Genitourinary, Electrolytes, and Nutritional Deficiences/Supplementation in Older Adults

Question 1

1. A 77-year-old white man presents with a 2-month
   history of nocturia, dribbling, and decreased urine
   stream. His International Prostate Symptom Score
   (IPSS) is 6 of 35, his prostate is slightly enlarged, and
   his prostate-specific antigen concentration is within
   normal limits. He has not tried to treat his symptoms.
   He takes amlodipine 5 mg daily for hypertension
   (HTN) and oral diphenhydramine 50 mg at bedtime
   for insomnia. Which therapy plan is most appropriate
   for this patient?
   A. Initiate dutasteride 0.5 mg/day.
   B. Initiate tamsulosin 0.8 mg/day.
   C. Change amlodipine to terazosin.
   D. Discontinue diphenhydramine.

Answer 1

1. Answer: D
   This patient has mild symptoms that are associated with
   BPH. Because his symptom score is 6, watchful waiting
   would be an appropriate treatment option at this time
   (Answers A & B are incorrect). However, he is taking a
   first-generation antihistamine (diphenhydramine) known to
   contribute to or exacerbate his BPH symptoms, so discontinuing this drug might help reduce his symptoms (Answer
   D is correct). Changing his antihypertensive regimen to
   an α1-antagonist is not recommended by current HTN
   guidelines or the Antihypertensive and Lipid-Lowering
   Treatment to Prevent Heart Attack study because of
   inferior cardiovascular effects compared with other antihypertensive agents (Answer C is incorrect).

Question 2

2. An older adult man comes to the pharmacy for a medication therapy management visit. You begin discussing
   benign prostatic hyperplasia (BPH) with him, and he
   has many questions because his symptoms have not
   resolved with his current medication regimen. Which
   education point is best to include in your disease and
   drug discussion with him?
   A. α1-Antagonists (e.g., tamsulosin) are effective at
   reducing BPH symptoms, providing benefit by
   reducing the size of the prostate.
   B. The 5-α-reductase inhibitors (e.g., finasteride)
   should reduce BPH symptoms within 1–2 weeks.
   C. Increasing fluid intake and adding fiber to the diet
   will reduce the severity of BPH symptoms.
   D. BPH typically requires drug therapy to reduce
   symptoms, but when the symptoms become
   severe, surgery may be the only treatment option.

Answer 2

2. Answer: D
   Disease and drug therapy counseling for BPH is helpful for
   patients. Benign prostatic hyperplasia often requires surgery if the disease progresses beyond the benefits of drug
   therapy (Answer D is correct). Dietary changes (e.g., avoiding caffeine and alcohol, avoiding fluids at bedtime) might
   reduce symptoms. Adding fiber is not a change known to
   affect symptoms, and increasing fluid intake may actually
   worsen symptoms (Answer C is incorrect). The 5-ARIs
   are the only drug therapy capable of reducing prostate
   size; this category of medications can take 3–6 months
   to provide symptom relief (Answer B is incorrect). The
   α1-antagonists work very quickly to provide BPH symptom
   relief, but they have no effect on the size of the prostate
   (Answer A is incorrect)

Question 3

3. A 72-year-old woman with Medicare Part D presents
   to the ambulatory care clinic requesting help with her
   urgency incontinence medications. She tried darifenacin, but it caused too much dry mouth. Her physician
   gave her a prescription for fesoterodine, but it is not
   covered by her insurance. You review her plan’s formulary options for urinary incontinence. The plan
   covers oxybutynin transdermal patch and solifenacin
   at tier 2 and oxybutynin immediate release (IR) at tier
4. Her current medications include amlodipine 5 mg/
   day, lisinopril 10 mg/day, ranitidine 150 mg twice
   daily, and atorvastatin 20 mg/day. The patient wants
   to save money, if possible, because she is on a limited
   income. Which best fits her needs?
   A. Pay cash for fesoterodine.
   B. Discontinue fesoterodine and initiate the overthe-counter (OTC) oxybutynin patch.
   C. Discontinue fesoterodine and initiate oxybutynin
   IR.
   D. Discontinue fesoterodine and initiate solifenacin.

Answer 3

3. Answer: B
   The cash price for fesoterodine is quite expensive, with an
   average wholesale price of $297 (Answer A is incorrect).
   In addition, fesoterodine still has a high rate of anticholinergic adverse effects, such as dry mouth. Oxybutynin
   IR is tier 1, but it has the most peripheral anticholinergic
   adverse effects of all agents (Answer C is incorrect). The
   patient did not tolerate darifenacin (an M3-selective agent),
   so she would not be expected to tolerate solifenacin, which
   has the same mechanism (Answer D is incorrect). The
   oxybutynin patch has the lowest incidence of dry mouth
   of the formulary agents. This formulation avoids first-pass
   metabolism of the drug to the active metabolite N-DEO
   and, as such, has a reduced adverse effect profile compared
   with oxybutynin IR tablets (Answer B is correct)

Question 4

4. A 50-year-old woman presents to the family medicine
   clinic requesting help with her urinary incontinence
   symptoms and worsening depression. She states that
   she has had incontinence problems since she had her
   three children. She loses a small amount of urine
   mainly when she coughs and laughs or does highimpact exercise. Although she has tolerated these
   symptoms in the past, they are more bothersome to her
   now because she is trying to exercise more often. Her
   depression has been controlled for the past 2 years,
   but she is now experiencing worsening symptoms. Her
   current medications include simvastatin, fluoxetine, a
   multivitamin, calcium, vitamin D, and estrogen vaginal cream. Which recommendation is best at this time?
   A. Initiate pseudoephedrine.
   B. Change from estrogen vaginal cream to oral estrogen therapy.
   C. Change from fluoxetine to duloxetine.
   D. Initiate oxybutynin gel

Answer 4

4. Answer: C
   This patient likely has stress incontinence, possibly caused
   by bladder neck instability or urethral sphincter weakness
   from childbirth and/or changes associated with menopause.
   None of the treatment options are currently FDA approved
   for the treatment of stress incontinence. Pseudoephedrine
   is not recommended for stress incontinence treatment
   because the risk of adverse effects with alpha and beta
   agonism outweigh the potential benefit (Answer A is incorrect). Changing the patient’s topical hormone therapy to
   oral therapy could have no effect, or it could worsen her
   urinary symptoms (Answer B is incorrect). Oral estrogen
   is also not recommended for use in older women because
   of risk outweighing benefit. Fluoxetine does provide
   benefit for stress incontinence; however, fluoxetine is no
   longer controlling the patient’s depression. Duloxetine, an
   SNRI, is an alternative antidepressant that could improve
   her stress incontinence by improving urethral tone, most
   likely caused by the reuptake inhibition of norepinephrine. Several clinical trials have shown clinical benefits of
   duloxetine (Answer C is correct). Initiating oxybutynin gel
   would be an option if the patient had symptoms or a diagnosis of OAB (Answer D is incorrect).

Question 5

5. You are tasked with reviewing a new agent (“Wood-E”)
   for erectile dysfunction (ED) for your pharmacy and
   therapeutics committee. You include in your presentation a table of the odds ratios (ORs) pertaining to
   adverse events.
   Incidence Rate of Adverse Events and OR (n=500 in
   Each Group)
   Adverse Event
   Placebo,
   n (%)
   Wood-E,
   n (%)
   OR
   (95% CI)
   Headache 25 (5.0) 40 (8.0) 1.25
   (1.12–1.98)
   Acute respiratory
   infections
   12 (2.4) 16 (3.2) 1.11
   (0.85–1.26)
   Flushing 11 (2.2) 20 (4.0) 1.31
   (1.01–2.86)
   CI = confidence interval; OR = odds ratio.
   Genitourinary, Electrolytes, and Nutritional Deficiencies/Supplementation in Older Adults
   ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
   1242
   Which statement best describes the data in the table
   about adverse events?
   A. All three adverse events are statistically significantly more likely to occur in the “Wood-E”
   group.
   B. Headache is significantly less likely to occur in
   the “Wood-E” group.
   C. Acute respiratory infections are significantly
   more likely to occur in the “Wood-E” group.
   D. Flushing is significantly more likely to occur in
   the “Wood-E” group

Answer 5

5. Answer: D
   All three adverse events occurred more often in the
   “Wood-E” group; however, only two of the adverse events
   that occurred significantly more often were headache and
   flushing (Answers A and B are incorrect; Answer D is correct). This is based on the OR of 1.31 with a CI not including
   1.0 (i.e., 1.01–2.86) for flushing, and the OR of 1.25 with
   a CI not including 1.0 (i.e., 1.12–1.98). Acute respiratory
   infections had CIs including 1.0, thus suggesting the results
   did not meet the statistical requirements to state that they
   occurred significantly more often in the “Wood-E” group
   (Answer C is incorrect). For more information, it might be
   helpful to review the Biostatistics chapter

Question 6

6. You are a clinical pharmacist in a resistant HTN clinic
   working under a collaborative practice agreement. A
   78-year-old male patient in your care is currently prescribed the following antihypertensives: labetalol 400
   mg twice daily, valsartan 320 mg daily, chlorthalidone
   25 mg daily, amlodipine 10 mg daily, and spironolactone 25 mg daily. The patient’s blood pressure today
   is 132/84 mm Hg. As part of your HTN protocol, you
   order laboratory tests and identify that this patient is
   in acute renal failure and has a potassium concentration of 7.7 mEq/L. The patient noted the onset of some
   muscle weakness the previous day. Which is the most
   appropriate action at this time?
   A. Discontinue valsartan; recheck potassium concentration in 1 week.
   B. Increase chlorthalidone to 50 mg daily; recheck
   potassium concentration in 1 week.
   C. Discontinue spironolactone; recheck potassium
   concentration in 1 week.
   D. Send the patient to the emergency department for
   further evaluation.

Answer 6

6. Answer: D
   This patient has an elevated serum potassium concentration in addition to symptoms of hyperkalemia. Valsartan
   and spironolactone, in addition to acute renal failure, are
   likely contributing to this elevated concentration. Because
   he has symptoms and severe hyperkalemia currently, he
   should be sent to the emergency department (Answer D
   is correct). Discontinuing valsartan or spironolactone will
   Genitourinary, Electrolytes, and Nutritional Deficiencies/Supplementation in Older Adults
   ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
   1285
   likely be done after the patient’s visit to the emergency
   department (Answers A and C are incorrect). Increasing
   chlorthalidone could have some effect on further lowering
   his potassium concentration, but it would not acutely treat
   his elevated concentration (Answer B is incorrect).

Question 7

7. While training first-year medical residents in a family
   medicine clinic, you discuss the case of a 92-year-old
   man with a history of difficult-to-treat depression.
   Although this patient has previously attempted suicide,
   his depression has finally been treated successfully by
   psychiatry with venlafaxine extended release (ER) 75
   mg daily plus mirtazapine 7.5 mg daily, after several
   medication changes. His other medications include
   hydrochlorothiazide 12.5 mg, lisinopril 20 mg, and
   pravastatin 40 mg daily to treat his HTN and hyperlipemia. His blood pressure and lipid values are well
   controlled. His laboratory tests show a serum sodium
   concentration of 133 mEq/L (a decrease from 135
   mEq/L in the past month), but he is asymptomatic.
   Which therapy plan is most appropriate at this time?
   A. Change hydrochlorothiazide to amlodipine.
   B. Discontinue mirtazapine.
   C. Change venlafaxine to duloxetine.
   D. Continue current medications, increase dietary
   sodium, and reduce free water intake.

Answer 7

7. Answer: D
   This patient has mild hyponatremia, and his sodium concentration is not much lower than the normal range. The
   drugs that could be contributing to his condition include
   hydrochlorothiazide, venlafaxine, and mirtazapine.
   Because his venlafaxine plus mirtazapine dose appears
   to have been changed and/or adjusted recently, these two
   agents are the most likely culprits. Because of his difficult
   psychiatric issues, it would not be wise for the primary care
   provider to manipulate his antidepressants (Answers B and
   C are incorrect). In addition, his blood pressure is well controlled. Because his sodium concentration is mildly low, it
   is reasonable to continue with his current medications and
   try to increase his sodium concentration through nonpharmacologic means (Answer D is correct) rather than change
   his medications (Answer A is incorrect).

Question 8

8. An 83-year-old woman comes to the pharmacy for
   a medication therapy management visit. You begin
   discussing vitamin D with her, and she has many questions because she recently learned that her vitamin D
   concentration is 10 ng/mL. She does not currently take
   vitamin D. Which counseling point is best to include
   in your discussion with her about vitamin D?
   A. Individuals with obesity are less likely to develop
   vitamin D deficiency.
   B. Supplementing with vitamin D will likely reduce
   the risk of falling in this older adult.
   C. Only prescription vitamin D (ergocalciferol)
   should be used to correct and maintain vitamin D
   values.
   D. Vitamin D toxicity is common because vitamin D
   is a fat-soluble vitamin that can build up in the
   body

Answer 8

8. Answer: B
   Although vitamin D is a fat-soluble vitamin, toxicity is very
   rare (Answer D is incorrect). Individuals with obesity have
   lower vitamin D serum values and are more likely to have
   vitamin D deficiency. This is most likely because vitamin
   D is fat soluble and prefers storage in the fat to storage
   in the serum (Answer A is incorrect). Either prescription
   vitamin D (ergocalciferol) or cholecalciferol is a reasonable option to supply and maintain vitamin D (Answer C is
   incorrect). There is strong evidence to show that vitamin D
   doses of 700–1000 international units daily or higher and
   values higher than 24 ng/mL reduce fall risk in older adults
   (Answer B is correct)