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Avoid initiation or interrupt __________if absolute lymphocyte count is less than 500 cells/mm3, absolute neutrophil count is less than 1000 cells/mm3, or hemoglobin level is less than 8 g/dL.

a. Rheumatrex
b. Prograf
c. Rinvoq
d. Xcopri
e. Carboplatin


Avoid initiation or interrupt __________if absolute lymphocyte count is less than 500 cells/mm3, absolute neutrophil count is less than 1000 cells/mm3, or hemoglobin level is less than 8 g/dL.

a. Rheumatrex
b. Prograf
c. Rinvoq
d. Xcopri
e. Carboplatin

Answer: (c) Rinvoq (Upadacitinib) is a Janus kinase (JAK) inhibitor indicated for the treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate.

Use of Rinvoq (Upadacitinib) in combination with other JAK inhibitors, biologic DMARDs, or with potent immunosuppressants such as azathioprine and cyclosporine is not recommended.

Rinvoq (Upadacitinib) may be used as monotherapy or in combination with methotrexate. The recommended dose of Rinvoq (Upadacitinib) is 15 mg once daily. It is available as extended release tablet form.

It should be used with caution in patients receiving chronic treatment with strong CYP3A4 inhibitors (e.g., ketoconazole). Coadministration of Rinvoq (Upadacitinib) with strong CYP3A4 inducers (e.g. rifampin) is not recommended.

Serious infections leading to hospitalization or death, including tuberculosis and bacterial, invasive fungal, viral, and other opportunistic infections, have occurred in patients receiving Rinvoq (Upadacitinib).

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Which of the following statements is NOT TRUE about Xeljanz?

a. It is a Janus kinase (JAK) inhibitor.
b. It is indicated for the treatment of ulcerative colitis.
c. The active ingredient found in Xeljanz is Tofacitinib.
d. It should always prescribe with Cyclosporine to increase its efficiency.
e. If a serious infection develops, interrupt Xeljanz/Xeljanz XR until the infection is controlled.


Which of the following statements is NOT TRUE about Xeljanz?

a. It is a Janus kinase (JAK) inhibitor.
b. It is indicated for the treatment of ulcerative colitis.
c. The active ingredient found in Xeljanz is Tofacitinib.
d. It should always prescribe with Cyclosporine to increase its efficiency.
e. If a serious infection develops, interrupt Xeljanz/Xeljanz XR until the infection is controlled.

Answer: (d) Use of Xeljanz/Xeljanz XR in combination with biologic DMARDs or with potent immunosuppressants such as azathioprine and cyclosporine is not recommended.

The active ingredient found in Xeljanz is Tofacitinib. It is a Janus kinase (JAK) inhibitor. It is indicated for treatments of:
1. Rheumatoid Arthritis
2. Psoriatic Arthritis
3. Ulcerative Colitis

The recommended dose is 5 mg twice daily or 11 mg once daily. It can be taken with or without food. It is available in tablet and extended release tablet forms.

Do not initiate Xeljanz/Xeljanz XR in patients with an absolute lymphocyte count less than 500 cells/mm3, an absolute neutrophil count (ANC) less than 1000 cells/mm3 or who have hemoglobin levels less than 9 g/dL.

Patients treated with Xeljanz/Xeljanz XR are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as methotrexate or corticosteroids. If a serious infection develops, interrupt Xeljanz/Xeljanz XR until the infection is controlled.

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In which way is Tolsura (Itraconazole) different from Sporanox (Itraconazole)?

a. Different dosing frequency
b. Less side effects
c. Different indication
d. Different dosage form
e. No difference


In which way is Tolsura (Itraconazole) different from Sporanox (Itraconazole)?

a. Different dosing frequency
b. Less side effects
c. Different indication
d. Different dosage form
e. No difference

Answer: (c) different indication.

Tolsura (itraconazole capsules) and Sporanox (itraconazole) are azole antifungals used to treat different types of infections. Tolsura is used to treat blastomycosis, pulmonary and extrapulmonary; histoplasmosis, including chronic cavitary pulmonary disease and disseminated, non-meningeal histoplasmosis; and aspergillosis, pulmonary and extrapulmonary, in patients who are intolerant of or who are refractory to amphotericin B therapy.

Sporanox is used to treat fungal infections of the lungs, mouth or throat, toenails, or fingernails.

The dose of Tolsura to treat blastomycosis and histoplasmosis is 130 mg to 260 mg daily. The dose of Tolsura to treat aspergillosis is 130 mg to 260 mg daily.

Dosage of Sporanox depends upon the condition for which it is being used to treat.

Side effects of Tolsura and Sporanox that are similar include nausea, vomiting, skin rash, headache, diarrhea, itching, and dizziness.

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A 35-year-old man who is a regular patient of yours comes to your pharmacy counter with a new prescription. His shoulders appear tense and his eyebrows are knit tightly.

He says to you, "I can't believe I have to fill another prescription today. I was just in three weeks ago and spent $75 dollars on some fancy new medication that didn't do a darn thing!" What might be an appropriate active listening response to this patient?

a. It must be very frustrating to have to try something new.

b. It's too bad we can't take a prescription back for a refund.

c. I can provide you with a smaller quantity this time.

d. Your doctor is trying to find the best medication for you.


A 35-year-old man who is a regular patient of yours comes to your pharmacy counter with a new prescription. His shoulders appear tense and his eyebrows are knit tightly.

He says to you, "I can't believe I have to fill another prescription today. I was just in three weeks ago and spent $75 dollars on some fancy new medication that didn't do a darn thing!" What might be an appropriate active listening response to this patient?

a. It must be very frustrating to have to try something new.

b. It's too bad we can't take a prescription back for a refund.

c. I can provide you with a smaller quantity this time.

d. Your doctor is trying to find the best medication for you.

Answer (a). It must be very frustrating to have to try something new. Answer "b" does not acknowledge the patient's feelings; answer "c" moves to finding a solution without acknowledging the patient's feelings and "d" is placating.

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Which of the following information is/are TRUE ABOUT Naloxone? [Select All That Apply].

a. Naloxone hydrochloride is a pure opioid antagonist that competitively binds to μ-opioid receptors only when opioids are present.

b. No tolerance or dependence is associated with naloxone use

c. When comparing the μ-opioid receptor affinity of naloxone with that of most opioids, including heroin, naloxone has a greater affinity to bind to the receptor site.

d. Naloxone has a short duration of activity about 30 to 90 minutes.


Which of the following information is/are TRUE ABOUT Naloxone? [Select All That Apply].

a. Naloxone hydrochloride is a pure opioid antagonist that competitively binds to μ-opioid receptors only when opioids are present.

b. No tolerance or dependence is associated with naloxone use

c. When comparing the μ-opioid receptor affinity of naloxone with that of most opioids, including heroin, naloxone has a greater affinity to bind to the receptor site.

d. Naloxone has a short duration of activity about 30 to 90 minutes.

Answer: (a, b, c and d). Naloxone was patented in 1961, was first approved by the Food and Drug Administration (FDA) in 1971, and is currently on the World Health Organization's List of Essential Medicines.

Naloxone hydrochloride is a pure opioid antagonist that competitively binds to μ-opioid receptors only when opioids are present and bound at the receptor site. Naloxone demonstrates no effect on mu, kappa, or delta receptors in a person who has not taken opioids. No tolerance or dependence is associated with naloxone use.

The reversal of opioid toxicity with naloxone is dose dependent. Individuals who have used a particularly potent opioid (e.g., fentanyl), have high concentration of opioids in their system, or have used a long-acting opioid may require more frequent and/or larger doses of naloxone to reverse symptoms.

When comparing the μ-opioid receptor affinity of naloxone with that of most opioids, including heroin, naloxone has a greater affinity to bind to the receptor site. This mechanism allows naloxone to remove the opioid from the receptor site and then bind it more securely. When this occurs, respiratory depression resolves partially or fully (depending on the amount, form, and route of opioids taken), hypotension resolves, and CNS depression abates.

Depending on the type of opioid used, the individual may be at risk for experiencing rebound opioid toxicity and/or acute respiratory depression because of the short duration of activity of naloxone (i.e., 30-90 minutes).

This effect most often occurs when an individual has taken a long-acting opioid such as methadone or extended-release oxycodone. Naloxone's short duration of action is an important reason to convey to patients that receiving emergency medical care for an opioid overdose is important, even if the person has responded to the naloxone.

Naloxone is not effective in treating overdoses of non-opioid prescription medicines like benzodiazepines or barbiturates. It also is not effective in overdoses with stimulants, such as cocaine and amphetamines, or other non-opioid illicit drugs such as MDMA (Ecstasy, Molly), GHB (G), or ketamine (Special K). However, a polysubstance overdose that includes opioids warrants the use of naloxone.

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Which of the following information is/are TRUE ABOUT Essential Fatty Acids? [Select ALL That Apply]

a. Linoleic and alpha-linolenic are essential fatty acids.
b. Arachidonic acid is classified as 'conditionally essential' fatty acid.
c. Ideally, in the diet, the ratio of omega-6 to omega-3 fatty acids should be between 1:1 and 4:1.
d. Excessive intake of omega-6 fatty acids can cause the deficiency of omega-3 fatty acids.


Which of the following information is/are TRUE ABOUT Essential Fatty Acids? [Select ALL That Apply]

a. Linoleic and alpha-linolenic are essential fatty acids.
b. Arachidonic acid is classified as 'conditionally essential' fatty acid.
c. Ideally, in the diet, the ratio of omega-6 to omega-3 fatty acids should be between 1:1 and 4:1.
d. Excessive intake of omega-6 fatty acids can cause the deficiency of omega-3 fatty acids.

Answer (a, b, c and d). Essential fatty acids, or EFAs, are fatty acids that humans and other animals must ingest because the body requires them for good health but cannot synthesize them.

Only two fatty acids are known to be essential for humans: alpha-linolenic acid (an omega-3 fatty acid) and linoleic acid (an omega-6 fatty acid). Some other fatty acids are sometimes classified as "conditionally essential," meaning that they can become essential under some developmental or disease conditions; examples include docosahexaenoic acid and gamma-linolenic acid.

It is not only important to incorporate good sources of omega-3 and omega-6s in a diet, but also consume these fatty acids in the proper ratio. Omega-6 fatty acids compete with omega-3 fatty acids for use in the body, and therefore excessive intake of omega-6 fatty acids can inhibit the use of omega-3 fatty acids by the body.

Ideally, the ratio of omega-6 to omega-3 fatty acids should be between 1:1 and 4:1. Instead, most Americans consume these fatty acids at a ratio of omega-6: omega-3 between 10:1 and 25:1, and are consequently unable to reap the benefits of omega-3s.

This imbalance is due to a reliance on processed foods and oils, which are now common in the Western diet. To combat this issue it is necessary to eat a low-fat diet with minimal processed foods and with naturally occurring omega-3 fatty acids. A lower omega-6: omega-3 ratio is desirable for reducing the risk of many chronic diseases.

Arachidonic acid is not one of the essential fatty acids. However, it does become essential if there is a deficiency in linoleic acid or if there is an inability to convert linoleic acid to arachidonic acid.

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The laboratory finding reveals that 57 year-old patient is suffering from metabolic acidosis. What kind of metabolic acidosis is he suffering from?
 
ABG: 7.21/32/98   
100% O2 Sat on Room Air
Electrolytes: Na 145 mEq/L, K 4.5 mEq/L, Cl 105 mEq/L, HCO3 25 mEq/L  
 
a.            Anion-gap metabolic acidosis
b.            Non-Anion-gap metabolic acidosis
c.             Cation gap metabolic acidosis
d.            Non-Cation-gap metabolic acidosis


The laboratory finding reveals that 57 year-old patient is suffering from metabolic acidosis. What kind of metabolic acidosis is he suffering from?
 
ABG: 7.21/32/98   
100% O2 Sat on Room Air
Electrolytes: Na 145 mEq/L, K 4.5 mEq/L, Cl 105 mEq/L, HCO3 25 mEq/L  
 
a.            Anion-gap metabolic acidosis
b.            Non-Anion-gap metabolic acidosis
c.             Cation gap metabolic acidosis
d.            Non-Cation-gap metabolic acidosis

Answer(a):  If the patient is suffering from metabolic acidosis (low pH with low HCO3), the next step is to calculate the anion gap because the anion gap helps determining the etiology of the metabolic acidosis.
 
The anion gap is the difference between the measured serum cations (positively charged particles) and the measured serum anions (negatively charged particles). The commonly measured cation is sodium and the measured anions include chloride and bicarbonate.
 
Anion gap = [Na+] - ([Cl-] + [HCO3-])
 
The normal anion gap value is between 8 and 12. An anion gap of greater than 12 is "increased".
 
The differential diagnosis for an elevated anion gap metabolic acidosis (simply called "anion gap acidosis") differs from the differential diagnosis for an non-elevated anion gap metabolic acidosis (simply called "non-anion gap acidosis").
 
So, in the above example:
 
Anion gap = [Na+] - ([Cl-] + [HCO3-])
 
Anion gap = 145 - (105 + 25)
 
Anion gap = 15
 
The calculated anion gap = 15(above the normal gap of 8-12), therefore there is an anion gap acidosis.


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NABP reports a recent rise in forged prescriptions for Promethazine with Codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as:

a. Elixir of Heaven
b. Purple Drank
c. Orange Cocktail
d. Levoni's Drink
e. ProCod Mix


NABP reports a recent rise in forged prescriptions for Promethazine with Codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as:

a. Elixir of Heaven
b. Purple Drank
c. Orange Cocktail
d. Levoni's Drink
e. ProCod Mix

Answer: (b) Purple Drank. NABP reports a recent rise in forged prescriptions for promethazine with codeine. Promethazine with codeine, a Schedule V CS, has been used for years as a cough medication. Abusers commonly refer to it as "purple drank." "Purple drank" is a combination of promethazine with codeine mixed with a carbonated soda, such as Sprite or Mountain Dew, and candy, such as crushed Jolly Ranchers, mixed in for additional flavor.

The NABP has seen an increase in forged prescriptions for promethazine with codeine, and pharmacists have unknowingly filled them across United States in recent months. Pharmacists should be on the alert for promethazine with codeine prescriptions and perform due diligence in confirming that the prescription is legitimate.

Look for common red flags such as a prescription being presented right before closing, an out-of-the-area prescriber you do not recognize, a patient you do not recognize, a large quantity or exact quantity for "473 mL," or a cash-paying patient you do not know.

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Which of the following information is/are TRUE about PMP InterConnect?

I. InterConnect is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

II. InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.

III. It is mandatory for all states to participate in PMP Interconnect.

a. I only
b. III only
c. I and II only
d. II and III only
e. All


Which of the following information is/are TRUE about PMP InterConnect?

I. InterConnect is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

II. InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.

III. It is mandatory for all states to participate in PMP Interconnect.

a. I only
b. III only
c. I and II only
d. II and III only
e. All

Answer: (I and II only). PMP InterConnect is a highly secure communications exchange platform that facilitates the transmission of PMP data across state lines to authorized requestors, while ensuring that each state's data-access rules are enforced.
It is comprehensive and thorough tool for prescribers and dispensers to use in identifying potential opioid abuse.

The benefits of state PMPs are enhanced by PMP InterConnect because the system provides the means for physicians and pharmacists to more easily identify patients with prescription drug abuse and misuse problems, especially if those patients are crossing state lines to obtain drugs.

Utilizing the program's connected web of information allows appropriate intervention and aid in the prevention of substance abuse and diversion of controlled substances.

Additional information about PMP InterConnect, including a map of participants, is available in the Programs section of the NABP website.
It is NOT MANDATORY for states to participate in PMP InterConnect.

NABP also continues to work with other states to facilitate their participation.

Please visit website for more information. https://nabp.pharmacy/initiatives/pmp-interconnect/

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A List of Drugs with Their Normal Therapeutic Concentrations.


A List of Drugs with Their Normal Therapeutic Concentrations.

Amikacin: 15 to 25 mcg/mL
Aminophylline: 10 to 20 mcg/mL
Amitriptyline: 120 to 150 ng/mL
Carbamazepine: 5 to 12 mcg/mL
Cyclosporine: 100 to 400 ng/mL (12 hours after dose)
Desipramine: 150 to 300 ng/mL
Digoxin: 0.8 to 2.0 ng/mL
Disopyramide: 2 to 5 mcg/mL
Ethosuximide: 40 to 100 mcg/mL
Flecainide: 0.2 to 1.0 mcg/mL
Gentamicin: 5 to 10 mcg/mL
Imipramine: 150 to 300 ng/mL
Kanamycin: 20 to 25 mcg/mL
Lidocaine: 1.5 to 5.0 mcg/mL
Lithium: 0.8 to 1.2 mEq/L
Methotrexate: varies with use
Nortriptyline: 50 to 150 ng/mL
Phenobarbital: 10 to 30 mcg/mL
Phenytoin: 10 to 20 mcg/mL
Primidone: 5 to 12 mcg/mL
Procainamide: 4 to 10 mcg/mL
Quinidine: 2 to 5 mcg/mL
Salicylate: varies with use
Sirolimus: 4 to 20 ng/mL (12 hours after dose; varies with use)
Tacrolimus: 5 to 15 ng/mL (12 hours after dose)
Theophylline: 10 to 20 mcg/mL
Tobramycin: 5 to 10 mcg/mL
Valproic acid: 50 to 100 mcg/mL




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