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NSG 533 ADVANCED PHARMACOLOGY EXAM 2 (2025/2026)
QUESTIONS AND ANSWERS GRADED A+ WILKES
UNIVERSITY
What would you be concerned with regarding the first patient's use of Vicodin in terms of the dose acetaminophen?
In elderly patients, it is recommended not to exceed >3,000mg per day of acetaminophen.
What medication could you recommend for a diabetic patient in pain that could also be used to help treat depression?
SNRIs; either duloxetine or venlafaxine have been successfully used in diabetic peripheral neuropathy.
In addition, be sure to understand which non-opiod medications you would use for a patient with neuropathic pain.
Gabapentin, pregabalin, transdermal lidocaine, TCAs.
If a patient has a true allergy to morphine, what opioid, if any, could you try instead?
True opioid allergies are rare. When a true allergy is present, an agent from another opiate classed should be used. For example, a patient with a true opiate allergy could receive fentanyl.
Know the common side effects which opioids can cause:
Excessive sedation (reduce dose by 25%), constipation (senna, dulcolax, N/V (hydroxyzine/ diphenhydramine), gastroparesis, vertigo, resp. depression, CNS irritability.
Know the WHO pain treatment algorithm:
Mild pain (1-3) non-opioid analgesic scheduled ATC
Moderate pain (4-6) Add opioid to scheduled non-opioid ATC
Severe pain (7-10) Switch to high dose opioid, ATC
Understand when you would use acetaminophen versus an NSAID or an NSAID instead of acetaminopehn
NSAIDs work best on inflammatory pain or pain mediated by prostaglandins (RA, menstrual and post-surgical pain) and bony metastasis. NSAIDS come with increased GIB risk and renal impairment.
APAP is a good first line for mild to moderate pain and considered the first line in low back pain and osteoarthritic. APAP hepatotoxicity has occured in those w. liver injury or chronic drinkers.
What class of prophylaxis for migraines should be avoided in asthmatics?
Beta blockers would usually be a medication used in the prophylaxis of migraines but this would not be the best choice in an asthmatic.
What triggers would you want to tell a patient to avoid to help prevent migraines (non- pharmacologic interventions):
-emotional stress
-sleep excess or deficient
-strong smells
-alcohol
-caffeine
-fermented foods
-nitrates
-tobacco
-MSG
Know what are the "red flag symptoms" of headaches which signify the need for urgent medical care:
-new onset sudden, severe pain
-systemic signs (fever, weight loss, HTN)
-focal neuro symptoms
-papilledema (swelling of both optic discs in eyes d/t increased ICP
-cough/ exertion triggered by HA
-pregnancy or postpartum state
-HIV
-cancer patients
-seizure activity
Know the stepwise treatment algorithm for the treatment of chronic headaches/ migraines:
- PMH, family hx, med hx
- Assess info: triggers? Timing?
- Develop POC: recommend pharmacotherapy that is financially feasible
- Implement plan- log HA diary
What doses of calcium and vitamin D would you recommend for a patient based on their age?
Men: 51-70: 1,000 mg calcium
Woemn 51+/ Men 71+: 1,200mg calcium
Men/ Women 50+: 800-1000 iu vitamin D
Know current treatment guidelines of The American College of Rheumatology for the tx of OA:
-lifestyle modifications
-PT
-heat/ cold therapy
-oral NSAIDs, topical NSAIDs on superficial joints
-APAP
-tramadol
-duloxetine
Know which herbal/ OTC product is commonly used in the tx of OA
Glucosamine and chondroitin
Know all about tramadol; how it works, daily dose limits, interactions and side effects:
-centrally acting synthetic opioid
-weak SSRI/ SNRI
-can cause dizzinesss, vertigo, N/V, lethargy
-seizures reported; dose related, more so with TCAs and other SSRIs
-risk for SEROTONIN SYNDROME
-Max 200mg/ day
Understand when you would initiate prophylaxis therapy in a patient w. gout (you would not typically recommend prophylaxis for a patient experiencing symptoms for the first time):
-patients with 2 or more flares/ year
-radiographic evidence attributable to gout
-or one subcutaneous tophi are candidates for prophylaxis treatment
-those taking anticoagulants
What non-pharmacological interventions could you recommend to help a patient avoid gout attacks (what triggers should they avoid)?
-life style modifications: weight loss, smoking + alcohol cessation
-lower BP by following DASH diet
-increase non-sugary fluid intake
If a physician said a patient's community acquired pneumonia was caused by a virulent pathogen, what is the physician saying about the pathogen?
More virulent pathogens will cause more severe disease
What are risk factors for aspiration pneumonia?
-dysphagia
-change in oropharyngeal bacterial colonization
-GERD
-lowered host defense
-oropharyngeal colonization can be from poor oral care, dental disease, tube feedings and medications
-GERD creates lowered mucosal and cilia production, altered cough reflex and promotion of gram-negative bacilli colonization
What microorganisms would you expect to cause CAP?
S. pneumoniae is the predominant microorganism associated w/ CAP
-other common organisms: haemophilus influenzae, mycoplasma pneumoniae, mortadella catarrhalis
If the patient w/ CAP has comorbidities, what would an appropriate treatment regimen include?
Beta-lactam or cephalosporin in combination w/ either a macrolide or doxycycline
If opting for monotherapy, current reccomendations are a fluoroquinolone such as levofloxacin 750 mg daily, moxifloxacin 400 mg daily or gemifloxacin 320 mg daily
If you chose monotherapy w/ a fluoroquinolone, what counseling points would you want to give regarding the use of antacids in a patient also taking a fluoroquinolone?
Antacids may cause decreased effects of antibiotics, separate meds by at least 2 hours.
Which of the medication options for the second patient carries the highest risk of causing c. diff?
Clindamycin
Also, fluoroquinolones, cephalosporins, carbapenems and penicillins are most associated w/ c. diff
If the patient was diagnosed w/ methicillin-sensitive staphylococcus aureus (MSSA) and had a penicillin allergy, how would this change your recommendation, if at all?
Cefezolin
Know about acute bacterial rhinosinusitis (ABRS)- common causes (bacterial pathogens) and treatment.
ABX should target S. pneumoniae and H. influenzae
Standard dose amoxicillin or amoxicillin clavulanate
Know about serious side effects associated w/ the use of tetracyclines
-Avoid use in pregnancy and children (tooth discoloration)
-N/V/D
-Photosensitivity
Know the treatment guidelines for otitis media
Most cases of AOM do not require abx, except in children younger than 2
ABX should be reserved for those likely to benefit
Our second patient, Jimmy Chipwood had a mild cause of CAP MRSA. What oral antibiotics could you recommend?
Dicloxacillin or cephalexin w/ cover s. aureus
But if CAP MRSA is suspected, oral abx include
-clindamycin, doxycycline or trimethoprim- sulfamethazole (TMP/ SMX)
What if the patient had a penicillin allergy (there is another class of antibiotics, other than penicillins, that you would want to avoid in a patient w/ a penicillin allergy)?
doxycyline or trimethoprim-sulfamethazole for (ca) MRSA and SEVERE PCN allergy
MILD non-immunologic pcn allergies may receive B-lactam abx.
Non-IgE reactions like Stevens-Johnson syndrome, toxic epidermal necrolysis or interstitial nephritis should avoid offending agents.
AD
functional pain
pain sensitivity due to an abnormal processing or function of the central nervous system in response to normal stimuli
neruopathic pain
Pain caused by lesions or other damage to the nervous system.
Diabetic peripheral neuropathy
progressive deterioration of nerve function that results in loss of sensory perception
acute pain
is pain that occurs as a result of injury or surgery, under 3 months. Poorly treated acute pain can cause psychological stress and compromise the immune system. Somatic acute pain is an injury to skin, bone, joint, muscle and connective tissue. Visceral pain involves injury to nerves on internal organs. Treat aggressively. Examples: cut hand, menstrual cramps.
chronic pain
can be intermittent or persistent, more than 3 months. Main affects include a) effects on physical function b) psychological changes c) social consequences and d) societal consequences. Usually involving life threatening diseases such as cancers, aids, progressive neurological diseases, end stage organ failure, dementia. Management should be multimodal with cognitive interventions, physical manipulations, pharmacological agents, surgical interventions, and regional or spinal anesthesia.
chronic malignant pain
Painn is associated with a progressive life-threatening disease like cancer, aids, neurologic diseases, end stage organ failure, and dementia. Goal is pain alleviation and prevention. Dependence or addiction is not a concern. Pain not associated with life threatening disease and lasting more than 6 months beyond the healing period is referred to as "chronic nonmalignant pain."
What are some non-pharmacological approaches to pain?
imagery, distraction, relaxation, psychotherapy, biofeedback, cognitive behavioral therapy, support groups, and spiritual counseling. Physical therapy, heat, cold, water, ultrasound, TENS, massage and therapeutic exercise.
WHO 3 step analgesic ladder
WHO first step pain ladder
mild pain/nonopioid analgesics such as NSAIDS or acetaminophen w/ or w/out adjuvants (such as pregablin) .. "soreness." Med examples: apap 1000mg q 6hrs, ibu600mg q6 hrs
NSAIDs
severe and persistent pain, potent opioids (morphine, tapentadol, oxycodone, hydromorphone, fentanyl, w/ or w/out non-opioid analgesics and with or without adjuvants "no matter what I do it hurts, theres a bone sticking out of my skin!" Examples; morphine 10mg q4 hrs, hydromorphone 4mg q4 hr
What is the mechanism of NSAIDs and precautions to use?
NSAIDS are either nonselective (inhibit cox 1 and cox 2) or selective (inhibit cox 2). Cox 2 inhibition is responsible for anti-inflammatory effects. - Cox 1 contributes to increased GI and renal toxicity assoc with nonselective NSAIDS. Use with caution in patients with dyspepsia, peptic ulcers, bleeding, and patients taking corticosteroids. Nephrotoxicity can occur in the elderly. A boxed warning is now required for prescription nonselective NSAIDs and Celecoxib due to the increase risk of cardiovascular events and GI bleeding. Generally pts prescribed NSAIDS will need PPI's.
Managment for NSAID risks
Pts more pre-disposed to GI toxicity if pre-existing ulcer or dyspepsia, H Pylori infection, older age, and some concurrent medications increase risk. Management options for GI side effects include taking with food or milk, Switch to different NSAID with better safety profile, COX selective agent (celecoxib) and/or gastroprotection (H2RA, PPI, misoprostol
Celecoxib
is recommended for patients at increased risk of gastrointestinal bleeding / ulcer who require a NSAID -Side effects can also include htn, and worsening asthma symptoms.
Tordol (Ketorolac)
40mg, max 5 days.. huge bleeding risk beyond that!
When are NSAIDs indicated and is one NSAID better / safer than another in a given patient?
Useful for mild to moderate pain that are mediated by prostaglandins (RA, menstrual cramps, and postsurgical pain). Works well for pain assoc with bone metastasis. Will dose escalation provide greater benefits (i.e. is there a ceiling effect)? Higher doses produce no greater efficacy than moderate doses.
What is the mechanism of acetaminophen?
Blocks prostaglandin synthesis in the CNS and block pain impulses in the periphery.
AD
When is APAP indicated and are there precautions / restrictions / limitations to use or in dosing (you MUST know maximum daily doses in general population and older adults)?
Apap does NOT have anti-inflammatory properties. It is used for mild to moderate pain and as an antipyretic. - Considered first line for low back pain and osteoarthritis. Causes a hypoprothrombinemic response to warfarin in patients receiving 2000 mg/day. Hepatotoxicity has been reported with excessive use especially in patients with hepatitis or chronic alcohol use. - All providers and patients should be aware of the maximum daily doses of APAP and be conscious of the fact APAP can be found in many products in combination with other medications.... -Max dose for patients with normal renal + hepatic function if 4000mg/day -Max dose for elderly is 3000mg/ day. Reduce dose 50% to 75% in patients with renal or hepatic dysfunction.
*Practice question: What would you be concerned with regarding the first patient's use of Vicodin in terms of the dose Acetaminophen?
