 50 mL (one vial).
• $0.9\%$ NaCl is iso-osmotic with plasma; $0.45\%$ is half-strength maintenance.
• $1:1000$ w/v prep for 88 mL requires $0.088\,g$ solute.

Mnemonic Hints
• “LMNOP” for breastfeeding no-nos: Lithium, Metronidazole (high dose), Nitrofurantoin (G6PD risk neonate), Oestrogens (↓ milk), Phenobarbital (sedation).
• “Old People Need Lower Doses” – decreased water, ↑ fat, ↓ renal clearance, polypharmacy.