BCGP Practice Questions

Answer A. With aging, blood pressure and total peripheral resistance increase, however, a decrease in cardiac output is seen. A progressive decline in baroreceptor sensitivity is a characteristic feature of human aging as is a decrease in Beta-adrenergic receptor sensitivity.
Reference:
1. Martin WH 3rd e. Effects of aging, gender, and physical training on peripheral vascular function. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/1860209. Accessed October 12, 2016.
2. O'Mahony D e. Reduced baroreflex sensitivity in elderly humans is not due to efferent autonomic dysfunction. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10600664. Accessed October 12, 2016.
3. Ferrara N, Komici K, Corbi G et al. β-adrenergic receptor responsiveness in aging heart and clinical implications. Frontiers in Physiology. 2014;4. doi:10.3389/fphys.2013.00396.

The recommendation to avoid Nitrofurantoin in patients with a CrCl< 60 mL/min was revised with the 2015 update. There is evidence that it can be used in patients with a CrCl of 30 mL/min or higher for short duration.
Reference:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.

Doxazosin is a peripheral alpha blocker, which is considered a potentially inappropriate medication (PIM) in the elderly. Nifedipine IR is also listed on the Beers Criteria to be avoided in the elderly.
Reference:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.

Seizure threshold can be lowered by Bupropion, Chlorpromazine, Clozapine, Maprotiline, Olanzapine, Thioridazine, Thiothixene, and Tramadol.
Reference:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.

Expiratory flow rates decrease with aging and typically show changes in the flow-volume curves. Other age-related changes that occur in the lungs include weakening of the respiratory muscles as well as a decrease in lung measures of lung function such as vital capacity, which is the maximum amount of air that can be breathed out following a maximum inhalation.
Reference:
I. Janssens J, Pache J, Nicod L. Physiological changes in respiratory function associated with ageing. European Respiratory Journal. 1999;13(1):197-205. Available at: http://erj.ersjournals.com/content/13/1/197.long. Accessed October 13, 2016.
II. System E. Effects of Aging on the Respiratory System. Merck Manuals Consumer Version. 2016. Available at: https://www.merckmanuals.com/home/lung-and-airway-disorders/biology-of-the-lungs-and-airways/effects-of-aging-on-the-respiratory-system. Accessed October 13, 2016.

Mineral oil should not be administered orally in the elderly due to the risk of aspiration. There are safer alternatives.
Reference: I. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702

ACE-inhibitors (such as lisinopril) and loop diuretics (furosemide) can both increase the risk of lithium toxicity.
Reference:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.

Amiodarone and NSAIDs can both interact with warfarin causing an increased risk of bleeding. Amiodarone should be avoided when possible.
Reference:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.

ANC = WBC * ((Segs/100) + (Bands/100)) ANC = 1.0 k/uL x (0.32 + 0.42) = 740
Reference:
Whalen KL, Borja-Hart N (2015). Interpretation of Clinical Laboratory Data. In: Nemire RE, Kier KL, Assa-Eley M. Nemire R.E., Kier K.L., Assa-Eley M Eds. Ruth E. Nemire, et al.eds. Pharmacy Student Survival Guide, 3e. New York, NY: McGraw-Hill; 2015.

Considering this patient had received chemotherapy (unable to determine when exactly), this dosage is consistent with the indication of primary prophylaxis in patients with nonmyeloid malignancies (5 mcg/kg/day subcutaneously).Erythropoietin is indicated for treatment of Anemia due to various causes. FFP is given in certain bleeding disorder to replace factors.
Reference:
Gold Standard, Inc. Filgrastim, G-CS. Clinical Pharmacology [database online]. Available at:https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=246&sec=monindi&t=0 Accessed: May 16, 2016.

There is a drug interaction between levofloxacin and amiodarone, which may increase the risk of QT prolongation. Levofloxacin is associated with QT prolongation and rarely torsades de pointes. Amiodarone also has a risk of QT prolongation and torsades de pointes. This drug interaction is possible for days to weeks after amiodarone is discontinued because amiodarone has a long half-life. There is also a drug interaction with furosemide and amiodarone. Caution must be used because loop diuretics can lower potassium and magnesium levels, which can cause amiodarone to not work effectively, but the patient is on electrolyte replacement protocol and on it for short duration.
Reference:
Gold Standard, Inc. Levofloxacin. Clinical Pharmacology [database online]. Available at:https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=746&sec=moninte&t=0. Accessed: May 18, 2016.
II. Gold Standard, Inc. Amiodarone. Clinical Pharmacology [database online]. Available at:https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=25&sec=moninte&t=0. Accessed: May 18, 2016.

Decrease the dose to 100mcg orally daily. The TSH level is below therapeutic range (0.358--3.740 uIUn/mL). The TSH level is generally inversely related to the thyroid hormones’ levels. Bioequivalent of oral to intravenous levothyroxine is 2:1 ratio, so changing any dose to IV above 75mcg dose wound be to increase the dose.
Reference:
Bahn R, et al. hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the american thyroid association and american association of clinical endocrinologists. EndocrPract. 2011;17(3). Available at: https://www.aace.com/files/hyper-guidelines-2011.pdf. Accessed May 18, 2016.

With aging, blood pressure and total peripheral resistance increase, however, a decrease in cardiac output is seen. A progressive decline in baroreceptor sensitivity is a characteristic feature of human aging as is a decrease in Beta-adrenergic receptor sensitivity.
Reference:
I. Martin WH 3rd e. Effects of aging, gender, and physical training on peripheral vascular function. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/1860209. Accessed October 12, 2016.
II. O'Mahony D e. Reduced baroreflex sensitivity in elderly humans is not due to efferent autonomic dysfunction. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10600664. Accessed October 12, 2016.
III. Ferrara N, Komici K, Corbi G et al. β-adrenergic receptor responsiveness in aging heart and clinical implications. Frontiers in Physiology. 2014;4. doi:10.3389/fphys.2013.00396.

A and B are incorrect because there is no MRSA coverage, and this patient has risk of MDR because she came from a nursing home. C is incorrect because Piperacillin/Tazobactam and cefepime provide duplicate coverage for pseudomonas. D. is the correct answer because she came from a nursing home she should be treated as having healthcare-care associated pneumonia risk for MDR. She should be started on IV empiric therapy with Levofloxacin, Vancomycin, and Piperacillin/Tazobactam.
Reference:
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J RespirCrit Care Med. 2005;171(4):388-416. doi:10.1164/rccm.200405-644st

Answer A. is the correct answer because according to the IDSA CAP guidelines, antibiotics that should be started are a beta-lactam and either azithromycin or a fluoroquinolone for patients without penicillin allergy. For pseudomonas infections, empiric therapy can be with Piperacillin/Tazobactam plus levofloxacin or ciprofloxacin. B is wrong because this option does not include a beta-lactam. C and D are wrong because Piperacillin/Tazobactam is for pseudomonas infections. Vancomycin is inappropriate because this is community-acquired pneumonia and therefore the patient is not at risk for MRSA as he would be if he had healthcare or hospital acquired pneumonia.
Reference:
Mandell L, Wunderink R, Anzueto A et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement 2):S27-S72. doi:10.1086/511159.

Antibiotic treatment can be with a respiratory fluoroquinolone (levofloxacin or ciprofloxacin) alone. Another option is to give ceftriaxone plus a macrolide such as Azithromycin. A and C are incorrect because Levofloxacin monotherapy is sufficient. B is incorrect because a macrolide should be given with a 3rd generation cephalosporin. Azithromycin and Levofloxacin provides overlap in atypical coverage.
Reference:
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J RespirCrit Care Med. 2005;171(4):388-416. doi:10.1164/rccm.200405-644st.

The IDSA guidelines for CAP PNA list risk factors specific for pseudomonas which are alcoholism, structural lung diseases, such as bronchiectasis, or repeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic use, on mechanical ventilator for >3 days, as well as prior antibiotic therapy.
Reference:
Mandell L, Wunderink R, Anzueto A et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement 2):S27-S72. doi:10.1086/511159.
II. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J RespirCrit Care Med. 2005;171(4):388-416. doi:10.1164/rccm.200405-644st.

The ISDA guidelines for CAP PNA list risk factors specific for MRSA, which are end-stage renal disease, injection drug abuse, prior influenza, and prior antibiotic therapy, especially with fluoroquinolones. Infection with the influenza virus has been shown to be a risk factor for MRSA. Other risk factors for multi-drug resistant HAP, VAP, and HCAP are previous use of antibiotics within the last 90 days, current hospitalization of 5 days or more, local high occurrence antibiotic resistance, immunosuppressive state, or risk factors for HCAP (2 or more days of hospitalization in past 30 days, residence in a long term care facility or nursing home, family member with multidrug-resistant pathogen, home wound care, family member with multidrug-resistant pathogen, chronic dialysis within the last 30 days, or home infusion therapy). Investigations have shown that fluoroquinolones are associated with predisposing patients to MRSA infections. Several case control studies demonstrate that exposure to either levofloxacin or ciprofloxacin use was associated with MRSA infection but not MSSA.
Reference:
I. Weber SG, Gold HS, Hooper DC, Karchmer AW, Carmeli Y. Fluoroquinolones and the Risk for Methicillin-resistant Staphylococcus aureus in Hospitalized Patients. Emerging Infectious Diseases. 2003;9(11):1415-1422. doi:10.3201/eid0911.030284
II. Mandell L, Wunderink R, Anzueto A et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement 2):S27-S72. doi:10.1086/511159.

An unbiased Cockcroft-Gault creatinine clearance can be calculated using actual body weight in underweight patients and ideal body weight in patients of normal weight. Using ABW(0.4) for overweight, obese, and morbidly obese patients appears to be the least biased and most accurate method for calculating their Cockcroft-Gault creatinine clearance. In addition, the common practice of rounding or replacing low Serum Creatinine values with an arbitrary value of 1.0 mg/dl for use in the CG equation should be avoided. Rounding S(c) (r) in patients with low S(c) (r) did not improve accuracy or bias of the creatinine clearance calculations.
Reference:
I. Dowling T, Wang E, Ferrucci L, Sorkin J. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2013;33(9):912-921. doi:10.1002/phar.1282.
II. Winter MA e. Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation. - PubMed - NCBI. Ncbinlmnihgov. 2016. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22576791. Accessed October 13, 2016.

The following 5 elements are part of the Institute of Healthcare Improvement VAP bundle: oral care with Chlorhexidine, head of bed elevation, DVT prophylaxis, SUP, and daily sedation assessment and spontaneous breathing trials. Other suggested measures for VAP prophylaxis are small bowel feeding instead of gastric feeding, prophylactic probiotics, alcohol based hand washing policy, early discontinuation of invasive devices, early tracheostomy, and reducing reintubation rates. Giving prophylaxis antibiotic is not recommended.
Reference:
Kalanuria AA, Zai W, Mirski M. Ventilator-associated pneumonia in the ICU. Critical Care. 2014;18(2):208. doi:10.1186/cc13775.

Thiamine should be administered to prevent Wernicke’s encephalopathy.
Reference:
I. Management of moderate and severe alcohol withdrawal syndromes. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal Accessed May 24, 2016.

Benzodiazepines are the most studied drugs for alcohol withdrawal treatment. Long-acting agents such as Diazepam and Chlordiazepoxide may be used. Antipsychotics are not recommended to treat alcohol withdrawal. Haloperidol and is an inappropriate choice.
Reference:
I. Kosten T, O’Connor P. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786- 95. A good general review of the management of the most common syndromes.
II. Management of moderate and severe alcohol withdrawal syndromes. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes. Accessed May 24, 2016

Acamprosate is indicated for ethanol dependence, but only in patients who have become abstinent. Diazepam is not indicated for ethanol dependence but for acute alcohol withdrawal. Metronidazole may interfere with the metabolism of ethanol, resulting in disulfiram-like effects. Patients should try to avoid ethanol ingestion to avoid the risk of undesirable side effects. Duloxetine is not indicated to treat alcohol withdrawal.
Reference:
I. Doering P, Boothby L. Substance-related disorders: overview and depressants, stimulants, and halluci­nogens. In: DiPiro J, Talbert R, Yee G, et al., eds. Pharmacotherapy. A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008.
II. Gold Standard, Inc. Acamprosate (Indications/Dosage). https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=2097&sec=monindi&t=0. Accessed May 24, 2016.

Surgery, trauma (major trauma or lower-extremity injury), immobility, lower-extremity paresis, cancer (active or occult), cancer therapy (hormonal, chemotherapy, angiogenesis inhibitors, radiotherapy), venous compression (tumor, hematoma, arterial abnormality), previous VTE, increasing age, pregnancy and the postpartum period, estrogen-containing oral contraceptives or hormone replacement therapy, selective estrogen receptor modulators, erythropoiesis-stimulating agents, acute medical illness, inflammatory bowel disease, nephrotic syndrome, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, obesity, central venous catheterization, and inherited or acquired thrombophilia.
Reference:
Prevention of Venous Thromboembolism*: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6_suppl):381S.

SUP is indicated for patients who have coagulopathy, a requirement for mechanical ventilation for over 48 hours, a history of GI ulceration or bleeding within one year before admission, and in patients with at least two of the following: ICU stay of more than one week, sepsis, use of high-dose corticosteroids (>250 mg of hydrocortisone or the equivalent per day) and occult bleeding lasting six days or more.
Reference:
ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;56(4):347-379.

Piperacillin/Tazobactam and Meropenem are broad spectrum antibiotics. Levofloxacin should not be continued because the P. Mirabilis is resistant to it. Ampicillin is appropriate because both the P. Mirabilis and strep group G strain are susceptible to Ampicillin, and it has the narrowest spectrum of activity.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014.

The main effect of an increased volume of distribution is a prolongation of half-life. An increase VD and half-life have been observed for agents such as diazepam. Although, in general, the volume of distribution of most benzodiazepines tends to increase with age, for reason that are not clear, the VD of alprazolam (short half-life BZD) specifically decreases in elderly men but remains unchanged in elderly women. Triazolam is also considered to have a short half-life, compared to diazepam (highly lipophilic). Phase 2 reactions usually involve conjugation of phase 1 metabolites and appear to be unchanged by the ageing process although they may be impaired in some frail elderly people, an example of this would be lorazepam (no accumulation due to inactive metabolites.)
Reference:
I. Mangoni AJackson S. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology. 2003;57(1):6-14. doi:10.1046/j.1365-2125.2003.02007.x.
II. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148-57.

A is wrong because ampicillin-sulbactam covers Acinetobacter and piperacillin-tazobactam has variable coverage for Acinetobacter. B. is wrong because neither ampicillin-sulbactam nor piperacillin-tazobactam covers ESBL. D. is wrong because both ampicillin-sulbactam and piperacillin-tazobactam cover anaerobes.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014.

Meropenem is the drug of choice for ESBL empirically due to higher percentage of sensitivity. It can be de-escalated once culture and sensitivity available.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014

Advanced age, previous antimicrobial usage, duration of hospitalization, cancer chemotherapy, GI surgery, tube feeding, and use of acid-suppressing medications.
Reference:
Cohen S, Gerding D, Johnson S et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431-455. Doi: 10.1086/651706

Absolute risk reduction: 0.027 = 2.7%
(Event rate in enoxaparin group) – (Event rate in rivaroxaban group) = (57/1473) – (17/1513) = 0.02746
Reference:
Barratt A, Wyer PC, Hatala R, et al. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. CMAJ. 2004;171(4):353-8. doi: 10.1503/cmaj.1021197.

Risk factors for myopathy are hypothyroidism, reduced renal or hepatic function, and rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

ACC/AHA 2013 found that the use of statins for prevention of ASCVD is extensive and consistent. Statin therapy is recommended for patients at a higher risk of ASCVD who are most likely to experience a net benefit in terms of the potential for risk reduction vs the potential for adverse effects. Nonstatin therapies do not provide sufficient benefits in the reduction of ASCVD risk in regards to their potential for adverse effects.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Creatine Phosphokinase (CPK) should be evaluated if a patient experiences unexplained severe muscle symptoms or fatigue while receiving statin therapy.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Cefepime coverage is narrower than that of piperacillin-tazobactam and the culture is sensitive to Cefepime. Ciprofloxacin is not appropriate due to patient’s allergy to moxifloxacin.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014.

A stroke falls under the category of clinical ASCVD, which includes acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin. Patients with clinical ASCVD are at an increased risk for recurrent ASCVD and ASCVD death. This patient is under 75 years old, and such patients with clinical ASCVD should receive moderate-intensity statin therapy. Given the options above, a high intensity statin is the most appropriate option. The decision to start at the 80 mg dose of atorvastatin instead of the 40 mg dose is based on the recommendation to down titrate if the patient is unable to tolerate the 80 mg dose as opposed to up-titrating in accordance with the IDEAL trial.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Diltiazem has a major drug interaction with simvastatin. Diltiazem is a CYP3A4 inhibitor, and since simvastatin is metabolized by CYP3A4, its level can build up and the risk of myopathy increases. Clinical Pharmacology recommends the use of switching to a non-CYP3A inhibitor such as pitavastatin, pravastatin, or rosuvastatin, and if simvastatin is to be kept on it should not exceed 10 mg/day. The same interaction also exists with lovastatin, and the recommendation is to not exceed a total dose of 20 mg/day po of lovastatin. Given the current options, the best choice is to change to Atorvastatin 40 mg po daily.
Reference:
I. Gold Standard, Inc. Lovastatin (Interactions). Clinical Pharmacology [database online]. Available at: https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=359&sec=moninte&t=0. Accessed: June 1, 2016
II. Gold Standard, Inc. Simvastatin (Interactions). Clinical Pharmacology [database online]. Available at: https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=565&sec=moninte&t=0. Accessed: June 1, 2016

LDL can be elevated by diuretics, cyclosporine, glucocorticoids, and amiodarone.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013; 129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

A Is correct because the rate of death is significant as indicated by the 95% CI does not contain the value 1. So it is appropriate to make a statement: The rate of death from any cause was lower in the Apixaban group than in Warfarin group the meaning of 1 in a confidence ration indicates that the risk reduction in the outcome is the same between the two groups. Answer C is wrong because the rate of death in the warfarin group was higher than the rate in the apixaban group (3.94% vs 3.52% perspectively). Answer D is wrong because although there is no p value listed, statistical significance can still be inferred from a 95% confidence interval, which is presented here as 0.80 to 0.99.
Reference:
Windish DM, Huot SJ, Green ML. Medicine resident’s understanding of the biostatistics and results in the medical literature. JAMA 2007;298:1010-22.

Answer A is incorrect because presented p-value is for noninferiority, not for superiority. Based on the given information, no conclusions about superiority can be made. Answer B. is correct. The p-value provided is for noninferiority, it can be concluded that Apixaban is as effective as warfarin in reducing rate of stroke or systemic embolism among patients with atrial fibrillation. Answer C is incorrect. Stroke and systemic embolism were combined into one primary outcome here for this confidence interval, so more information is needed to determine which agent did better for the specific type of event, either stroke or systemic embolism. Answer D. is incorrect because the rate of the primary outcome was higher in the warfarin group compared to the apixaban group, meaning stroke or systemic embolism occurred more so in the warfarin group. For the same reason as with C, these two events are represented as combined into one primary outcome and more information would be needed.
Reference: I. Windish DM, Huot SJ, Green ML. Medicine resident’s understanding of the biostatistics and results in the medical literature. JAMA 2007;298:1010-22.

Answer A is false because there is a difference between the two groups, but it is not statistically significant due to the 95% confidence interval containing 1. Answer C is wrong because although there is no p value listed, statistical significance can still be inferred from a 95% confidence interval. Answer D incorrect because usually, statistical significance should be demonstrated before considering clinical significance. There is a difference in the rate of systemic embolism, but it is so small (0.01%) that other factors of the two agents would weigh more in a decision to use one over the other.
Reference: DiCenzo R, ed. Clinical Pharmacist’s Guide to Bio¬statistics and Literature Evaluation. Lenexa, KS: ACCP, 2010.
Answer A is false because there is a difference between the two groups, but it is not statistically significant due to the 95% confidence interval containing 1. Answer C is wrong because although there is no p value listed, statistical significance can still be inferred from a 95% confidence interval. Answer D incorrect because usually, statistical significance should be demonstrated before considering clinical significance. There is a difference in the rate of systemic embolism, but it is so small (0.01%) that other factors of the two agents would weigh more in a decision to use one over the other. Reference:
Windish DM, Huot SJ, Green ML. Medicine resident’s understanding of the biostatistics and results in the medical literature. JAMA 2007;298:1010-22.

Adding spironolactone may provide reduction in mortality and morbidity. Since JK has an ejection fraction of 30-35%, spironolactone would be appropriate since it is recommended for patients with an LVEF of 35% or less to reduce morbidity and mortality. Digoxin does not reduce mortality or morbidity. However, it can be beneficial in decreasing hospitalizations for HF. JK is already taking lisinopril. Therefore, Valsartan would not be added. Use of both an ACE inhibitor and an ARB may result in potentially harmful adverse effects such as hypotension, renal dysfunction, and hyperkalemia. The use of Hydralazine in combination with Isosorbide Dinitrate is recommended in African Americans with NYHA class III-IV HFrEF, who have received optimal therapy with ACE inhibitors and beta-blockers, to reduce morbidity and mortality. Hydralazine alone has no benefit in reducing morbidity and mortality.
Reference:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2013;62(16):1495-1539. doi:10.1016/j.jacc.2013.05.020.

The contraindications for using aldosterone receptor antagonists in a patient with congestive heart failure are a serum creatinine > 2.5 mg/dL and a potassium level > 5 mEq/L. A potassium level > 5 mEq/L may result in life-threatening hyperkalemia. A serum creatinine > 2.5 mg/dL in men may indicate worsening renal function, which may lead to discontinuation of the aldosterone receptor antagonist. Aldosterone levels are not considered a contraindication for using aldosterone receptor antagonists in those patients with congestive heart failure.
Reference:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am CollCardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019.

Adding the beta-blocker, metoprolol succinate, would be most appropriate to give in addition to lisinopril and atorvastatin. Initiation of a beta-blocker in a hospitalized patient is recommended after optimization of fluid status and once IV diuretics have been discontinued. Since the patient is stable, adding metoprolol succinate would be appropriate. Use of a beta-blocker has also been proven to reduce morbidity and mortality.
Diuretics would be prescribed to patients who have evidence of fluid retention, to treat relieve symptoms. Therefore, spironolactone, bumetanide, and hydrochlorothiazide would not be given since the patient is now stable. Fluid status is normal and his edema has resolved.
Reference:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2013;62(16):1495-1539. doi:10.1016/j.jacc.2013.05.020.

Because she just had a stroke, which is considered ASCVD, this patient is a candidate for statin therapy. Because she is less than 75 years old, she should receive a high intensity statin, which B and C fall under. 80 mg of atorvastatin has been shown to reduce LDL counts by more than 50%, and 40 mg was only tested in one RCT. It is better to start at the higher dose of 80 mg and down titrate if the patient experiences intolerance.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a

As the patient is over the age of 60 and he does not have CKD or diabetes, his goal BP should be SBP< 150 mmHg or DBP < 90 mmHg, and he is not currently at this goal with his medication regimen. Options are to maximize the current medication dosage (option A), or to add a second agent. Since calciumchannel blockers like Norvasc are recommended as initial treatment options in African Americans, choosing Norvasc over lisinopril would probably be the more effective option.
Reference:
James P, Oparil S, Carter B et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA. 2014;311(5):507. doi:10.1001/jama.2013.284427.

The best option is B because this includes an ACE-inhibitor. His goal BP is SBP <140 mmHg and DBP < 90 mmHg, so he should be treated with pharmacological therapy since his SPB is above 140 mmHg. It is recommended that patients with CKD should receive an ACE-inhibitor or an ARB as initial or added-on therapy regardless of race.
Reference:
James P, Oparil S, Carter B et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA. 2014;311(5):507. doi:10.1001/jama.2013.284427.

Either vancomycin or linezolid could be used due to the presence of 70% of S. aureus isolates being methicillin resistant. He also has a risk factor for multidrug-resistant pathogens due to being in the hospital for 5 days. Therefore, 2 antipseudomonal antibiotics would be used for empiric treatment. The antibiogram for the agents listed indicate that Pseudomonas aeruginosa are sensitive to these agents. An appropriate combination therapy would be cefepime, linezolid, and ciprofloxacin since there is coverage for MRSA and Pseudomonas aeruginosa.
Reference:
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;ciw353. doi:10.1093/cid/ciw353.

This patient’s symptoms of excessive thirst and urination over the past month plus random plasma glucose ≥ 200mg/dl gives him diagnosis for diabetes. Answer choices A, B, and C are also correct options for criteria to meet diagnosis for any patient, however they do not fit this patient specifically. Only one of these 4 criteria has to be met to meet diagnosis. The AACE/ACE 2015 guidelines defines possible symptoms of diabetes mellitus as frequent thirst (polydipsia), frequent urination (polyuria), polyphagia (extreme hunger), blurred vision, weakness, and unexplained weight loss.
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
II. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. EndocrPract. 2016; 22(1):84-113

Adults aged 65 or older who are immunocompetent and who have not received PCV13 but who have 1 or more doses of PPSV23 at age <65 years administer PCV13 at least 1 year after the most recent dose of PPSV23, thus C is wrong. Then, administer a dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23, thus D is wrong. The interval between PPSV23 doses should be at least 5 years, thus A is wrong.
Reference:
I. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016 


The patient is currently taking Sotalol 80mg via peg BID. SR has a QTc of 562 msec. Since this is greater than 560 msec, Sotalol should be discontinued. This dose is also not appropriate since SR has renal failure and is on hemodialysis. He has a CrCl of 22 mL/min. For ventricular arrhythmias, Sotalol should be extended to every 36 to 48 hours according to clinical response. However, for atrial fibrillation, a CrCl of less than 40 mL/min is contraindicated. Therefore, Sotalol should be discontinued.
References:
I. Sotalol. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Gold Standard; 2016 [updated 9 June 2016; cited 27 Aug 2016]. Available from: www.clinicalpharmacology.com.
II. Sotylize (sotalol oral solution) package insert. Atalnta, GA: Arbor Pharmaceuticals, LLC; 2016 Aug

In patients receiving Sotalol, serum creatinine, magnesium, potassium, heart rate, blood pressure, and ECG (QTc interval) should be monitored. If the baseline QTc is greater than 450 msec, then sotalol use is contraindicated. If the QTc is greater than or equal to 500 msec, then the dose should be reduced, interval prolonged, or discontinued. If the QTc is less than 500 msec after 3 days, then the patient may be discharged on the current regimen. QTc would be monitored periodically afterwards. Sotalol has the potential to cause life-threatening ventricular tachycardia associated with QT interval prolongation. The dosing interval should be adjusted based on CrCl since QTc prolongation is directly related to the concentration of sotalol. Having a reduced CrCl and reduced heart rate increases the risk for QTc prolongation and torsades de pointes. Other conditions that may increase the risk of QT prolongation include bradycardia, hypertension, hypomagnesemia, and hypokalemia. Potassium should be greater than 4
References:
Sotylize (sotalol oral solution) package insert. Atalnta, GA: Arbor Pharmaceuticals, LLC; 2016 Aug Sotalol. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Gold Standard; 2016 [updated 9 June 2016; cited 27 Aug 2016]. Available from: http://www.clinicalpharmacology.com

Therapy with PPI is also associated with an increased risk of enteric infections such as Clostridium difficile-associated diarrhea, bone fractures, pneumonia, nutritional deficiencies and interference with the metabolism of antiplatelet drugs. In older patients, overprescribing of a PPI is associated with increases in morbidity, adverse drug events, hospitalization, and mortality. These risks are possibly due to geriatric patients having a higher risk of experiencing adverse drug reactions, presence of multiple morbidities, and use of other medications.
References:
Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012;5(4):219-32. doi: 10.1177/1756283X12437358. Delcher A, Hily S, Boureau AS, Chapelet G, Berrut G, De decker L. Multimorbidities and Overprescription of Proton Pump Inhibitors in Older Patients. PLoS ONE. 2015;10(11):e0141779. doi: 10.1371/journal.pone.0141779.

CHA2DS2-VASc: 4. 1 point each: Congestive heart failure, vascular disease (MI) 2 points: Age > 75 years (79 YO) SR’s score is based off the amount of points assigned to each condition that increases his risk of stroke. He received two points for being 79 years of age. Two more points were given for his congestive heart failure and prior history of MI. Therefore, SR has a total score of 4. Condition Score Congestive heart failure 1 Hypertension 1 Age ≥ 75 y 2 Diabetes mellitus 1 Stroke/TIA/TE 2 Vascular disease (prior MI, PAD, or aortic plaque) 1 Aged 65 to 74 y 1 Sex category (ie, female) 1 Maximum score = 9
Reference:
Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012;126(7):860-5. doi: 10.1161/CIRCULATIONAHA.111.060061. Retrieved on Feb 8th, 2017 from: http://circ.ahajournals.org/content/126/7/860

CHA2DS2-VASc Score of 0: recommend no antithrombotic therapy. CHA2DS2-VASc Score of 1: recommend antithrombotic therapy with oral anticoagulation or antiplatelet therapy but oral anticoagulant preferred. CHA2DS2-VASc Score ≥ 2: recommend oral anticoagulation
Reference:
Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012;126(7):860-5. doi: 10.1161/CIRCULATIONAHA.111.060061. Retrieved on Feb 8th, 2017 from: http://circ.ahajournals.org/content/126/7/860

HAS-BLED: 4. 1 point each: Elderly (age > 65 y), bleeding tendency/predisposition, drugs, and abnormal renal function
SR has a HAS-BLED score of 4. SR is 79 years old. He has abnormal renal function due to renal failure on hemodialysis with a serum creatinine > 200 mmol/L, has a history of anemia, and is taking aspirin. These conditions are considered bleeding risk factors. Since SR has a score of 4, he is at a high risk for bleeding. Scores greater than or equal to 3 indicate a high risk for bleeding. Caution with treatment and regular review of the patient is recommended due to this score.
Condition Score Hypertension (systolic blood pressure > 160 mm Hg) 1 Abnormal renal or liver function (1 point each) 1 or 2 Stroke 1 Bleeding tendency/predisposition 1 Labile INRs (if on warfarin) 1 Elderly (eg, age > 65 y) 1 Drugs or alcohol (1 point each) 1 or 2 Maximum score = 9 HAS-BLED Score of 0 or 1: low risk of bleeding. HAS-BLED Score of 2: intermediate risk of bleeding. HAS-BLED Score of ≥ 3: high risk of bleeding (indicates that caution is warranted when prescribing oral anticoagulation and regular review is recommended)
Reference:
Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012;126(7):860-5. doi: 10.1161/CIRCULATIONAHA.111.060061. Retrieved on Feb 8th, 2017 from: http://circ.ahajournals.org/content/126/7/860

The indication for Acetylcysteine 20% 600mg inhalation q12h is an adjunct to the treatment of his COPD as a mucolytic. Indications: Acetaminophen overdose, amyloidosis, bronchiectasis, chronic bronchitis, COPD, emphysema, mucolytic off label: Prevention of contrast-induced nephropathy, distal intestinal obstruction syndrome (DIOS), giant papillary conjunctivitis (GPC). MOA: As a mucolytic, the free sulfhydryl groups in acetylcysteine are believed to open up the disulfide bonds of the mucoproteins in bronchial secretions, which results in decreased hypersecretion and mucous viscosity of the lungs. This also helps in the removal of secretions through coughing, mechanical mechanisms, or postural drainage.
References:
Acetylcysteine. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Gold Standard; 2016 [updated 2 Aug 2016; cited 26 Aug 2016]. Available from: www.clinicalpharmacology.com

The electrolytes that should be closely monitored in patients taking bumetanide include potassium, sodium, chloride, calcium, magnesium, bicarbonate, ammonium, and phosphate. Electrolyte abnormalities reported during bumetanide therapy have included hypochloremia (14.9%), hypokalemia (14.7%), and hyponatremia (9.2%). Bumetanide may also increase urinary calcium and phosphate excretion with resultant hypocalcemia and/or hypophosphatemia. Bumetanide is a potent diuretic with a Boxed Warning of fluid/electrolyte loss. If given in excess, profound diuresis with water and electrolyte depletion may occur. Loss of these electrolytes may lead to metabolic alkalosis. This can be treated with potassium chloride replacement. Other concerns include serious cardiac arrhythmias that may occur due to the electrolyte disturbances.
References:
Bumetanide. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Gold Standard; 2016 [updated 1 July 2015; cited 26 Aug 2016]. Available from: www.clinicalpharmacology.com.

Epoetin Alfa should be initiated at 50 units/kg IV (or SubQ) 3 times a week for chronic anemia. This would be given due to his hemoglobin being at 6.9. Treatment would stop when his hemoglobin approaches 11 g/dL. Erythropoiesis-stimulating agents have been approved for the treatment of anemia in patients with chronic kidney disease who are undergoing hemodialysis to maintain a hemoglobin level of 10 to 11 g/dL. In patients with CHF with moderate to severe anemia (Hgb < 11 g/dL) and concomitant moderate to severe chronic kidney disease, guidelines of the National Kidney Foundation recommend treatment with erythropoietic agents and supplemental iron. For patients with CKD on dialysis the dose of Darbepoetin Alfa is 0.45 mcg/kg IV or subcutaneously once a week or 0.75 mcg/kg once every 2 weeks as appropriate. Blood transfusion is indicated in patients with acute anemia due to blood loss.
References:
I. National Kidney Foundation. KDOQI Clinical practice guidelines and recommendations for anemia of chronic kidney disease. Am J Kidney Dis 2006;47(suppl 3):S1-S146. Available at www.kidney.org/professionals/kdoqi/guidelines_anemia/ pdf/AnemiaInCKD.pdf. Accessed November 24, 2016.
II. Tang YD, Katz SD. Anemia in chronic heart failure: prevalence, etiology, clinical correlates, and treatment options. Circulation. 2006;113(20):2454-61.
III. Voak D, Chapman JF, and Phillips P. Quality of transfusion practice beyond the blood transfusion laboratory is essential to prevent ABO-incompatible death. Transfusion Medicine, 2000; 10: 95-96.

There is a progressive reduction in total body water and lean body mass that occurs and which results in a relative increase in body fat. Renal mass decreases with age and reflects the reduction in nephrons. Both renal plasma flow and as well as glomerular filtration rate decline with age.
Reference:
I. Mangoni AJackson S. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology. 2003;57(1):6-14. doi:10.1046/j.1365-2125.2003.02007.x. II. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148-57. Available at: http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines.pdf

Expiratory flow rates decrease with aging and typically show changes in the flow-volume curves. Other age-related changes that occur in the lungs include weakening of the respiratory muscles as well as a decrease in lung measures of lung function such as vital capacity, which is the maximum amount of air that can be breathed out following a maximum inhalation.
Reference:
I. Janssens J, Pache J, Nicod L. Physiological changes in respiratory function associated with ageing. European Respiratory Journal. 1999;13(1):197-205. Available at: http://erj.ersjournals.com/content/13/1/197.long. , /a> Accessed October 13, 2016.
II. System E. Effects of Aging on the Respiratory System. Merck Manuals Consumer Version. 2016. Available at: https://www.merckmanuals.com/home/lung-and-airway-disorders/biology-of-the-lungs-and-airways/effects-of-aging-on-the-respiratory-system.,/a> Accessed October 13, 2016.

Nadolol is not proven to reduce mortality in patients with systolic CHF. The efficacy of nadolol in HF has not been determined. For patients taking nadolol, it should be used with caution in those with compensated heart failure and patients should be monitored for a worsening of the condition. Bisoprolol, carvedilol, and sustained-release metoprolol succinate are the beta-blockers that have been proven to reduce mortality in patients with systolic CHF. These 3 beta-blockers have been effective in reducing the risk of death in patients with chronic HFrEF. Other beta-blockers were found to be less effective. Bucindolol did not exhibit uniform effectiveness across different populations. Metoprolol tartrate was found to be less effective in HF clinical trials.
References:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240

Diltiazem has a major drug interaction with Simvastatin. Diltiazem is a CYP3A4 inhibitor, and since Simvastatin is metabolized by CYP3A4, its level can build up and the risk of myopathy increases. It is recommended to switch to a non-CYP3A inhibitor such as Pitavastatin, Pravastatin, or Rosuvastatin, and if Simvastatin is to be kept on it should not exceed 10 mg/day. The same interaction also exists with lovastatin, and the recommendation is to not exceed a total dose of 20 mg/day po of Lovastatin. Given the current options, the best choice is to change to Atorvstatin 40 mg po daily.
Reference:
I. FDA Drug Safety Communication: New restrictions, contraindications, and dose limitations for Zocor (simvastatin) to reduce the risk of muscle injury. December 15, 2011. Retrieved on Feb 8th, 2017 from : http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm
II. Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a. Retrieved on Feb 6th 2017 from : http://circ.ahajournals.org/content/129/25_suppl_2/S1

Short-course antibiotic therapy is associated with less antibiotic exposure and antibiotic resistance. This would result in reduced costs and side effects. The benefits of therapy are not reduced with a shorter duration.
Reference:
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;ciw353. doi:10.1093/cid/ciw353. Retrieved on feb 8th, 2017 from : https://academic.oup.com/cid/article/63/5/e61/2237650/Management-of-Adults-With-Hospital-acquired-and

A single dose of zoster vaccine is recommended for all adults 60 years or older, regardless of whether they report a prior episode of herpes zoster, thus A is wrong. Also, although 2nd and 3rd episodes of herpes zoster can occur, the annual incidence of recurrence is not known. Although the FDA recommends the administration of the vaccine for individuals 50 years or older, the ACIP recommends that vaccinations begin at 60 years, thus C and D are incorrect.
Reference:
I. Shingles | Clinical Overview - Varicella Vaccine | Herpes Zoster | CDC. Cdcgov. 2016. Available at: http://www.cdc.gov/shingles/hcp/clinical-overview.html. Accessed September 27, 2016.
II. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016

A stroke falls under the category of clinical ASCVD, which includes includes acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin. Patients with clinical ASCVD are at an increased risk for recurrent ASCVD and ASCVD death. This patient is over 75 years old, and such patients with clinical ASCVD should receive moderate-intensity statin therapy. However, ATP4 acknowledges that the older patients in the corresponding RCTs were likely to be healthier than those in the general population, so treatment can be individualized. Given the options above, a high intensity statin is the most appropriate option. The decision to start at the 80 mg dose of atorvastatin instead of the 40 mg dose is based on the recommendation to down titrate if the patient is unable to tolerate the 80 mg dose as opposed to up-titrating in accordance with the IDEAL trial.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a. Retrieved on Feb 6th 2017 from : http://circ.ahajournals.org/content/129/25_suppl_2/S1

In Table 3, all these conditions are reasons to avoid benzodiazepines. These medications affect the CNS and the elderly population can be more sensitive. With benzodiazepines having a depressant effect on the CNS it makes since that patients may be at risk for these conditions since the patient’s balance, reaction time, and cognitive abilities would be reduced.
Reference:
Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

Initiating Lasix 40 mg IV twice daily would be the immediate course of action in order to improve symptoms of fluid retention. Fluid status would be monitored.Normal saline would not be given. DM would most likely have fluid restricted (1.5 to 2 L per day) to reduce congestive symptoms. For enalapril, the max dose is 20 BID for the treatment of heart failure. Increasing Enalapril would not improve symptoms of heart failure in the short term. Carvedilol would not be increased until after the patient is stable and IV diuretics stopped as well as any vasodilators and inotropic agents.
Reference
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240/

Nitroglycerin would be the most appropriate to initiate when DM is maxed out on diuretics. IV nitroglycerin helps to rapidly reduce pulmonary congestion. There is also no dosage adjustments provided for renal impairment. Sodium nitroprusside can also dilate pulmonary vasculature. However, in patients with renal impairment, there is a risk of thiocyanate accumulation and toxicity. Nesiritide has a longer half-life compared to nitroglycerin and nitroprusside and may result in adverse effects occurring for a longer period of time, such as hypotension. Studies have also indicated that patients may be at risk for worsening renal function and increased mortality while taking nesiritide. A recent meta-analysis indicated that there was no significant increase in mortality. When compared to placebo, there was no increased risk of mortality in those treated with nesiritide. However, it is associated with an increased risk of cardiovascular adverse events such as bradycardia and hypotension. Dobutamine would not be used in this case. It would be used as short-term management in those with cardiac decompensation in order to maintain perfusion and preserve end-organ performance in those with cardiogenic shock; bridge therapy in those with stage D heart failure who are unresponsive to guideline-directed medical therapy and device therapy awaiting a heart transplant or mechanical circulatory support; treat those with severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output, or to provide palliative therapy in select patients. The guidelines also stated that intermittent IV positive inotropic therapy has no proven value in patients with stage C heart failure.
Reference
I. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240
II. Nesiritide. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Gold Standard; 2016 [updated 2 Aug 2010; cited 2 Sept 2016]. Available from: www.clinicalpharmacology.com
III. Gong B, Wu Z, Li Z. Efficacy and safety of nesiritide in patients with decompensated heart failure: a meta-analysis of randomised trials. BMJ Open. 2016;6(1):e008545. doi: 10.1136/bmjopen-2015-008545.

The next appropriate course of action would be to increase Carvedilol. Since all diuretics have been stopped and her hemodynamics stable, initiating a beta-blocker is appropriate. The dose would be gradually increased every 2 weeks to the highest dose tolerable. She would also be monitored for congestive signs and symptoms of HF Digoxin would not be added. Even though digoxin can improve symptoms in mild to moderate HF, long-term treatment had no effect on mortality. It does have the potential to decrease hospitalizations for HF. Carvedilol would not be changed to metoprolol tartrate since metoprolol tartrate was found to be less effective in patients with heart failure. Enalapril would not be increased.
Reference
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240

Incidence rate = New reported cases / summed person-years of observation (avg population during time interval) Prevalence = Cases in a population in a given time period / total population at that time

I. Dicker, R. C., Coronado, F., Koo, D., et al. Principals of Epidemiology in Public Health Practice, Third Edition: An Introduction to Applied Epidemiology and Biostatistics; Lesson 3, Section 2. Oct. 2006 Retrieved Jan. 24, 2017 from: https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson3/section2.html Updated: Nov. 2011 II. Numerators, denominators and populations at risk. Jun. 20, 2010. Retrieved Jan. 24, 2017 from: http://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology/numerators-denominators-populations

Pioglitazone is not a good option since it can exacerbate his CHF and caries a black box warning. Empagliflozin is not a good option since it is contraindicated in patients with eGFR <30. Exenatide use is not recommended in patients with CrCL<30 mls/hr. Exenatide is not a good option because the patient’s hx of GI bleed is a precaution for use since the drug can slow gastric emptying. Increasing patient’s long acting insulin and adding low dose short acting is an appropriate choice.
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1) Avaiable at: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf II. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113. Retrieved on Feb 8th, 2017 from : http://journals.aace.com/doi/10.4158/EP151126.CS

The patients A1C goal should be <8 because they have multiple chronic illnesses of HTN, CKD stage 4, osteoarthritis, and heart failure and they are elderly. The patient does not have end stage chronic illness that meets the <8.5 criteria. The <7.5% goal is solely due to age >65 years. The <7% goal is for non, elderly, healthy adults per ADA. The goal <6.5 is only for healthy, non elderly adults per AACE/ACE.
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1) Avaiable at: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf II. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113. Retrieved on Feb 8th, 2017 from : http://journals.aace.com/doi/10.4158/EP151126.CS

Relative risk can be stated as 0.79 times as likely or 0.79 times the risk, but it could also be illustrated as a relative risk reduction and stated as a 21% risk reduction or 21% lower risk by taking the medication.
Reference:
I. Irwig, Les. Chapter 18: Relative risk, relative and absolute risk reduction, number needed to treat and confidence intervals. Smart health choices: making sense of health advice. Judy Irwig, 2007. Retrieved Jan. 24, 2017 from: https://www.ncbi.nlm.nih.gov/books/NBK63647/ II. Confidence Intervals for the Risk Ratio (Relative Risk). (n.d.) Retrieved Jan. 24, 2017 from: http://sphweb.bumc.bu.edu/otlt/mph-modules/bs/bs704_confidence_intervals/bs704_confidence_intervals8.html

Influenza vaccine is recommended annually, thus, WM should not skip it this year, and B is incorrect. Also, per the CDC, seasonal influenza outbreaks can occur as early as October, however, most activity peaks in January or later. Thus, it is not too late for WM to receive his vaccine in December, thus A is incorrect. Lastly, antiviral medications such as Tamiflu are an important adjunct to vaccinations. They are recommended as early as possible for any patient with confirmed or suspected influenza who, is 1) Hospitalized, 2) has severe, complicated, or progressive illness or 3) is at higher risk for influenza complications. Thus, WM is not a candidate with the given information and C is incorrect.
Reference:
Key Facts About Seasonal Flu Vaccine. Centers for Disease Control and Prevention. 2016. Available at: http://www.cdc.gov/flu/protect/keyfacts.htm. Accessed September 27, 2016.

. Relative risk can be stated as 0.77 times as likely or 0.77 times the risk, but it could also be illustrated as a relative risk reduction and stated as a 23% risk reduction or 23% lower risk by taking the medication.
Reference:
Irwig, Les. Chapter 18: Relative risk, relative and absolute risk reduction, number needed to treat and confidence intervals. Smart health choices: making sense of health advice. Judy Irwig, 2007. Retrieved Jan. 24, 2017 from: https://www.ncbi.nlm.nih.gov/books/NBK63647/

Hazard ratio can be used to compare time-to-event data between 2 groups. In this case the time to event was 20 years-to-death from colorectal cancer and the groups were patients taking aspirin 325mg 2 or more times a week and patients that did not. With the HR being 0.72, the patients taking the aspirin were 0.72 times likely to die at any time during the 20 years. This means that aspirin had a 28% reduction in death from colorectal cancer, 1 – 0.72 = 0.28.
Reference:
Sedgwick, Philip, and Katherine Joekes. "Interpreting hazard ratios." BMJ: British Medical Journal 351 (2015).

Influenza vaccine is recommended annually, thus JM is a candidate, as he hasn’t received it since 2013. Patient is also a candidate for the herpes zoster vaccine as he is over the age of 60. A Tdap booster is recommended every 10 years, thus JM is a candidate as his last Tdap was 12 years ago. Lastly, patient is a candidate for the PCV13 vaccine as it is recommend 1 or more years after PPSV23 shot (given 3 yeas ago.) Patient is not a candidate for MMR, as individuals, who have been born prior to 1957 are considered immune to measles and mumps (patient born in 1944.)
Reference:
Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 5, 2016

Primary treatment for stenotrophomonas maltophilia is SMX-TMP. Meropenem, ciprofloxacin, and vancomycin have no coverage.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014

RR = rate of an outcome occurring in an exposed group (treatment group/intervention group) divided by the rate of an outcome occurring in an unexposed group (control group) Ex: Relative Risk = Rate of UTI in patients taking drug XYZ / rate of UTI in patients not on drug XYZ
Reference:
I. 2x2 Contingency Table with Odds Ratios, etc. (n.d.). Retrieved Jan. 24, 2017 from: http://www.vassarstats.net/odds2x2.html II. Szumilas, M. "Explaining odds ratios." J Can Acad Child Adolesc Psychiatry 19 (2010): 227. Retrieved Jan. 24, 2017 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938757/

As the patient is over the age of 60 and he does not have CKD or diabetes, his goal BP should be SBP < 150 mmHg or DBP < 90 mmHg, and he is not currently at this goal with his medication regimen. Options are to maximize the current medication dosage (option A), or to add a second agent. Since calcium channel blockers like Norvasc are recommended as initial treatment options in African Americans, choosing Norvasc over lisinopril would probably be the more effective option.
Reference:
James P, Oparil S, Carter B et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA. 2014;311(5):507. doi:10.1001/jama.2013.284427. Retrieved Jan. 24, 2017 from: http://jamanetwork.com/journals/jama/fullarticle/1791497

Odds ratio of 0.44 (44%) means that this group was associated with an event happening 44% of the time, compared to 1 (an event happening 100% of the time if unexposed), therefore 100 - 44 = 56%, which is the reduction caused by the exposure. Exposure is the use of ascorbic acid.
Reference:
Davies, Huw Talfryn Oakley, Iain Kinloch Crombie, and Manouche Tavakoli. "When can odds ratios mislead?." Bmj 316.7136 (1998): 989-991. Retrieved Jan. 24, 2017 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112884/

These bacteria are some of the ones most commonly associated with VAP in the United States. This is based on surveillance data. They are also some of the most frequent isolates identified in international surveillance programs. Therefore, the guidelines recommend treatment to cover these bacteria.
Reference:
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;ciw353. doi:10.1093/cid/ciw353. Retrieved on feb 8th, 2017 from : https://academic.oup.com/cid/article/63/5/e61/2237650/Management-of-Adults-With-Hospital-acquired-and

In Table 2, the AGS states that glyburide is risky because of the possibility of severe prolonged hypoglycemia. Also mentioned in this section is Chlorpropamide, which has a prolonged half-life in older adults and can cause SIADH or prolonged hypoglycemia.
Reference:
Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

Incidence rate = New reported cases / summed person-years of observation (avg population during time interval). Prevalence = Cases in a population in a given time period / total population at that time Mortality rate = deaths during specified time interval / population size at risk for death
Reference:
Dicker, R. C., Coronado, F., Koo, D., et al. Principals of Epidemiology in Public Health Practice, Third Edition: An Introduction to Applied Epidemiology and Biostatistics; Lesson 3, Section 2. Oct. 2006 Retrieved Jan. 24, 2017 from: https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson3/section2.html Updated: Nov. 2011

Aging has been associated with various GI changes such as: a decrease in splanchnic blood flow, delayed gastric emptying, and an increase in gastric pH.
Reference:
Mangoni AJackson S. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology. 2003;57(1):6-14. doi:10.1046/j.1365-2125.2003.02007.x.

The use of PCT levels can decrease antibiotic exposure without increasing treatment failure or mortality. As a result, costs are reduced as well as the occurrence of side effects. Current evidence does not support the use of CPIS to guide discontinuation of antibiotics since it is not reliable enough to determine whether antibiotic therapy should be continued or not. CRP was not mentioned in the guidelines as to whether it can be used to determine discontinuation of antibiotic therapy or not.
Reference:
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;ciw353. doi:10.1093/cid/ciw353. Retrieved on feb 8th, 2017 from : https://academic.oup.com/cid/article/63/5/e61/2237650/Management-of-Adults-With-Hospital-acquired-and

It is reasonable to add triglyceride-lowering medications such as fibrates or niacin to prevent pancreatitis in those with triglyceride levels >500 mg/dL, which applies to this patient as his TG level is 640 mg/dL . C. is wrong because gemfibrozil should not be initiated in patients on statin therapy because of an increased risk for muscle symptoms and rhabdomyolysis. Fenofibrate may be considered concomitantly with a low- or moderate- intensity statin when triglycerides are above 500 mg/dL,2, however he is on a high intensity statin therapy. For niacin, the IR dose should start at 100 mg TID2 and niacin does not lower triglyceride levels as much as fibrate do.4 Fenofibrates are dose adjusted for renal function lower than 60 mL/min to 54 mg/mL, so this dose is appropriate for this patient because of his renal function being above 60 mL/min. The best option is fenofibrate 162 mg daily, but this needs to be monitored for any symptoms of muscle pain exhibited by the patient, especially as the patient is at a higher risk due to being a diabetic.
Reference:
I. Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a. Retrieved on Feb 6th 2017 from : http://circ.ahajournals.org/content/129/25_suppl_2/S1
II. Miller M, Stone N, Ballantyne C et al. Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2011;123(20):2292-2333. doi:10.1161/cir.0b013e3182160726.

Empagliflozin is the best option for this patient. Linagliptin is not an option since patient has already tried Sitagliptin (in the same drug class), and patient had pancreatitis. GLP1- agonists also are associated with pancreatitis so use of Exenatide would not be recommended. Pioglitazone should not be used because the patient is ~52% overweight and it can cause weight gain. Increasing the long acting insulin dose and adding short acting sliding scale is an not an appropriate option since sliding scale in elderly adults in on the BEERs list due to potential increased risk of errors/hypoglycemia.
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1) Avaiable at: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf
II. Food and Drug Administration (US FDA) Drug Medwatch-FDA investigating reports of possible increased risk of pancreatitis and pre-cancerous findings of the pancreas from incretin mimetic drugs for type 2 diabetes. Retrieved Mar. 14, 2013. Available on the World Wide Web at http://www.fda.gov/Drugs/DrugSafety/ucm343187.htm.
III. Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

In Table 4, the AGS recommends to use these medications with caution, the patient should be monitored for these conditions. Other medications that have the potential to cause SIADH or hyponatremia include: Antipsychotics, Diuretics, Carbamazepine, Oxcarbazepine, Carboplatin, Cisplatin, Vincristine, and Mirtazapine.
Reference:
Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

Since there is 70% of S. aureus isolate in the ICU that is methicillin resistant, vancomycin would be indicated since it is the only agent of the options given above that has activity against MRSA.
Reference:
Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;ciw353. doi:10.1093/cid/ciw353. Retrieved on feb 8th, 2017 from : https://academic.oup.com/cid/article/63/5/e61/2237650/Management-of-Adults-With-Hospital-acquired-and

Agents that can cause elevated triglycerides: oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), and thiazides.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a. Retrieved on Feb 6th 2017 from : http://circ.ahajournals.org/content/129/25_suppl_2/S1

Glipizide should be discontinued because it works by increasing insulin secretion and one of its main side effects is hypoglycemia. Since the patient does not eat stable meals, this is what is contributing to his episodes of hypoglycemia and this drug should not be used for him. Dapagliflozin would not get to goal A1c. Its A1c reduction capabilities is from 0.5% - 1%. Pioglitazone is not a good option for this patient since there is a black box warning for exacerbating heart failure. Dapagliflozin is not a good option since it works by reducing reabsorption in the kidney which can cause volume depletion in this patient who is already on furosemide. Adding Dulaglutide 0.75mg once weekly would simplify regimen and drop A1c to goal. GLP-1 agonist can drop A1c by average 1%-1.5%. Option D is not ideal either because increasing a long acting insulin glargine in addition to sliding scale will just contribute to hypoglycemia. Sliding scale insulin are potentially inappropriate medication per the beer’s criteria. IBW = 68.4 kg; actual BW = 107.3 kg. >120% overweight; adjBW = 84 kg, CrCL = 82.8 mL/min
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1) Avaiable at: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf
II. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113. Retrieved on Feb 8th, 2017 from : http://journals.aace.com/doi/10.4158/EP151126.CS
III. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.
IV. Actos (pioglitazone) package insert. Deerfield, IL: Takeda Pharmaceuticals America, Inc.; 2013 Nov.
V. Farxiga (dapagliflozin) package insert. Princeton, NJ: Bristol-Myers Squibb Company; 2016 Aug.
VI. Trulicity (dulaglutide) package insert. Indianapolis, IN: Eli Lilly and Company; 2014 Sept.

This patient is elderly >65 years old which qualifies him for A1C goal <7.5%. While they do have certain co-morbidities/chronic illnesses of CHF, stage 2 CKD (CrCl 82.8 mL/min), and HTN, this patient does not meet at least 3 chronic illnesses that meet the criteria per the guidelines to have a less stringent A1C goal of <8. This list consists of “arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke”. This patient only meets 2 of these. In order to meet goal for <8.5 goal A1C, the patient must qualify with presence of one of the following: “single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer”. The goal <6.5 is only for healthy, nonelderly adults per AACE/ACE.
Reference:
I. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1) Avaiable at: http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf
II. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113. Retrieved on Feb 8th, 2017 from : http://journals.aace.com/doi/10.4158/EP151126.CS

The guidelines state that class III is defined as an individual who has marked limitation of physical activity, comfortable at rest, but ordinary physical activity results in symptoms of HF. Class IV is defined as an individual who is unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. Stage D is when an individual has refractory HF that requires specialized interventions. And Stage C is when there is structural heart disease with prior or current symptoms of HF.
Reference:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240

All of the above are known to prevent heart failure in patients with MI. The guidelines state that in all patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic HF and cardiovascular events. Those with known atherosclerotic disease are more likely to develop HF. Therefore, aggressive treatment with statins can help to reduce the likelihood of HF in at-risk patients. The guidelines also state that in all patients with a recent or remote history of MI or ACS and reduced EF, ACE inhibitors should be used to prevent symptomatic HF and reduce mortality. ARBs would be appropriate if patients are intolerant to ACE inhibitors. This can also be applied to beta-blockers. Patients with a recent or remote history of MI or ACS and reduced EF should use evidence-based beta-blockers to reduce mortality. In addition, ACE inhibitors and beta-blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they do not have a history of MI.
Reference:
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019. Retirved on Feb 6th from : http://circ.ahajournals.org/content/128/16/e240

The AGS 2015 Beers Criteria is a guide but should not replace clinical judgement. If the patient has been taking a medication and does not experience any adverse effects while also having their condition under control, then the medication will most likely be fine for the time being. There may be another alternative for the medication that could be safer but that would have to be discussed with their clinician. It will be a process to switch medications and the patient and clinician will have to work together through the process in order to have a successful transition to the new medication.
Reference:
I. Hanlon, Joseph T., Todd P. Semla, and Kenneth E. Schmader. "Alternative Medications for Medications in the Use of High‐Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly Quality Measures." Journal of the American Geriatrics Society 63.12 (2015): e8-e18. II. Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

Dichotomous data is considered categorical data that only has two categories, or two answer choices. All 3 answer choices have only 2 categories: sex has male or female, pain is yes or no, and alive or dead is only two options also.
Reference:
"Statistics at Square One | The BMJ". Bmj.com. 2016. Web. 7 Nov. 2016. Available at: http://www.bmj.com/about-bmj/resources-readers/publications/statistics-square-one

In Table 6, the AGS recommends these medications be avoided in the case of a CrCl less than 30, though for apixaban it is less than 25. These medications can put the patient at risk for bleeding. Enoxaparin can be used in patients with a CrCl less than 30 but it is recommended to reduce the dose. Both Edoxaban and Rivaroxaban can be used in patients with a CrCl between 30 to 50 but their doses should be reduced as well.
Reference:
Radcliff, Sue, et al. "American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 63.11 (2015): 2227-2246. Available at: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

This patients has diabetes, is aged between 40 and 75 years, and has an LDL between 70 and 189 mg/dL , which places him in one of the four statin benefit groups. These characteristics also warrant using the Pooled Cohort Risk Assessment Equation to estimate his 10-year ASCVD risk. Using the ASCVD Risk Estimator, and assuming he is a nonsmoker and is Caucasian, his 10-year ASCVD risk is 22.1%. Since it is greater than 7.5%, he should receive a high intensity statin therapy. Rosuvastatin 10 mg and Simvastatin 40 mg are considered moderate-intensity statin therapies, and gemfibrozil is not a statin. A is the best option because Atorvastatin 80 mg is high intensity statin therapy.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a. Retrieved on Feb 6th 2017 from : http://circ.ahajournals.org/content/129/25_suppl_2/S1
ASCVD Risk Estimator. Tools.acc.org. 2016. Available at: http://tools.acc.org/ASCVD-Risk-Estimator/ . Accessed June 8, 2016.