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100 DRUG RELATED PROBLEMS

1. Interaction of grapefruit juice with fexofenadine, Itraconazole, Clopidogrel,


Cyclophosphamide and Losartan
In all these interactions, the level of the medication is decreased, which is
contrary to the interaction of grape fruit juice with other medications,
where the level of the medication is enhanced. The exact mechanism is not
well established
Apple and orange juice had effects similar to those of grapefruit juice
Management is to avoid grape fruit juice. If used in combination, monitor
for decreased effectiveness
2. Disease drug interaction for a patient with hyperthyroidism using Amiodarone for
his ventricular arrhythmia
Thyroid dysfunction (Hypo or hyperthyroidism) may occur, since it
contain iodide in its formulations
Thyroid function should be monitored prior to treatment and periodically
thereafter. Because of the slow elimination of amiodarone and its
metabolites, high plasma iodide levels, altered thyroid function tests may
persist for several weeks or even months following Cordarone
(Amiodarone) withdrawal.
3. Pregnant lady using anti-epileptic medications such as CBZ, valproic acid,
Gabapentin and lamotrigine
Here there is a risk of birth defects due to use of the above medications
during pregnancy to avoid seizures of the mother, and risk of neural tube
defects (NTDs) in fetus.
So for the management, we monitor serum drug levels throughout
pregnancy as concentrations may fluctuate. Also giving supplements of
Vitamin K and Folic acid
4. Patient with asthma using Zafirlukast tablet. He is 20 years old, and intolerant to
lactose
Zafirlukast contains in its tablet lactose and hence the patient should be
monitored for GI problems.
If severe avoid using it, and substituted by other antiasthmatic
preparations
5. Asthmatic patient with infection (sore throat) using Zafirlukast and Erythromycin
Here there is a drug-drug interaction, and Erythromycin decreases plasma
level of Zafirlukast by 40%

6. Olizapril 5 mg once daily. Diminished effect at the end of the day i.e. during dose
monitoring of BP of the patient rises at the end of the day.
Management is by splitting the dose to twice daily or increasing the dose
to 10mg.

7. Female patient with Pagets disease, her Doctors prescribed for her 35mg
Actonel Risedronate every week for treatment of Pagets disease.
Here the dose of the medication is wrong since that dose is for
osteoporosis and the recommended regimen for Pagets disease is Actonel
(Risedronate) 30mg daily for two months taken orally. Retreatment may
be considered if the treatment fails to normalize serum alkaline
phosphatase

8. Patient with renal failure having D.M.which is not controlled. He is currently
taking pioglitazone 30mg po qd and Glyburide 5mg BID. He is develop
hypoglycemia. The doctor thinks that his hypoglycemia is due to the combination
effect potentiated by Pioglutazone, in addition to the renal failure which
potentiates both medications, and initiated a dose reduction of both medications
The DRP here is hypoglycemia and the dose reduction should be with
glyburide only since pioglitazone is only 15%-30% is excreted from the
kidney and no dose adjustment is required in renal diseases. CPS
monograph of Actos (Pioglutazone)

9. Patient using warfarin 3mg, he is weak, tired and needs multiple vitamins
Here there is a DRP since multivitamins contain vitamin K which reduces
the INR value

10. Patient using Advair diskus for his asthma treatment. He is allergy to milk
Here there is a DRP since Advair diskus 250 contains lactose which result
in allergic reaction.
To manage that, it is better to tell the doctor to switch the patient to advair
diskus 250 is one inhalation twice daily i.e. half the dose
11. Doctor switches a patient from Amprenavir 50mg capsule in an HIV regimen to
amprenavir oral solution 15mg/ml (3.33ml)
The DRP here is that Amprenavir capsule and solution are not
interchangeable on mg-mg basis
Amprenavir solution is 14% less bioavailability than the Amprenavir
capsule (CPS monograph of Amprenavir)
12. Patient using Amprenavir 15mg/ml solution and he is experiencing renal failure.
His CrCl is 30ml/min
The DRP here is that Amprenavir contains propylene glycol which results
incase of renal failure in glyco-associated adverse events including
seizures, stupor, tachycardia, hyperosmolality, lactic acidosis, renal
toxicity and hemolysis
Amprenavir capsule as soon as they are able to take the capsule
formulation
13. Patient taking Captopril 25mg for his hypertension and also taking Allopurinol
200mg once daily or any dose of allopurinol
There is DRP in general ACEI when administered concurrently with
allopurinol, there is a risk of increase of hypersensitivity reactions like
Stevens-J ohnson syndrome

14. Patient 60 years old using Carbolith (Lithium) for his bipolar depression, and was
given Amitriptyline for his depression
A DRP will result from that combination since the use of Amitriptyline in
patient with bipolar disorder may precipitate a hypomanic or manic state.

15. A Patient with post M.I. developed depression. His doctor wants to prescribe
Amitriptyline for him
There is a DRP since Amitriptyline is not recommended during the acute
recovery phase following M.I. or in the presence of CHF due to
arrhythmias and conduction abnormalities.

16. Patient with sore throat using Amoxicillin 500mg capsule qid, and also using
MTX for his rheumatoid arthritis
The DRP here is that penicillin in general compete with renal tubular
secretion of MTX, decreasing its clearance. Concomitant use may increase
MTX serum concentrations resulting in increase in the risk of toxicity e.g.
neutropenia
Management for that DRP is to monitor MTX toxicity
17. Doctor wants to prescribe Tetracyclines (e.g. Doxycycline, minocycline,
tetracycline) with Amoxicillin for mixed aerobic infection
A DRP exists here since the bacteriostatic action of tetracycline may
inhibit bactericidal activity of penicillins, so avoid this combinations

18. A patient taking warfarin for his supra ventricular tachycardia, and developed sore
throat and his doctor wants to prescribe Ampicillin 500mg QID
Effects of warfarin may be increased resulting in increased risk of
bleeding
INR should be monitored upon addition of Ampicillin and withdrawal of
Ampicillin. INR should be periodically reassessed for at least 3 weeks
after ampicillin D/C, since adjustment in the warfarin dose may be
necessary to maintain an effective level of anticoagulation
19. Patient who is diabetic with advanced prostatic cancer was given for him
Cyproterone acetate as an anti-androgen
A DRP results since cyproterone may impair carbohydrate metabolism.
Fasting blood glucose and glucose tolerance test should be examined
carefully in all patients

20. Doctor prescribes Androderm patch with usual starting dose of 5mg applied in the
morning
It should be applied at night preferably @ 10:00pm and worn for 24 hours
providing a total dose of 5mg of testosterone/day
To ensure proper dosing, the morning serum testosterone concentration
may be measured following patch application the previous evening (CPS
monograph of adroderm)
21. Patient with a history of seizures, he is experiencing anemia due to chronic renal
failure. His Doctor wants to prescribe Dabepoetin alfa
There is DRP here since seizures have occurred in patients with chronic
renal failure taking Darbepoetin. Therefore monitoring is important
closely during the first several months of therapy
Also it is recommended that the dose of Darbepoetin be decreased if the
Hb increase exceeds 10g/L
22. 5-ASA (Asacol) and the doctor wants to add lactulose
5-ASA is a colon targeted tablet with a special coating. Giving lactulose
will lower the pH of the stool snd the tablet can be disintegrated in the
colon since it requires acidic medium

23. Patient with thrombocytopenia. His doctor wants to prescribe him inactivated
Hepatitis A i.m. vaccine since he is raveling
I.M. may result in bleeding, so the vaccine may be infected by the s.c.
route, however this may be associated with a higher risk of local reaction
including injection site nodule

24. Pharmacist dispenses Clindamycin phosphate, Benzoyl peroxide, mixes the ontent
and dispenses it to the patient
The DRP is that the pharmacist should put an expiration date of 3 months
after mixing on the label

25. Doctor prescribes clobazam 5mg/day for an adult patient experiencing anxiety
disorder.
The DRP here is that Clobazam is used for seizure disorder. The doctor
can substitute that by alprazolam, Bromazepam, chlordiazepoxide, and
many others

26. Meclizine 12.5 mg tablet for 8-year-old child one hour before traveling as for
prophylaxis from motion sickness
The DRP is that meclizine as with all antihistamines may cause
hyperexcitability in children. So for children relying on non-
pharmacological way is the best choice to avoid motion sickness

27. A physician is tapering the dose of Duragesic 100 patch by ddecreasing the dose
by 25%, so he tapers every 3 days by giving 75 patch then 50 patch then 37.5
patch then 25 patch and lastly 12.5 patch which is least patch strength
The decrease in decrements is not correct for the last dose because when
the physician switches from patch 25 to 12.5 he is decreasing by 50% and
not by 25% as the CPS mentions which result in withdrawal symptoms
In Addition to that the physician at patch 25 and because he cant swotch
to patch 12.5, he should calculate the equivalent dose of Duragesic patch
to oral morphine which is 60-134mg/day. So consider 20mg/day, then he
should taper each day by 25% i.e. 45, 30, 15
28. Patient requires thyroid replacement therapy. He is also under glucocorticoid
activity
The DRP here is that patient with concomitant adrenal insufficiency
should be treated with replacement glucocorticoids prior to initiation
treatment with levothyroxin sodium
Failure to do so may precipitate an acute adrenal crisis when thyroid
hormone is initiated due to increase metabolic clearance of glucocorticoids
by thyroid hormone
29. Dr prescribes Docasanol cream 10% 5 times daily for acute cold sore in lips and
for 10 days
The DRP is that Docasanol is prescribed for recurrent cold sores

30. Ciclopiroxolamine lotion 1% once daily for the nail infection
The DRP here is that concentration 1% is for Tenia pedis or T cruris while
8% is for nail infection

31. Pregnant woman with a fixed dose of 100ug Levothyroxine before pregnancy,
during pregnancy and after delivery
The DRP is that during pregnancy, serum T4 may decrease and serum
TSH may increase since elevations in serum TSH may occur as early as 4
weeks gestation, pregnant woman taking L-thyroxine should have their
TSH measured during each trimester
An elevated TSH should be corrected by increasing the dose of
levothyroxine.
In post partum the TSH decreases and T4 increases, thus reducing the dose
of levothyroxine is important
32. A patient with major depressive disorder, he is taking fluoxetine 60mg/day since
28 months ago. He is allergic to Amitriptyline. His doctor wants to prescribe CBZ
100mg BID for 5 days, then 200mg BID for 1 month, for his grand mal epilepsy
DRP here is that CBZ has the structure of TCA and since the patient is
allergic to amitriptyline i.e. TCA, then taking CBZ for his grand mal
epilepsy will result in hypersensitivity reaction

33. Androderm patch 12.5mg po qd am
The DRP here is that the patch should be applied at night due to circadian
variation

34. Patient with symptoms of gastric malignancy was given Cimetidine 200mg BID
to reduce the signs and symptoms of stomach upset
The DRP here is that cimetidine may mask the symptoms of gastric
malignancy

35. A patient with NSAID-induced lesions and symptoms in GIT was given
800mg/day in one or two divided doses for 6 months
The DRP here is the duration of treatment. The duration should be for
recurrent duodenal or gastric ulcer
(Ref: CPS monograph of Cimetidine)
36. A 10-year-old patient using methyl phenydate. He is exercising severely to reduce
his hyperactivity
The DRP here is that severe physical exercise with methyl phenidate will
result in arrhythmia
(Ref: ESP monograph of concerta under warnings and precautions)
37. Patient with proctitis, his doctor prescribed for him corteneme (H.C.) for 3 weeks.
In his profile he started Riseperidone 0.25mg once daily since a week ago due to
first episode psychosis
The DRP here is that corteneme is contraindicated in acute psychosis, and
hence in this case the patient should be switched to oral 5-ASA full dose
to treat his proctitis (T.C. Pg 761)

38. Patient suffering from fibromyalgia, his doctor prescribed for him
cyclobenzaprine 5mg t.i.d for 3 weeks. In his profile he is using Tranyl cypromine
for his major depressive disorder
The DRP here is that concurrent use of MAOI with cyclobenzaprine is
contraindicated so avoid the use of both medications together. Any
NSAID may be given to relieve pain if not contraindicated

39. Dr. initiated treatment of Caduet (Amlodipine +Atorvastatin) for a patient that is
hypertensive with high cholesterol level
The DRP here is that Caduet is not for initial treatment. The dose of
Caduet should be determined by the titration of individual components

40. Nifedipine 10mg INR was prescribed for a patient with hypertension
Nifedipine IR and in combination therapy is indicated for angina and not
hypertension
Nifedipine XL 30mg may be used for hypertension or angina
41. Patient taking cholestyramine for his dyslipidemia and MTX for his rheumatoid
arthritis
Cholestyramine interferes with enterohepatic recirculation of MTX,
thereby reducing the elimination t and increasing the rate of clearance
of the drug
To manage this condition, replace cholestyramine by another class of
antilipidemia.
Adjust the dose of MTX to compensate for reduced exposure during
treatment with cholestyramine.
Monitor for altered response to MTX when initiating, discontinuing or
changing the dose of cholestyramine
42. Patient using Danazol as a treatment regimen for fibrocystic disease for one year
The treatment course should be limited to 3-6 months maximum
(Ref: CPS monograph of cyclamen (danazol))
43. Clindamycin vaginal cream used by a lady for a week, starting from first day of
menstruation to treat her vaginosis
The Clindamycin vaginal cream should not be used during menstruation
and the treatment should not be used delayed until menstruation is
complete

44. Deca-Durabolin (Nandrolone) used by an athlete to enhance his activity
Nandrolone is not used to enhance activity but it may increase the weight
of the athlete

45. Lady is using Depo-provera (Medroxy-progesterone acetate) 100mg for 3
moonths for contraception)
The Depo-provera 150mg is used for contraception while progesterone
50mg and 100mg are used for 2 weeks in endometriosis

46. A pregnant lady taking Diclectin (Doxylamine +Pyridoxine) on prn.
Diclectin tablets of a delayed release formulation should not be prescribed
on prn
It is important that Diclectin is taken daily for optimal effect.
47. Patient with Pagets disease using etidronate for 1 year
Etidronate should be monitored every 3-6 months and retreatment should
not be initiated until the patient has had at least a three month drug-free
interval to determine whether remission has occurred and to promote
mineralization of any unmineralized osteoid which may have develop

48. Cabergoline capsule 0.5mg is given for a lady for the purpose of suppression of
already established post partum lactation
Cabergoline is indicated for the prevention of the onset of physiological
lactation in the puerperium for clearly medical reasons
(Ref: CPS monograph of dosfinex (cabergoline)
49. Patient traveling to a tropical area, he took dukoral first dose and traveled the 2
nd

day
Protection against ETEC diarrhea and cholera can be expected
approximately one week after primary immunization is concluded

50. Doctor is tapering Duragesic dose of 100ug/hr as such 100, 50, 25, 12.5.
Steps of 25% is recommended i.e. 100, 75, 50, 37.5, 25.

51. Woman taking oral estrogen. Her doctor stopped oral Estrogen and gave her
estrogen gel
Women who are currently taking oral estrogen treatment with estrogen gel
can be initiated 1 week after withdrawal of oral therapy or sooner if
symptoms reappear before the weeks end
(Ref: CPS monograph of estrogel)
52. A 55-year-old patient is on Paroxetine 20mg/day. His doctor wants to switch him
to sertraline 50mg/day, and he is doing in a vacation for 90 days. Best therapy is
a) Give 90 tabs of sertraline 50mg
b) Give 30 tabs of sertraline 50mg
c) Give 180 tabs of sertraline 25mg
d) Give 30 tabs of sertraline 25mg
e) Give 60 tabs of sertraline 25mg
(E) Here the switching is within the same class and there is no need for
washout period. However since the doctor switch the patient to a new
medication, then the supply should be for one month since the doctor may
adjust the dose later on; and because he is traveling, there is possibility
that the patient cannot tolerate sertraline 50mg tab and therefore it is better
to give him sertraline 25mg, just in case if he cannot tolerate the one daily
dose of 50mg, then he can split the dose to two tabs of 25mg.
The supply of 90 days is not acceptable since the patients dose may be
adjusted by the doctor
53. 60 year old patient taking 100mg imipramine once daily. He develop sore throat
and his doctor prescribe for clarithromycin 50mg qid
The problem here is not because clarithromycin here is an enzyme
inhibitor of 3A4, but the problem rises since both affect Torsade de
pointes resulting in arrhythmia. So the solution is to ask the patient for the
main purpose of using imipramine. So if it is for neuropathic pain, he may
take Imipramine until the end of the dose of clarithromycin and substitute
imipramine by codeine or NSAIDs until the end of the dose of
Clarithromycin
This applies also for intermittent use of imipramine for insomnia.
However if imipramine is used for depression, then in that case, there is no
choice other than calling the doctor to change clarithromycin to another
antibiotic like Azithromycin or Amoxicillin
54. A 55-year-old patient who is taking Tramacet 200mg 1x3 for wrist pain with
Tylenol #3 1x3/ He has been using these two medications for the last 15 days.
Now his doctor decided to prescribe him citalopram 20mg/day to correct his
depression that developed from his condition. The main concern of the pharmacist
there is:
a) Major interaction of citalopram with tylenol #3
b) Major interaction with tramacet (Tranodol and acetaminophen)
c) Major interaction of citalopram with tramacet and tylenol #3
d) The acetaminophen that is in tramacet and Tylenol #3
e) No concern about any interaction
(B) The major interaction which of the highest concern is between
Tramadol and Citalopram resulting in the serotonin syndrome. However
there is a minor interaction between codein and Tylenol #3 and citalopram
but it is not as major as that of tramadol and citalopram
The combination of acetaminophen in Tylenol #3 and tramacet according
to dose and direction will not reach 4g/day and therefore it is safe to be
given together
55. A 70-year-old patient is taking Paroxetine 20mg/day and ketorolac 30mg/dose for
which his ankylosing spondylitis. The patient should be monitored for
a) Increased sedation of paroxetine caused by ketorolac
b) No monitoring is required
c) Monitor in the increase in BP due to sodium retention caused by
ketorolac
d) Monitor GI upset caused by ketorolac
e) Monitor GI upset due to the combination
(E) SSRI and NSAIDs increase the risk of GI bleeding

56. A 35-year-old patient who is pregnant in her second trimester is experiencing
allergic rhinitis and requesting an antihistamine medication for her itchiness. She
is a housewife. Best Medication to be given for her as an OTC medication is:
a) Desloratidine tab
b) Diphenhydramine tab
c) Loratidine tab
d) Diphenhydramine and Loratidine
e) Desloratadine and Loratadine
(D) Diphenhydramine and loratadine are given in pregnancy and they are
under category (B) while desloratidine is under category (C)
So we can tell the patient that there is a good evidence for the use of
diphenhydramine and loratadine in pregnancy
57. A 45-year-old patient was diagnosed to have vaginal yeast infection. Her doctor
started to give her itraconazole 200mg/day for 7 days to treat her vaginal lesions.
In her profile she is using lansoprazole 50mg BID. Best therapy is:
a) To continue on both medications as both of them were prescribed
by her doctor
b) Itraconazole increases the concentration of lansoprazole and
therefore lansoprazole should be given once daily
c) Reduce the dose of itraconazole to a level to keep lansoprazole at
its therapeutic level
d) Call the doctor to switch the patient from itraconazole to
fluconazole to avoid any drug interaction
e) None of the above
(E) The best thing is to stop for 1 week lansoprazole until the patient
completes his cycle of itraconazole since lansoprazole increases the pH of
the stomach and affects the absorption
Switching is not popular if we can handle the situation safely by keeping
the same medication in this case itraconazole and discontinuing
lansoprazole just for a short period of time which is one week
58. A 56-year-old patient is using pantoprazole 40mg once daily. In this profile, the
patient is using itraconazole 200mg/day for 21 days for esophageal lesions, which
were resistant to fluconazole. After receiving his new prescription for
pantoprazole the pharmacist should:
a) Do not dispense the new prescription since pantoprazole reduces
the absorption of itraconazole which may result in flare ups
b) Space apart pantoprazole with at least 46 hours from itraconazole
c) Call the doctor to switch the patient to nebeprazol
d) No problem we can give both medications together
e) None of the above
(E) In this scenario pentolac is a long acting medication and thats why it
is given once daily, so spacing apart or switching to another PPI or even
H2 blocker will not solve the problem.
Discontinuation of pantolac for 21days will result in GI problem. So the
best thing is that the pharmacist should advise the patient to take
itraconazole with pop (any acidic beverages) to enhance absorption
59. A 44-year-old patient came to the pharmacy with a new prescription for
salbutamol inhaler to use 2 puffs qid prn, and coActifed tab for dry cough which
contains codeine to be used as TID. In his profile he is using advair diskus
(salmeterol plus fluticasone) as 1 puff BID. The pharmacist should counsel the
patient on the following:
a) Stop using advair since you are using salbutamol
b) Stop using CoActifed since it suppresses cough and hence it
masks the signs and symptoms of asthma
c) There is no drug interaction or any DRP and the pharmacist
should counsel on each medication in the new prescription
d) Call the doctor to switch the patient from Actifed tab to first
generation antihistamine
e) None of the above
(E) The DRP here is that the CoActifed is a cough suppressant and thus it
will mask the signs and symptoms of any asthmatic attack which make the
patient unaware of his worst condition especially his doctor has started to
give him 8 puffs prn which is the highest dose so that the pharmacist
should counsel now is that during the use of CoActifed to treat the cough
of the patient should use his salbutamol puffer regularly to avoid any mask
of symptoms that may happen during the use of cough suppressant after
recovery from his cough.
The use of antihistamine (first generation) in asthma may aggrevate
asthma, resulting in dryness and crushings
Stop using Co-actifed is not a good option since all the cough medications
that are used for dry cough they contain either codein or
dextromethorphan
60. A 53-year-old lady came to the pharmacy with a prescription for Wellbutrin
150mg SR. Her profile shows that she was on Wellbutrin 150mg XL. The
pharmacist asked the patient whether she is aware of any changes thata her doctor
made for her therapy, and she replied that nothing her doctor told her about that.
The best action the pharmacist should do is:
a) Dispense Wellbutrin 150mg SR since there is no difference
between the two
b) Dispense Wellbutrin XL as in her profile
c) Call the doctor to see if he has intended to change XL to SR
d) Give the generic Bupropion SR
e) None of the above
(C) Wellbutrin XL is once a day and Wellbutrin SR is twice a day but
could be given once a day, so the best option is to call the doctor that the
patient was on XL and not on SR since the patient was not aware of any
changes that her doctor has made

61. The patient is 44 years old and her doctor prescribed for her varenicline starter
pack (o.5mg tab) for two weeks. Best action the pharmacist should do to the
patient is:
a) Dispense the medication as it is written and counsel the patient
on quitting smoking within 2 weeks
b) Give the patient varenicline 1mg since it is stronger
c) Dispense varenicline starter pack and varenicline 1mg tab pack
d) Call the doctor
e) None of the above
(E) In this particular case we should ask the patient before calling the
doctor whether she has any appointment after two weeks or not since
varenicline starter (champix 0.5mg starter) ends up after two weeks. So, if
the patient says I have an appointment after two weeks, then, there is no
need to call the doctor, however if it says yes no, then we have to call the
doctor for continuation of therapy. The therapy should be at least for three
months. Two weeks for the starter pack and ten weeks for the continuation
pack. Stopping the smoking should be within the first two weeks, at the
starter dose should onefal (0.5mg) for the three days, then 0.5mg twice
daily for the consecutive four days an in week two the patient three hours
use 1mg twice daily in the same starting pack which is of different color
the medication may cause sedation, with food and pleats of water.

62. A 55 years old patient using His profile shows that he was on paroxetine
40mg/day three months ago, of then he was switched six weeks ago to
venlafaxine 75mg once daily. Now he came with a new prescription of
venlafaxine 75mg of paroxetine 40mg daily the pharmacist should interact with
patient as follows
a) Disperse both medications
b) Call the doctor for washout period of venlafaxine
c) Dont dispense the two medications, since they may cause
sertonin syndrome
d) Call the doctor to switch the patient to ECT
e) None of the above
(E) In case if there is no response after the second treatment (four to six weeks),
the doctor should prescribe either paroxetine plus bupropion or mirtazapine.
Another option is to prescribe venlafaxine plus bupropion or mirtazapine.
CBT should be attempted with medications. ECT in the patient cannot tolerate the
medications. Mirtazapine should not be prescribed if the patient has over weight.

63. A 62 years old patient came to the pharmacy with a new prescription for
venlafaxine 112.5 mg to treat his depression. His profile shows that he was on
venlafaxine 75mg for the past six weeks. He is not experiencing any except
sedation. Best action of the pharmacist is;
a) Call the doctor that there is no venlafaxine 112.5mg
b) Call the doctor to reduce the dose since he is experiencing sedation
c) Call the doctor to change the dose to either 75mg or 150mg which are available in
the market
d) Try to make a compound for venlafaxine of 112.5mg
e) None of the above
(E) Venlafaxine 112.5mg could be dispensed by making two transactions; one
transaction is for venlafaxine 75mg cap the other transaction is for venlafaxine
37.5mg cap. So tell the patient to use one cap of 75mg along with one capsule of
37.5mg. He can swallow both of them, or sprinkle them on food or apple sauce,
and it is better to be taken with food.

64. A 70 years old patient he has the history of heart failure and is using Digoxin
0.25mg Recently the patient was experiencing sore throat and the doctor
prescribed for him Biaxin 500mg tech (clarithromycin 500mg tal). He has no
allergy to any medication. Best action should the pharmacist do is;
a) Dispense clarithromycin and there is no problem of any interaction
b) Call the doctor to switch the patient from clarithromycin 500mg to Azithromycin
500mg
c) Call the doctor to switch the patient to Amoxycillin 500mg TFD
d) Stop Digoxin for the period of using clarithromycin
e) None of the above
(C) Clarithromycin, Azithromycin, doxycycline and tetracycline except
Amoxycillin kill the bacterial flora in the brush boarder of the small intestine
which may result in crease in the absorption of Digoxin.
The problem here is not that digoxin may be deceased excretion due to
clarithromycin CYPY50 3 Digoxin is not a substrate of CYP3AY.

65. A patient 5 years old experiencing common cold, sneezing, runny nose. His
mother approaches you for an OTC product. Best selection of OTC to treat his
common cold is;
a) Desloratidine syrup (Aerius)
b) Claritin syrup
c) Fexofenadine syrup
d) Combination of an antihistamine plus a decongestant
e) None of the above
(E) Under six years of age no cough and cold remedies. The patient may be
provided with saline drop for his decongestant nose, and acetaminophen syrup if
he has fever, humidifiers and eucalyptus are also good for him.
All first generation antihistamines with the decongestants should be reserved for
the children that are above six years of age.

66. A 22 years old patient had broken his wrist after a baseball game. Best
recommendation his doctor should prescribe for his severe pain is;
a) Diclofenac 75mg
b) Oxycodone 10mg 4-6 Hpru
c) Endodan 40mg (oxycodone +ASA)
d) Tramadol +acetaminophen
e) None of the above
(C) Since any broken limb result in swealling, there fore a pain killer with an
antiinflammatory agent should be siren while all the others are considered as pain
killer.
Diclofenac although it is an antiinflammatory and a pain killer since it is an
NSAID, however it is not potent as oxycodone plus ASA, and secondly
diclofenac 75mg is a sustained release medication which has not an immediate
action.

67. A patient 55 years old experiencing rheumatoid arthritis. He is using 25mg MTX
weekly for three months. His doctor decided to prescribe folic acid 5mg. The best
administration of folic acid is;
a) Take folic acid concurrently with MTX in the same day
b) Space apart folic acid from MTX at least 4 6 hours
c) It is better to give 0.4mg 1mg folic acid
d) Give folic acid another day in which the patient does not take folic acid
e) None of the above
(D) To avoid drug antagonism by folic acid it is better to give in a day where the
patient does not take any dose of MTX.
If MTX was given in alternating days, again it is preferable to give folic acid in
those days that the patient is using MTX.

68. A 45 years old female patient experiencing vaginal infection. Her doctor
prescribed for her fluconazole 150mg tal (Diflucan 150mg). In her profile she is
using chlordiazepoxide 5mg once daily.
Best recommendation from the pharmacist to the patient is;
a) There is no DRP between chlordiazepoxide and Diflucan 150mg since Diflucan is
used once daily
b) Space apart Diflucan and chlordiazepoxide at least 4 6 hours
c) Call the doctor to replace fluconazole by another azole that does not interact with
chlordiazepoxide
d) Tell the patient not to use chlordiazepoxide in that day of using fluconazole
e) None of the above
(D) There is a severe drug drug interaction between fluconazole and
chlordiazepoxide and the literature mentrous that increased and prolong
psychomotor impairment and depression. Possibly continuing a few days after
fluconazole discontinuation. However, because here the dose of fluconazole is for
one day, then we can advise the patient to stop using chlordiazepoxide for one day
and to resume using it after 24 hours.

69. A 33 years old patient experiencing migraine. Her doctor prescribed for her
rizatriptan 10mg tab for five days. The strength that is available is 5mg RPD
tablets. The number of tablets that should be provided to the patient is
a) 10 tablets
b) 20 tablets
c) Call the doctor and tell him 10mg tablets is not available
d) 30 tablets
e) None of the above
(B) Because the dose of Rizatriptan may be repeated in 24 hours. Then we should
give 20 tablets of 5mg. Rizatriptan tablets.
This also apples for all triptans whether tablets or injections.

70. A patient 35 years old was prescribed topiramate 250mg for the first week and to
increase the dose of topiramate by 25mg each week till she reaches the
maintenance dose of 350mg per days. It take the patient
a) 7 weeks to reach the maintenance dose
b) 6 weeks to reach the maintenance dose
c) 5 weeks to reach the maintenance dose
d) 4 weeks to reach the maintenance dose
e) None of the above
(E) First week 250mg, each week till 100 till it reaches 350mg dose.

71.For the above patient the number of pills prescribed for the patient will be
a) 30 tablets topiramate 250mg and 30 tablets topiramate 25mg
b) 30 tablets topiramate 250mg and 35 tablets topiramate 25mg
c) 35 tablets topiramate 250mg and 70 tablets of topiramate 25mg tablets
d) 30 tablets topiramate 250mg and 70 tablets of topiramate 25mg tablets
e) None of the above
(C) Since he is taking the each week 250mg, then 35tablets of topiramate 250mg
for 5 weeks to read the maintenance dose.
For topiramate 25mg it is not used for the first week of the dose is titrated up by
one tablet starting form the second week thus.
2
nd
week 3
rd
week 4
th
week 5
th
week
7 tablets 14 tablets 21 tablets 28 tablets
The combination is; 7 +14 +21 +28 =70 tablets of topiramate 25mg and 35
tablets of topiramate 250mg tablets.

72.A patient 70 years old was admitted to the hospital due to severe congestive heart
failure. The nurse practitioner in the hospital called the pharmacy where the admitted
patient has his profile to send the profile of the patient. In his profile the following
medications were seen;
1. Digoxin 0.25mg GD active
2. Bisoprolol 0.125mg BID deactivated
3. Carvidilol 0.25mg BID on hold
4. Carvidilol 0.25mg BID active
5. Spironolactone 12.5mg GD on hold
The pharmacist is his report to the nurse practitioner the following;
a) All of them
b) Only 1, 2, 3 and 4
c) Only 1, 4, 5
d) Only 1 and 4
e) Only 2
(D) The pharmacist should provide only the medication that the patient is using
from 3 and 4 only. 4 since it is active and 3 is on hold not using it and the
deactivated we dont list them since the patient is not using them.
However if the patient profile was containing only on hold and deactivated
medication, later the on hold only should be provided to the nurse since the
deactivated ones reflect the on hold medication, which he is using them
currently.

73. A 65-year-old patient has red eye. His doctor wants to prescribe him an eye drop
that is mast cell stabilizer. The patient has a problem with compliance
Best antihistamine/mast cell stabilizer that suites this patient is
a) Emedastine
b) Ketotifen fumarate
c) Iodoxamide
d) Nedocromil
e) Olopatidine
(D) Nedo-cromil (Alocril) is used as 1-2 drops BID while the rest ranges from
TID to QID

74. 45-year-old patient has diabetis and currently experiencing anxiety disorders. His
profile shows that he is on metformin 500mg BID and used alprazolam 1mg QID. He
approaches your counter with a new prescription. The new prescription to treat his
anxiety disorder in which has not improved yet is:
a) Should contain higher dose of alprazolam
b) Should contain pregabalin 150mg/day
c) Gabapentin 300mg/day
d) Riseperidone 1mg/day
e) None of the above
(c) Gabapentin is not a first-line agent, and maybe useful in patients not
responding to first line measures. Pregabalin causes peripheral edema and
should not be used in peripheral circulatory impairment as in diabetes.
Resiperidone is used as augmentation therapy with first line agents in
PTSD

75. 10 years patient with ADHD. His doctor diagnosed his condition and prescribed
methyl phenidate CR capsule 10mg twice daily. Best thing the pharmacist should do is
a) Call the doctor to switch the patient to methylphenidate SR tab
20mg/dose since the later is given in divided doses
b) Call the doctor to ensure him that methylphenidate SR is given
once daily and not twice daily
c) Dispense the prescription as it is
d) Call the doctor to prescribe him methyl since the capsule can be
opned and sprinkled on soft foods
e) None of the above
(B) methylphenidate SR is given as 20mg/dose 8 hours apart and
controlled release as a single dose

76. 33-year-old patient experiencing insomnia. His profile shows that he used temazepam
30mg/day 2months ago. He still experiencing insomnia and came wih new prescription
from his doctor. Best therapy his doctor should recommend is:
a) Continue Zopiclone
b) Continue on Zopiclone and none pharm
c) Melatonine herbal product
d) L-tryptophan
e) Zopiclon and temazepam
(D) L-tryptophan with 1-3g 20 min before bedtime is an alternative to
BZD and non-BZD agonists
Melatonine differs from batch to batch since it is a herbal product.
Non-pharm always be recommended but it appears in this case that they
will not improve the patient condition since he has already used a BDZ
with no benefits which indicates the necessity to go to the alternative
medication in addition to the non-pharm which should be followed too

77. A 60-year-old patient came to the pharmacy with a prescription for citalopram 10mg
tablet for 30 days. The patient has problem with compliance and requested to be put in a
blister pack. The pharmacist in this case should:
a) Tell the patient to sign a form because he is ordering a blister
pack (dosette)
b) Dispense the medication in one week blister pack
c) Dispense the medication in a blister pack as it is written in the
prescription
d) Dispense the medication in a blister pack for 4 weeks only
e) None of the above
(D) The pharmacist can not dispense for 30 days in a blister pack. Blister
packs are only on weekly basis
There is no form for blister packs. Forms are for non-child resistant vials
or when the patient requests the medication to be given to an agent.

78. Doctor prescribes citalopram 60mg QD to a patient who didnt find any
improvement in his citalopram 40mg QD. The available citalopram in the pharmacy
is 10mg, 20mg, 40mg. Best thing the pharmacist should do is:
a) Call the doctor to fell him that the pharmacy does not have that
strength
b) Order citalopram 60mg from warehouse
c) Give citalopram 20mg along with citalopram 40mg tablet
d) Call other pharmacies to provide the pharmacy with citalopram
60mg tablet
e) None of the above
(C) We can give citalopram 20mg tab along with citalopram 40mg tab

79. Health Canada wants to recall prevacid medication. The pharmacist should call the
patients using this medication for at least:
a) 1 month ago
b) 2 months ago
c) 3 months ago
d) 1 year ago
e) 1 week ago
(c) At least 3 months ago since such kind of PPIs may be supplied up to 90
or 100 days

80. Health Canada wants to recall Amoxicillin 250 medication. The pharmacist should
call the patient using this medication for at least:
a) 1 week ago
b) 2 weeks ago
c) 1 month ago
d) 3 months ago
e) 6 months ago
(B) Since antibiotics especially Amoxicillin is not for long periods of time,
then 2 week supply is generally sufficient

81. The pharmacist should keep the inventory of his medication for at least
a) 1 month
b) 2 months
c) 3 months
d) 6 months
e) 1 year
(C) At least 3 months are required to cope with the idealistic turnover of
his medications
82. A pharmacist is processing a prescription signed by the pharmacist himself for
glucose strips. He is doing that instead of selling it over the till directly because
a) Strips can not be sold over the till
b) It is more organized to process it in that way
c) To release an official receipt that could be submitted to the third
party
d) Doctors do not issue prescriptions for glucose strips
e) None of the above
(C) If we scan the medication over the till, there is no official receipt
unless the prescription is processed

83. A pharmacist during in putting a prescription into the computer forgot to enter the
number of refills that were indicated in the prescriptions, and the patient pick up his
medication from the pharmacy and went home. The best action the pharmacist should do:
a) Call the patient to tell him that you forgot to put the number of
refills
b) No problem, next time when he comes you can tell him to go to
his doctor to write other refills
c) Dont tell the patient that you forgot to put the refills
d) Call the patient inform him that you forgot to put the refills and
tell him that you are going to enter the refills into the computer
e) None of the above
(E) We have to call the patient inform him about the error, and input the
number of refills into the computer, and issue a drug incident error for that
and inform the manager or district manager about that, and take the steps
of not repeating this error again

84. A customer comes to the pharmacy requesting 2 packs of birth control portia 21 tabs
(1 qd ud). When the pharmacist checks the profile of the customer he sees that she has
taken the medication one month ago. Best action the pharmacist should do is:
a) Call the doctor and tell him if he accepts the early refill
b) Refuse to dispense the birth control due to early refill
c) Dispense the portia
d) Tell the customer to go to walk-in-clinic to bring a new
prescription
e) None of the above
(C) Because the medication direction is UD which means as directed, then
this birth control medication might be given continuously, which means
42 days (30) (42) =70.
Any medication medication if was requested after 2/3 period has past
could be given the refills of that medication except for narcotics.
So in such conditions, there is no need to call the doctor to get his
permission for refill nor to call the third party drug plans if the patient is
covered.

85. Doctor wants to prescribe methotrexate vial 25mg/ml 52per week for 6 months. The
vial has the volume of 2 ml. The quantity authorized by the doctor to treat that condition
is:
a) 26 ml. Or 13 vial
b) 52 ml. Or 26 vials
c) 24 ml. Or 12 vials
d) 48ml. Or 24 vials
e) none of the above
(B) the quantity authorized is 52ml. Or 26 vials, however, the patient is
going to inject 1ml each week and discard the other ml since the vial of
2ml does not contain any preservative

86. Patient calls a pharmacy X, he wants to fax his prescription to the pharmacy. Best
action the pharmacist should do:
a) Accept the fax
b) Call the doctor to see whether the fax is true or not
c) Dont accept any fax from a patient
d) Ask the patient to tell you what medications are in the fax so that
to release a verbal prescription
e) None of the above
(E) We can tell the patient to fax and also to bring the original prescription
when he comes to the pharmacy

87. A pharmacist wants to pull out his close to expiration date medications from the
shelves so that not to dispense them to the patients. He is now out the end of 3
rd
week of
September. He decided to pull out October and November ahead of time. He has the
following medications that expired on November:
1- Ceftin suspension
2- Apo-Risperidone suspension
3- Azithromycin capsule
4- Tramacep capsule
5- Fluconazole tablet

a) All of them should be pulled out
b) Only 2 and 4
c) Only 1,3 and 5
d) Only 1 and 3
e) Only 5
(B) Since 1, 3 and 5 are all antibiotics, and there is no need to pull them two
months ahead. The quantity of the dispensed antibiotic is for one or two weeks in
the majority of cases

88. 65-year-old patient broke his knee 15 days ago while he was playing soccer. His
doctor prescribed for him endocef (Percocet) tab to be taken as one tab QID. His profile
shows that he is still using Tylenol #3 which was filled 15 days ago.
Best action the pharmacist should do:
a) Refuse to fill the prescription
b) Call the doctor to inform him that he still has Tylenol #3
and using it
c) Dispense the new prescription and caution the patient about
the addiction of codeine
d) Tell the patient to D/C Tylenol #3
e) None of the above
(E) The patient should be cautioned about the high dose intake of acetaminophen
which should not exceed 4 years/day and not for codeine or oxycodon which is in
addition to that our concern here is the relieving of pain as not the addiction

89. A 45-year old approaches your counter with a new prescription for Zyban m150mg.
In your pharmacy, there is no Zyban but you have other generics of Bupropion of the
same strength. The best action you should do:
a) Dispense Sandoz-Bupropion 150mg or any generic of the
same strength
b) Call the doctor to change the medication from Zyban to any
other generic
c) Tell the patient that you dont have Zyban and you can
choose other OTC smoking cessation medications
d) Tell him sorry I dont have that now
e) None of the above
(E) You should order Zyban from the warehouse if you dont have it. Sorry I
dont have it is not serving the patient property
Any generic is not interchangeable with Zyban since Zyban is specific for
smoking cessation and not to treat depression

90. Doctor wants to prescribe methadone as a part of methadone program for a patient
who is addicted to morphine for more than 1 year. The dosage form of methadone to
treat that condition should be:
a) Capsule
b) Tablet
c) Suppository
d) Injection
e) Liquid form
(E) Always should be in liquid form which the other solid forms could be in
hidden under the tongue and not used
The solid dosage forms and injections may be kept for acute cases of pain
The pharmacist should keep talking with the patient to ensure that he swallowed
the dose
The dose should be witnessed by the pharmacist. For holidays, the physician
should release another prescription to be bought from another pharmacy

91. A patient wants to quit smoking and he wants to do that by a short duration. He
has hypertension which is under control. Best shortest therapy is:
a) Nicoderm transdermal patch
b) Varnicline
c) Zyban
d) Nortriptylline
e) Clonidine (Dixarit)
(E) Clonidine (Dixarit) 0.1mg po BID. Increase by 0.1mg/day once per week if
needle. Duration of therapy ranges from 3-10 week. B.P. and heart rate should be
monitored especially for a patient with hypertension during treatment initiation.
The dose should be tapered off gradually to avoid rebound hypertension.

92. A 35 years old lady, her doctor wants to prescribe a medication for his migraine
which starts usually few days before her period. Best medication to prevent her
migraine that suits her condition is;
a) Atenolol
b) flunan zin
c) Topiramate
d) Ibuprofen 400mg
e) Naproxen sodium 275mg (Anaprox)
(E) It is useful in preventing premenstrual migraine attacks when taken twice
daily perimenstrually for two weeks, starting 7days before menses.

93. A 45 years old patient was admitted to the hospital experiencing severe and
prolonged migraine headache. His doctor in the hospital prescribed for him
dihydroergotamine to be taken parenterally as 0.25mg/dose i.v. to be repeated three
times every 20 minutes. Best action from the clinical pharmacist in this situation is;
a) Dispense the prescription as it is
b) Call the doctor to switch him to Triptans since he is experiencing severe
prolonged migraine
c) Counsel the patient on flushing tingling of extremities, and N&V
d) Call the doctor to prescribe DHE nasal spray so that to discharge the patient
e) None of the above
(E) The clinical pharmacist should call the doctor to prescribe metoclopramide
0.2mg/kg/dose (maximum 20mg) 30minutes prior to iv DHE to prevent the
nausea and vomiting due to DHE counselling the patient on N&V is not enough in
this situation since the patient requires prescription medication (metoclopramide)
to prevent the N&V prior to i.v. administration of DHE. DHE nasal spray is not
used for severe prolonged condition, but to moderate cases of migraine.

94. A 55 years old patient is experiencing Trigemeninal neuralgia. His doctor
prescribed for him Baclofen and carhazepine without any meaningful effect. Now his
doctor decided to add phenytoin and stop baclofen. Best action the community
pharmacist in this situation should do is
a) Dispense as the doctor prescribes
b) Call the doctor to tell him that gabapentin is better than phenytoin to be added to
the rgimen since there is no drug interetion
c) Caution the patient on the sedative effect
d) Call the doctor to continue baclofen to make the patient get better response.
e) None of the above
(E) The doctor should be called to D/C Baclofen gradually.

95. A 35 years old patient his doctor prescribed for him Tramadol CR 150mg daily
(Zytram). Currently he is using paroxetine 20mg/daily. The pharmacist should
caution the patient on;
a) Respiratory depression
b) Serotonin syndrome
c) Decrease seizure threshold
(All) Tramadol is ----- to respiratory depression and serotonin syndrome with
SSRI, it may cause a decrease in seizure threshold when combined with SSRI.

96. A 65 years old patient is experiencing chronic spasticity. His doctor prescribed for
him Nizatidine with no benefit. Now his doctor added Baclofen to the regimen. Best
action should the pharmacist do is;
a) Dispense the prescription as it is
b) Call the doctor to switch the patient to gabapentin
c) Call the doctor to switch the patient to Dantrolene.
d) Call the doctor to increase the dose of Nizatidine without prescribing Baclofen for
him
e) None of the above
(E) Calling the doctor telling him that Nizatidine is for stomach ulcer and not for
chronic spasticity. Tizanidine is for chronic spasticity and this error may occur
due to close nomenclature of the two medications.
Switching the patient to gabapentin may be done it there is a treatment failure for
Baclofen and Tizanidine.
In this particular condition the doctor may initiate the treatment with the patient
on a monotherapy like Tizanidine since the patient was not taking the right
medication.

97. A 70 years old patient is experiencing nocturnal leg cramps. His doctor prescribed
for him Quinine sulfate to be given as 300mg QHS for 6 months, with one refine. His
cramps are frequent and severe. Best action the pharmacist should do is;
a) Call the doctor to refer the patient to a specialist
b) Dispense as it is
c) Call the doctor to tell him that with draw therapy is every 3 months to assess
therapy, and his recommendation is a leng treatment
d) Call the doctor to consider only non-pharm
e) Call the doctor to start with a single dose dopamine agonist 1-2 hours prior to
bedtime and to titrate to effectiveness.
(C) Quinine use should be assessed regularly as cramps can resolve spontaneously
or after a short period of therapy. Cramps rarely need referral unless associated
with other neurologic complaints or signs. The use of dopamine agonists is for
restless leg syndrome which is different from muscle cramps which are sudden
involuntary contractions of one or more muscle groups.
Non-pharm should be tried along with Quinine sulfate, since the cramps were
severe and frequent.

98. A 34 years old patient is experiencing grand mal epilepsy. His doctor initiated a
monotherapy treatment with phenytoin (Dilantin) 400mg/day. The main concern of
the pharmacist is;
a) Long term cosmetic adverse effects
b) Skin rash
c) Increase in liver enzymes
d) Dose related encephalopathy
e) None of the above
(E) When phenytoin is used the main concern of the pharmacist is thy loading
dose, which should be administered carefully.

99. A 38 years old patient her doctor prescribed for her topiramate 100mg/day to be
by 100mg every 3days till it reaches 400mg/day to continue then as a maintenance
dose. The main concern of the pharmacist is;
a) The medication is expensive
b) Cognitive problems which are common
c) Narrow spectrum of activity
d) Fast titrating dose
e) None of the above
The dose should be titrated slowly. The medication is abroad spectrum, safe and
few drug interactions. It is also a potent AED.
Cognitive problems commonly limit its use but come in concern after the rapid
titrating dose.

100. A 70 years old patient had a cataract surgery and his doctor prescribed for him
Gentamicin drop post operatively for two weeks. Now the patient is seen in the
patient selected area to look for a decongestant eye drop, and requests that from the
pharmacist. Best recommendation the pharmacist should do;
a) Give Naphazoline adult eye drop
b) Give Polysporin eye drop
c) Refer to doctor
d) Tell the patient to D/C Gentamicin
e) None of the above
(D) This drop should be used for 7-10 days only. Extended use may cause
conjunctivitis or epitheliopathy reactions to the eye.

101. A 75 years old patient was discharged after cataract surgery. His doctor wants to
discharge him and to prescribe a Fluoroquinolone with higher activity against gram-
positive organisms. Best recommendation the physician should do is;
a) Prescribe ciprofloxacin drop 7-10days.
b) Gatifloxacin drop 7- 10 days
c) Ofloxacin drop (Ocuflox) 7-10 days
d) Ciprofloxacin oral 500mg Pa 12 hours 7-10 days
e) None of the above
(B) 4
th
generation fluoroquinolone has improved broad spectrum activity
especially against gram positive organisms.

102.A 80 years old patient was discharged after cataract surgery, her doctor
prescribed for her fluorometholone (FML) drop for 3-4 weeks. The main concern of
the pharmacist here is;
a) Long duration of use
b) Short duration of use
c) Call doctor to switch her to NSAID drop which are safer
d) Antiinflammatory effects can mask signs of infection
e) None of the above
(D) Since the treatment is considered as a long duration, so in this particular case
and since the patient is 80 years old which make him more prove to eye infection
after operation. NSAIDs are used as a substitute for steroids to inflammation
without the risk of elevating intraocular pressure. In this case the patient has no
history of glaucoma, and the risk of elevation of intraocular pressure should be
considered beyond that duration of time.
103. A 65 years old patient was discharged from the hospital after cataract surgery.
His doctor prescribed for him Brimonidine 0.2% (Alphagan) two days ago. Now he
came to the pharmacy with red eye itchiness, requesting an OTC eye drop to treat his
itchiness and redness. Best recommendation the pharmacist should do is;
a) Give Naphazoline eye drop as decongestant
b) Call the doctor and suggest to him Brimonidine 0.15% (Alphagan P)
c) Call the doctor to tell him to switch the patient to other PGs drops
d) Ensure the patient that these signs and symptoms are temporary and they will go
off as the patient continues using the drop
e) None of the above

Ans: (B) Brimonidine 0.15% contains purite as preservative rather than
Benzalkonium chloride which makes it to have slightly lower incidence of ocular
allergy than Brimonidine 0.2%

104. For the above patient if the doctor was not satisfied about giving Brimonidine
0.15%, the pharmacist should suggest
I. Dorzolamide 2% (Trusopt)
II. Brinzolamide 1% (Azo patient)
III. Dorzolamide 2% preservative free (Trusopt)

Ans: (III) Since it is advantageous for patients with allergies to Benzalkonium
chloride

105. 65 year old patient experiencing glucoma. His doctor prescribed for him
latanoprost us 0.005% (Xalatan) twice daily to continue on it for six months. After
one month he came to the pharmacy requesting advice from the pharmacist for his
eye condition that has not been progressed. The main concern of the pharmacist in
this particular condition is:
a) non-compliance of the patient towards his medication
b) not storing the medication in the fridge
c) Incorrect recommendation from the doctor about the direction of use of
the drug
d) Incorrect recommendation from the doctor about the direction of use of
the drug
e) Patient is not following the non-pharm.

Ans: (D) Once daily dosing should not be exceeded more frequent administration
may reduce effectiveness

106. 16-year-old patient came the pharmacy with a new prescription for his
glaucoma. His doctor prescribed for him pilocarpine 2% QID. The major concern of
the pharmacist in this particular case is:
a) High dose
b) Better to be switched to isoptocarpine 2% gel since it is given one time only
c) Pilocarpine is poorly tolerated in young adults
d) It is better to start with cholinergic medication rather than cholinergic drops
e) None of the above

Ans: (C) Pilocarpine is poorly tolerated in children and younger adults

107. 33-year-old patient was using naphazoline eye drop since a week ago as 1-2
drops Q 3-4H prn. Now she came requesting something from the pharmacist to help
her reduce the redness of her eye. Best recommendation the pharmacist should take
is:
a) Recommend to see her doctor for a prescription medication
b) Give her oxymetazoline (Claritin eye allergy relief)
c) Tell the doctor her previous medication
d) Tell her that these might be signs and symptoms of glaucoma and it is better to
see a doctor
e) None of the above

Ans: (C) Ophthalmic vasoconstrictors are used for occasional and short term use like
3-4 days even if they are used as prn. Overuse may cause rebound hyperemia

108. A 30-year-old patient was diagnosed as bacterial conjunctivitis, and this was
confirmed by culture and sensitivity test as having pseudomonas infection. His doctor
prescribed chloramphenicol (pentamycetin) eye drop for him as 1 drop q3h from 48
hours, then frequency may decrease.
The major concern of the pharmacist is:
a) High dose of chloramphenicol drop
b) Chloramphenicol is not the first choice and it is better to initiate with fusidic acid
drop
c) It is better yo start with fluoroquinolone eye drops
d) It is better to start with systemic antibiotics
e) It is better to start with antibiotic eye ointments since they persist on the eye for
longer period of time

Ans: (C) Fluoroquinolones should be reserved for serious infection such as
pseudomonas

109. 55-year old patient presented to the pharmacy with a prescription of Trifluridine
(Viroptic) to treat his eye from his herpes simplex. His doctor told him ti use it as 1
drop q2h while awake, maximum of 9 drops/day, until lesion is reepithelialized, then
1 drop q4h, maximum five drops for 30 days.
Major concern of the pharmacist;
a) Trifluridine drop is used for herpes-zoster rather than herpes simplex
b) High dose is given
c) Call the doctor about the duration of use
d) It is better to give prednisolone 5mg/day as an adjunct to trifluridine to treat the
viral infection
e) None of the above

Ans: (C) chronic use of trifluridine may result in corneal epithelial toxicity

110. 223-year-old patient is experiencing ocular allergy due to contact lease wearing.
His doctor can prescribe all these medication to be instilled four times daily
EXCEPT:
a) Sodium cromoglycate eye drop
b) Emadastine (Emadine) eye drop
c) Fodoxamide eye drop (Alomide)
d) Nedocromil (Alocril) eye drop
e) Olopatadine (Petanol)

Ans: (D)
Nedocromil eye drop is given as 1-2 drops BID. All the rest as 3-4 times daily.
Ketotifen fumarate (Zadilor) is given as 1 drop in 8-12 hours, however it was not
mentioned as one of the above options. Antihistamines/mast cell stabilizers
ophthalmic are mostly given for ocular allergies, contact lens wears or contact
artificial eyes

111. The auxiliary labels with respect to Synthroid should be
I. Take it in the morning
II. Avoid other medications at least 4-6 hrs
III. To be taken on empty stomach
Ans: All

112. In the above example, if the patient was using nitroglycerine pump and
metoprolol. The best initiating dose is:
a) Start with 100mg/day
b) Start with 50mg/day
c) Start with 12.5-25mg/day
d) Start with liothyronine 25mg BID
e) None of the above

Ans: (C) starting dose is 12.5-25mg/day in those with the risk of angina

113. The onset of action of insulin glulisine is
I. 10-15 minutes
II. 15-30 minutes
III. 5 minutes

Ans: (I) Insulin as part (NOVO rapid, insulin glulisine (Apidra), and Insulin lispro
(Humalog) is 10-15minutes and it peaks in 60-90 minutes and duration is 4-5h

114. Patient 65-year old his doctor switched him from novolinged 40/60 to insulin
glargine i.m. to be taken once daily i.m. to be taken once daily as 100ml/day. The
main concern of the pharmacist
a) The patient is taking high dose
b) The patient is taking low dose
c) The patient should take the medication as I.V.
d) The patient should take the medication S.C.
e) None of the above

Ans: do not inject lantus im or iv except sc

115. All of the following insulins should appear cloudy EXCEPT:
a) Insulin glulisine
b) Insulin NPH
c) Insulin detemir
d) ATC
e) Humulin 20/80

Ans: (D)

116. A 58-year old patient is experiencing typw II D.M. his doctor prescribed him
240 mg once daily. The main concern of the pharmacist is:
a) Gliclazide (Diamicron) causes prolonged hypoglycemia
b) High dose is given
c) Low dose is given
d) Gliclazide has an antiplatelet effect which may result in bleeding
e) None of the above

Gliclazide when is given in a daily dose 160mg should be given in divided doses

117. 73-year old patient is experiencing Diabetes type II, his blood glucose is
undercontrol, but because he is an old patient his doctor wants to keep him on a
maintenance dose that can avoid non-compliance problems. Best therapy for this
patient if the doctor wants to prescribe sulfonylurea for him is/are:
I. Gliclazide 200mg in two divided doses
II. Glimpiride 4mg once daily
III. Gliclazide, long acting as 120mg once daily.

Ans: (D) II and III, they are given once daily

118. 57-year old patient with type II D.M. since 20 years ago. Currently his blood
glucose level is not under control. His doctor gave him metformin 1350mg (one tab 830
metformin +500 tab metformin). His glucose level is still not under control and his
doctor wants to give him 2200 metformin as (2 tab of 850mg) and (1 tab of 500mg). The
major concern of the pharmacist is:
a) High dose of metformin
b) Lactic acidosis of the medication
c) Little additional benefit above 1500mg/day
d) Weight gain
e) None of the above
Ans: (C) little additional benefit above 1500mg/day

119. 55-year old patient has been diagnosed as DM type II. His doctor prescribed him
metformin 850mg BID without controlling the blood glucose level. Doctor wants to add
acarbose as 50mg TID. Patient profile reveals that the patient has inflammatory bowel
disease. Best thing the pharmacist should do:
a) Call the doctor to reduce the dose of metformin
b) Call the doctor to reduce the dose of Acarbose to twice daily with major meal
c) Call the doctor t inform him that acarbose should not be recommended
d) Dispense as it is
e) None of the above

Ans: (c) Acarbose is contraindicated in irritable bowel syndrome or inflammatory bowel
disease

120. 35-year old lady patient has a prescription from her doctor Orlistat (Xenical) as
120mg TID with each meal containing fat. Best action that the pharmacist should do in
dealing with this prescription is:
a) Dispense as it is
b) Call the doctor since it is a high dose
c) Warn the patient about the decreased absorption of vitamin A,D,E,K.
d) Tell the patient to use non-pharm as an adjunct
e) None of the above

Ans: (E) Advise patients to take a multivitamins daily 2 hours before or after orlistat or
at bedtime. Warning is not sufficient. Non-pharm plus medication without advising for
multivitamins is insufficient therapy

121. A 60-year old patient has zinc deficiency which resulted in impairment of his
immune system. His diet is poor, and the doctor started a long term treatment of Zn
50mg/day. Main concern of the pharmacist to this therapy is
a) It is a high dose if Zn
b) It is a low dose of Zn
c) It is a wrong medication to enhance the immunity
d) Zinc is used for shortening the duration of common cold
e) None of the above
Ans: (E) long-term high dose of Zinc intake may block iron and copper absorption

122. The monitoring parameters for Ezetimibe is/are
I. Liver function
II. CK
III. Back pain
Ans: (C or I and II) Only liver function and CK. Back pain, arthralgia, fatigue and
headache are adverse effects of the medication which may appear or not.

123. A 65-year old patient has high lipid profile and the doctor wants to initiate a
treatment for high lipid by prescribing Rosuvastatin (Crestor) 10mg/day as an initial
dose. The patient has some hemoglobinopathies and is using currently cyclosporin.
Best action the pharmacist should do:
a) Dispense the prescription as it is
b) Call the doctor to reduce the dose of cyclosporin
c) Call the doctor to half the dose of Rosuvastatin
d) Call the doctor to switch him to atorvastatin
e) None of the above

Ans: (C) Asian patients and those receiving cyclosporine, initial dose should be 5mg/day

124. 65-year-old male has a prescription of duoloxetine 30mg/day. His profile shows that
he is currently on tramadol (150mg CR once daily).
Best Action the pharmacist should do is:
a) Dispense the prescription as it is
b) Call the doctor to switch the patient to Bupropion
c) Call the doctor to switch the patient to immediate release tramadol in order to
space apart with tramadol
d) Tell the patient to stop using tramadol due to drug-drug interaction between
tramadol and duoloxetine
e) None of the above
Ans: (E) The patient should be warned to monitor serotonin syndrome and lowering in
seizure threshold, and if these signs and symptoms happen tramadol, and if these signs
and symptoms happen tramadol should be stopped immediately with contracting the
physician. In addition to that the patient should be stopped immediately with contacting
the physician. In addition to that the patient should be counseled on lowest dose of
tramadol and on a short duration.

125. 78-year-old comes to the pharmacy requesting an advice from the pharmacist since
he was experiencing insomnia, depression and vivid dreams. The pharmacist checked in
his computer to see the profile of the patient, and the patient had no profile. After
questioning the patient about the medications he uses, he said that he used some
medications to decrease cholesterol and other for his blood pressure, and stable angina.
The pharmacist should realized that the medication is using most probably:
a) Atenolol
b) Atorvastatin
c) Propranolol
d) Amlodipine
e) Verapamil

Ans: (C) Propranolol is most likely to cause CNS side effects

126. The doctor of a 63-year-old patient prescribed him ASA coated 81mg nitroglycerin
puff and nitroglycerin topical ointment TID. After a period of stable condition, he started
to use the nitroglycerin pump more frequently. The major concern of the pharmacist is:
a) Nitroglycerine ointment is expired
b) Non-compliance of the patient
c) The doctor should switch him to nitroglycerin isosorbide
d) The Doctor should add a beta blocker to the regimen
e) None of the above

cts.




Ans: (E) The major concern of the pharmacist is to ensure a 10-20h nitrate-free period
daily to prevent tolerance.
Non-compliance means the patient is either reducing the number of doses such as from
three applications to two and such a condition, there is no problem it could be used BID-
TID or forgetting to use it and in such a condition will end up in heart attack with no
benefit of nitroglycerin pump in severe conditions
Switching to other nitrates is just in case if the patient is experiencing certain side
effects like local reactions of the ointment or allergic dermatitis due to the ointment,
or due to certain side effects

127. A 63-year-old patient is using Indomethacin for her rheumatoid arthritis. She uses
EE 30mg drospirenone 3mg (Yasmin) as an oral contraceptive, major action of the
pharmacist is:
a) Indomethacin may increase BP of the patient
b) Call the doctor to switch her to OTC Advil
c) Call the doctor to switch her to Alesse
d) Call the doctor to give a potassium depleting diuretic
e) None of the above

Ans: (E) The pharmacist should caution the patient about the hyperkalemia that may
result from drospirenone in the oral contraceptive and NSAID, indomethacin which
reduces the renal perfusion resulting in hyperkalemia (T.C. Pg 458)

128. A 70-year-old patient is on Digoxin 0.25mg/day. After playing sport, his wrist was
broken, and his doctor prescribed him naproxen 500mg TID. The major concern of the
pharmacist is:
a) High dose of naproxen
b) Naproxen may cause peptic ulcer
c) Hyperkalemia
d) Naproxen is ineffective and requires codeine preparations
e) None of the above

Ans: (C) same as #127 (TC pg 458)

129. A 63-year old patient came to you with a new prescription for Quetiapine (Serquel)
25-50mg po 6h prn, milt 30 tablet of 25mg. After looking at her profile it was shown that
30 days ago it was filled by a specialist for two weeks as Seroquel 100mg to be taken two
at bed time, followed by two another prescription by a family physician for 1 month
which she still has for coming couple of weeks. Her recent prescription was from a
specialist. Best action the pharmacist should take is:
a) Call the specialist to inform him about double doctoring
b) Call the family physician to inform him about double doctoring
c) Educate the patient and caution him about the sedative effect of taking higher
dose of Seroquel
d) Call the police to arrest the patient due to double doctor
e) None of the above

Ans: (E) The patient is simply taking an add/on dose from the specialist. His Seroquel
200mg may not be sufficient. The patient went to the family physician could be due to
unavailability of the specialist and the family physician prescribed as the same strength as
the specialist, so no double doctoring and it is clearly seen that the recent prescription is
on need basis which reveals as add/on therapy.

130. A 67-year old taking Seroquel 100mg tab as two tabs at bedtime, and now he came
with a new prescription containing Seroquel 200mg, two at bed time and Seroquel 25-
50mg q6h prn. To be dispensed as 25mg tablet
Best action the pharmacist should under take is
a) Call the doctor to fix the dose of prn as 25mg and 50mg
b) Dispense as it is
c) Call the doctor to dispense either one but not both of them
d) Dispense both of them and warn the patient about the sedative effect
e) None of the above

Ans: (B) Here again Seroquel is being given due to the end dose effect, where the level
goes below the therapeutic valve which makes the patient excited and not stabilized, so
the prn dose is not elevating the dose, however it is stabilizing the dose within the
therapeutic level to prevent any end dose effect which may result in flare up of the sign
and symptoms of the patient so counselling the patient to be aware of dizziness or
drowsiness due to the prn dose is important to keep you at the required therapeutic level
and to keep him with compliance with his medications.

131. A 44-year-old using Spiriva one daily. He comes to the pharmacy requesting
scopolamine patches since he is going to travel abroad. Best action the pharmacist should
do is:
a) dispense scopolamine patches
b) Give the patient dimenhydrinate instead of scopolamine patches
c) Give patient gravol ginger
d) Refer him to the doctor
e) None of the above

Ans: (C) Any scopolamine or dimenhydrinate will increase dryness so best thing is
ginger. Referring is incorrect

132. 57-year-old patient came with a prescription for magnesium glucoheptonate syrup to
be taken as 1 tablespoon daily as a magnesium supplement for the patient who has
hypoglycemia. Best thing the pharmacist should do is/are:
I. Tell him to use it with food
II. Tell him to drink plenty of water
III. Tell him to avoid salty food

Ans: I and II only. It is important to tell the patient to take it with food to lessen diarrhea
due to magnesium and also to drink plenty of water just to replenish the fluid loss in case
of diarrhea.

133. A 55 years old patient came to your pharmacy requesting sugar strips and lancets.
He has no prescription from the doctor but he told you that he is diabetic and he wants the
strips and lancets since he has run out of them. He also wants an official receipts that is
printed when dispensing prescription medications to submit it to his drug plan insurance
company in order to reimburse him. Best action the pharmacist should do is:
a) Refer him to the doctor t prescribe for him. The glucose strips and the lancets
b) Tell him that we can give him a slip from the register us a receipt but not as a
prescription receipt.
c) The pharmacist should issue a prescription containing the strips and the lancets
and sigh it and input in it the computer and process it as a prescription
d) Tell the patient that the strips and lancets must be bought with the glucometer
e) None of the above
Ans: (C) Because the medication is an OTC, the pharmacist can issue an and process it
under his signature and give official receipts as a prescription medication. Referring is
not acceptable since you are not offering any help to the patient where you can do this for
the patient.

134. A child 20 months old is experiencing watery diarrhea 5 times daily for the past two
days. His mother says that he eats too. Best recommendation from pharmacist is:
a) Stop eating and give him electrolytes
b) Tell the mother to give him Kaopectate
c) Tell the mother to give him ORS plus peptobismol
d) Tell the mother to give him plenty of fluids
e) None of the above
Ans: (E) In this situation since the child has been experiencing diarrhea for the last two
days, it is better to refer the patient to avoid dehydration, the mother may be advised to
give her child ORS.

135. A 55 years old patient came to the pharmacy with a new prescription for his dry
cough (co-Actifed syr). His profile shows that he is hypertensive ans using lisinopril tab
10mg BID. Best action from the pharmacist is:
a) Dispense the Px as it is
b) Call the doctor since co-Actifed was in pseudo ephedrine
c) Dispense dextromethorphan syr (OTC) instead of co-Actifed
d) Give him non-pharm only and tell him that you can not dispense the Px due to
drug-drug-interaction
e) None of the above
Ans: (E) We just tell the patient to monitor his blood pressure by measuring it on daily
basic, since the cough syr. has a substance which may increase her B.D.