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Which of the following statements correctly describes the mechanism of action of Invokana (Canagliflozin)?

a. Increase insulin sensitivity towards blood glucose.
b. Stimulates insulin release from functioning beta cells of pancreas.
c. Delayed the absorption of glucose from gut to blood.
d. Increase gluconeogenesis in the liver.
e. Increase excretion of glucose through kidney.



Which of the following statements correctly describes the mechanism of action of Invokana (Canagliflozin)?

a. Increase insulin sensitivity towards blood glucose.
b. Stimulates insulin release from functioning beta cells of pancreas.
c. Delayed the absorption of glucose from gut to blood.
d. Increase gluconeogenesis in the liver.
e. Increase excretion of glucose through kidney.

Answer: (e). Sodium-glucose co-transporter 2 (SGLT2), expressed in the proximal renal tubules, is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen. Canagliflozin is an inhibitor of SGLT2. By inhibiting SGLT2, Canagliflozin reduces reabsorption of filtered glucose and lowers the renal threshold for glucose (RTG), and thereby increases urinary glucose excretion (UGE).

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Which of the following drugs interacts with Invokana (Canagliflozin)? [SELECT All THAT APPLY]

a. Digoxin
b. Rifampin
c. Ketoconazole
d. Trazodone
e. Tramadol


Which of the following drugs interacts with Invokana (Canagliflozin)? [SELECT All THAT APPLY]

a. Digoxin
b. Rifampin
c. Ketoconazole
d. Trazodone
e. Tramadol

Answer: (a and b). Co-administration of Canagliflozin with rifampin, a nonselective inducer of several UGT enzymes, including UGT1A9, UGT2B4, decreased Canagliflozin area under the curve (AUC) by 51%. This decrease in exposure to Canagliflozin may decrease efficacy.

If an inducer of these UGTs (e.g., rifampin, phenytoin, phenobarbital, ritonavir) must be co-administered with Invokana (Canagliflozin) (Canagliflozin), consider increasing the dose to 300 mg once daily if patients are currently tolerating Invokana (Canagliflozin) 100 mg once daily, have an eGFR greater than 60 mL/min/1.73 m2, and require additional glycemic control.

Consider other antihyperglycemic therapy in patients with an eGFR of 45 to less than 60 mL/min/1.73 m2 receiving concurrent therapy with a UGT inducer and require additional glycemic control.

There was an increase in the AUC and mean peak drug concentration (Cmax) of digoxin (20% and 36%, respectively) when co-administered with Invokana (Canagliflozin) 300 mg. Patients taking Invokana (Canagliflozin) with concomitant digoxin should be monitored appropriately.

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Which of the following information is TRUE about Invokana (Canagliflozin)? [SELECT ALL THAT APPLY]

a. The 300-mg dose of Invokana is proven to show greater A1C reductions than Januvia.
b. It is a once-daily pill that works around the clock.
c. It is not for weight loss, but may help a patient to lose weight-on average 3%.
d. In most clinical trials, the majority of people taking Invokana reached an A1C goal of less than 7%.
e. The most common side effect associated with the use of Invokana is hypoglycemia.


Which of the following information is TRUE about Invokana (Canagliflozin)? [SELECT ALL THAT APPLY]

a. The 300-mg dose of Invokana is proven to show greater A1C reductions than Januvia.
b. It is a once-daily pill that works around the clock.
c. It is not for weight loss, but may help a patient to lose weight-on average 3%.
d. In most clinical trials, the majority of people taking Invokana reached an A1C goal of less than 7%.
e. The most common side effect associated with the use of Invokana is hypoglycemia.

Answer: (a,b,c, and d). Invokana (Canagliflozin) is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

The recommended starting dose is 100 mg once daily, taken before the first meal of the day. Dose can be increased to 300 mg once daily in patients tolerating Invokana (Canagliflozin) 100 mg once daily who have an eGFR of 60 mL/min/1.73 m2 or greater and require additional glycemic control.

Invokana (Canagliflozin) is limited to 100 mg once daily in patients who have an eGFR of 45 to less than 60 mL/min/1.73 m2. Assess renal function before initiating Invokana (Canagliflozin). Do not initiate Invokana (Canagliflozin) if eGFR is below 45 mL/min/1.73 m2. Discontinue Invokana (Canagliflozin) if eGFR falls persistently below 45 mL/min/1.73 m2.

It can increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue. A lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with Invokana (Canagliflozin).

It causes intravascular volume contraction. Symptomatic hypotension can occur after initiating Invokana (Canagliflozin), particularly in patients with impaired renal function (eGFR <60 mL/min/1.73 m2), elderly patients, patients on either diuretics or medications that interfere with the renin‐angiotensin‐aldosterone system, or patients with low systolic blood pressure.

The most common side effects of Invokana (Canagliflozin) include genital yeast infections, urinary tract infection, and changes in urination.

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After completing the therapy, H. pylori follow-up status testing shall be done within what time frame to ensure H. Pylori has been completely eradicated?

a. 7 days
b. 72 hours
c. 4 weeks
d. 6 months
e. a month


After completing the therapy, H. pylori follow-up status testing shall be done within what time frame to ensure H. Pylori has been completely eradicated?

a. 7 days
b. 72 hours
c. 4 weeks
d. 6 months
e. a month

Answer: (c) Before the seriousness of H. pylori infections was fully appreciated and when it was still believed that H. pylori eradication therapy could routinely cure more than 90% of patients, confirmation of cure testing was not routinely recommended.

Although confirmation for cure testing is currently considered the standard of care, preferably with noninvasive tests such as the stool antigen or a urea breath test, it is often not done.

Post eradication testing is not only useful to confirm H. pylori eradication but also serves to alert the clinician when resistance begins to undermine their locally effective current regimens. In this issue of Clinical Gastroenterology and Hepatology, Gatta et al report a pilot study suggesting that it may be possible to accurately assess cure using changes in serum pepsinogen II levels.

A positive urea breath test (UBT), histology, culture, or rapid urease test (RUT) any time after therapy is considered as evidence of treatment failure. However, it has been recommended that posttreatment testing be delayed for at least 4 weeks after the end of therapy.

This recommendation is based on the fact that it takes time for any remaining bacteria to recover and repopulate the stomach in sufficient numbers to be detected reliably. By 4 weeks, the accuracy of a negative test is in the range of 98% to 100%.

There is little or no gain by repeating negative tests to ensure success (e.g, 2 negative urea breath tests) as a second urea breath test has not shown an increase in accuracy and adds an incremental cost with little clinical benefit.

One caveat among available noninvasive tests is that when using the stool antigen to assess outcome, it may be best to increase the interval from 4 to 6 or 8 weeks to ensure that a positive result is not false positive.

The available data show that the stool antigen tests that use monoclonal anti-H. pylori antibodies are more reliable than polyclonal stool antigen tests and monoclonal antibody-based stool antigen tests are recommended.

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The FDA has recently approved Xywav for the treatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy. Another drug Xyrem is available for the same indication in the US. What is a principal advantage of using Xywav over Xyrem?

a. Less side effects
b. Less potential for abuse
c. Low sodium contents
d. More potency
e. Cheaper


The FDA has recently approved Xywav for the treatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy. Another drug Xyrem is available for the same indication in the US. What is a principal advantage of using Xywav over Xyrem?

a. Less side effects
b. Less potential for abuse
c. Low sodium contents
d. More potency
e. Cheaper

Answer: C

The active ingredients found in Xywav is (calcium, magnesium, potassium, and sodium oxybates) oral solution. It is for the treatment of cataplexy or excessive daytime sleepiness (EDS) in patients 7 years of age and older with narcolepsy.

Xywav is an oxybate product with a unique composition of cations resulting in 92 percent less sodium - or approximately 1,000 to 1,500 mg/night - than sodium oxybate at the recommended dosage range of 6 to 9 grams.

Multiple Xywav dosing options are available for adult and pediatric patients. Prescribers can titrate Xywav into unequal doses taken over the course of the night. When patients start Xywav after sodium oxybate, Xywav treatment is initiated at the same dose and regimen as sodium oxybate (gram for gram) and titrated as needed based on efficacy and tolerability.

Xywav makes it possible for patients to have a lower-sodium oxybate treatment option. This may help patients taking sodium oxybate better align with daily sodium intake recommendations including those by the American Heart Association. Excess sodium intake has been linked with increases in blood pressure, hypertension, stroke, and other cardiovascular disease.

Xyrem (Sodium oxybate) carries warnings about its high sodium content,10 and was previously the only product approved to treat both cataplexy and EDS in patients with narcolepsy 7 years of age and older and designated as a standard of care for the treatment of cataplexy and EDS by the American Academy of Sleep Medicine.
Xywav has a Boxed Warning as a central nervous system depressant, and for its potential for abuse and misuse. Because of the risks of CNS depression and abuse and misuse, Xywav is available only through a restricted program under a REMS called the Xywav and Xyrem REMS Program.

Most common adverse reactions in adults are headache, nausea, dizziness, decreased appetite, parasomnia, diarrhea, hyperhidrosis, anxiety and vomiting.

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Entresto is indicated for the treatment of:

a. Hypertension
b. Heart failure
c. Depression
d. Type II diabetes mellitus
e. Panic disorder


Entresto is indicated for the treatment of:

a. Hypertension
b. Heart failure
c. Depression
d. Type II diabetes mellitus
e. Panic disorder

Answer: b. The active ingredients found in Entresto are Sacubitril and Valsartan. Sacubitril is a neprilysin inhibitor whereas Valsartan is an angiotensin II receptor blocker.

It is available as tablets (24/26 mg, 49/51 mg and 97/103 mg).

It is indicated:

1. to reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction. It is usually administered in conjunction with other heart failure therapies, in place of an ACE inhibitor or other ARB.

2. for the treatment of symptomatic heart failure with systemic left ventricular systolic dysfunction in pediatric patients aged one year and older.



Hypotension, hyperkalemia, cough, dizziness and renal failure are reported side effects of the drug.

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Farxiga is:

a. 5HT-1 receptor Antagonist
b. Alpha-2 inhibitor
c. Renin inhibitor
d. SGLT2 inhibitor
e. SSRI


Farxiga is:

a. 5HT-1 receptor Antagonist
b. Alpha-2 inhibitor
c. Renin inhibitor
d. SGLT2 inhibitor
e. SSRI

The active ingredient found in Farxiga is Dapagliflozin (Farxiga). It is the first sodium glucose co-transporter 2 (SGLT2) inhibitor approved by the US FDA. It is available as tablets (5mg and 10mg).

Sodium-glucose co-transporter 2 (SGLT2) is the predominant transporter responsible for reabsorption of glucose from the glomerular filtrate back into the circulation. Dapagliflozin (Farxiga) is an inhibitor of SGLT2. By inhibiting SGLT2, Dapagliflozin (Farxiga) reduces renal reabsorption of filtered glucose and lowers the renal threshold for glucose, and thereby increases urinary glucose excretion.

Dapagliflozin (Farxiga) also reduces sodium reabsorption and increase the delivery of sodium to distal tubule. This may influence several physiological functions including, but not limited to, lowering both pre-and afterload of the heart and downregulation of sympathetic activity.

Dapagliflozin (Farxiga) is a prescription medicine used to:

1. improve blood sugar control along with diet and exercise in adults with type 2 diabetes

2. reduce the risk of hospitalization for heart failure in adults with type 2 diabetes and known cardiovascular disease or multiple cardiovascular risk factors

3. reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure (when the heart is weak and cannot pump enough blood to the rest of your body)

Dapagliflozin (Farxiga) should not be used to treat people with type 1 diabetes or diabetic ketoacidosis (increased ketones in your blood or urine).

Usual Adult Dose for Diabetes Type 2:

a. To improve glycemic control (can be taken with or without food):

1. Initial dose: 5 mg orally once a day
2. May increase to 10 mg orally once a day for additional glycemic control if lower dose has been tolerated
3. Maximum dose: 10 mg/day

b. To reduce the risk of hospitalization for heart failure: 10 mg orally once a day.

Dehydration, ketoacidosis, UTI infection, hypoglycemia and vaginal yeast infection are reported side effects of the drug.

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Which of the following rating scales is commonly used to evaluate the severity of extrapyramidal symptoms (EPS)? [Select ALL that apply]

a. SAS
b. BARS
c. AIMS
d. ESRS
e. PDS


Which of the following rating scales is commonly used to evaluate the severity of extrapyramidal symptoms (EPS)? [Select ALL that apply]

a. SAS
b. BARS
c. AIMS
d. ESRS
e. PDS

Answer: (a,b,c,d). Extrapyramidal symptoms (EPS) are drug-induced movement disorders that include acute and tardive symptoms.

These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), Parkinsonism (characteristic symptoms such as rigidity, bradykinesia, and tremor), and tardive dyskinesia (irregular, jerky movements).

Since it is difficult to measure extrapyramidal symptoms, rating scales are commonly used to assess the severity of movement disorders.

The Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), Abnormal Involuntary Movement Scale (AIMS), and Extrapyramidal Symptom Rating Scale (ESRS) are rating scales frequently used for such assessment and are not weighted for diagnostic purposes.

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Dificid should be used only to treat infections that are proven or strongly suspected to be caused by:

a. Staphylococcus aureus
b. Streptococcus pyogenes
c. Escherichia coli
d. Haemophilus influenzae
e. Clostridium difficile


Dificid should be used only to treat infections that are proven or strongly suspected to be caused by:

a. Staphylococcus aureus
b. Streptococcus pyogenes
c. Escherichia coli
d. Haemophilus influenzae
e. Clostridium difficile

Answer: (e).

The active ingredient found in Dificid is Fidaxomicin. It is a macrolide antibacterial drug for oral administration. Dificid is a macrolide antibacterial medicine indicated in adults and pediatric patients aged 6 months and older for treatment of Clostridium difficile-associated diarrhea (CDAD).

The recommended adult dose is one 200 mg Dificid tablet orally twice daily for 10 days with or without food. It is available as tablet and oral suspension dosage form.

Anemia, neutropenia, nausea, vomiting and abdominal pain are commonly reported side effects of Dificid.



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Which of the following inhibits CYP 3A4?

a. Omeprazole
b. Lansoprazole
c. Pantoprazole
d. Rabeprazole
e. Esomeprazole


Answer: (a) Below is the list of drugs that inhibit specifically CYP 3A4:

1. Amiodarone
2. Anastrozole
3. Azithromycin
4. Cannabinoids
5. Cimetidine
6. Clarithromycin
7. Clotrimazole
8. Cyclosporine
9. Danazol
10. Delavirdine
11. Dexamethasone
12. Diethyldithiocarbamate
13. Diltiazem
14. Dirithromycin
15. Disulfiram
16. Entacapone (high dose)
17. Erythromycin
18. Ethinyl estradiol
19. Fluconazole
20. Fluoxetine
21. Fluvoxamine
22. Gestodene
23. Grapefruit juice
24. Indinavir
25. Isoniazid
26. Ketoconazole
27. Metronidazole
28. Mibefradil
29. Miconazole
30. Nefazodone
31. Nelfinavir
32. Nevirapine
33. Norfloxacin
34. Norfluoxetine
35. Omeprazole
36. Oxiconazole
37. Paroxetine (weak)
38. Propoxyphene
39. Quinidine
40. Quinine
41. Quinupristin and Dalfopristin
42. Ranitidine
43. Ritonavir
44. Saquinavir
45. Sertindole
46. Sertraline
47. Troglitazone
48. Troleandomycin
49. Valproic acid

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