Question 1
A 55-year-old patient with rheumatoid arthritis (RA) is receiving methotrexate therapy at a dose of 25 mg once weekly. The patient develops mucositis and stomatitis 5 days after their last dose. What is the best strategy to minimize this side effect?
A) Reduce the methotrexate dose to 10 mg/week
B) Administer leucovorin after each dose of methotrexate
C) Administer folic acid supplementation to minimize methotrexate-induced mucositis
D) Discontinue methotrexate and switch to a biologic agent
E) Administer corticosteroids to manage mucositis
Correct Answer: C) Administer folic acid supplementation to minimize methotrexate-induced mucositis
Explanation: Folic acid supplementation helps to minimize methotrexate-induced mucositis and stomatitis, which are dose-dependent side effects. Folic acid is typically administered alongside methotrexate to reduce these toxicities.
Question 2
A 58-year-old woman with rheumatoid arthritis is taking methotrexate and starts taking trimethoprim-sulfamethoxazole (Bactrim) for a urinary tract infection. What is the most significant drug interaction to be aware of with this combination?
A) Increased risk of gastrointestinal upset
B) Increased risk of hepatotoxicity
C) Increased risk of pancytopenia and bone marrow suppression
D) Decreased effectiveness of methotrexate
E) Increased risk of QT prolongation
Correct Answer: C) Increased risk of pancytopenia and bone marrow suppression
Explanation: Trimethoprim-sulfamethoxazole can increase methotrexate’s effect on bone marrow, leading to an increased risk of pancytopenia and bone marrow suppression. This combination should be used cautiously, and blood counts should be monitored.
Question 3
A patient with rheumatoid arthritis is being treated with methotrexate and takes NSAIDs for pain relief. What potential interaction should the clinician monitor for when combining these two medications?
A) Increased risk of methotrexate toxicity due to reduced renal clearance
B) Increased effectiveness of methotrexate in reducing inflammation
C) Decreased pain relief from the NSAID due to methotrexate interference
D) Decreased risk of gastrointestinal side effects from NSAIDs
E) Increased risk of developing a rash from the combination
Correct Answer: A) Increased risk of methotrexate toxicity due to reduced renal clearance
Explanation: NSAIDs can reduce renal clearance of methotrexate, potentially increasing methotrexate levels and leading to toxicity. Patients on this combination should be monitored for signs of methotrexate toxicity, such as bone marrow suppression and liver damage.
Question 4
A 64-year-old man with rheumatoid arthritis is taking leflunomide and warfarin for atrial fibrillation. What is the most important drug interaction to monitor in this patient?
A) Decreased efficacy of leflunomide
B) Increased risk of warfarin resistance
C) Increased anticoagulant effect of warfarin, leading to bleeding
D) Decreased risk of bleeding due to interaction with leflunomide
E) Increased liver enzyme levels
Correct Answer: C) Increased anticoagulant effect of warfarin, leading to bleeding
Explanation: Leflunomide can increase the anticoagulant effect of warfarin, leading to an increased risk of bleeding. Regular INR monitoring is essential in patients taking both medications.
Question 5
A 45-year-old woman on tofacitinib for rheumatoid arthritis is prescribed fluconazole for a fungal infection. What potential interaction should be considered with this combination?
A) Decreased efficacy of tofacitinib
B) Increased risk of QT prolongation
C) Increased plasma levels of tofacitinib due to CYP3A4 inhibition
D) Decreased absorption of fluconazole
E) Increased risk of gastrointestinal upset
Correct Answer: C) Increased plasma levels of tofacitinib due to CYP3A4 inhibition
Explanation: Fluconazole is a potent inhibitor of CYP3A4, which can increase the plasma levels of tofacitinib, leading to a higher risk of adverse effects such as infections and liver toxicity. Dosage adjustments or close monitoring may be necessary.
Question 6
A patient with rheumatoid arthritis is taking hydroxychloroquine and is prescribed digoxin for heart failure. What is the most important interaction between these two drugs?
A) Hydroxychloroquine decreases digoxin absorption
B) Hydroxychloroquine increases digoxin levels, leading to toxicity
C) Hydroxychloroquine decreases the effectiveness of digoxin
D) Hydroxychloroquine increases the clearance of digoxin
E) No significant interaction between the two drugs
Correct Answer: B) Hydroxychloroquine increases digoxin levels, leading to toxicity
Explanation: Hydroxychloroquine can increase serum digoxin levels, which may lead to digoxin toxicity. Close monitoring of digoxin levels is recommended when these drugs are used together.
Question 7
A 55-year-old man with rheumatoid arthritis on methotrexate is considering taking omeprazole for gastrointestinal discomfort. What interaction should the pharmacist discuss with him regarding this combination?
A) Omeprazole decreases the effectiveness of methotrexate
B) Omeprazole increases methotrexate levels, potentially leading to toxicity
C) Omeprazole increases gastrointestinal side effects from methotrexate
D) Omeprazole reduces renal clearance of methotrexate, increasing the risk of nephrotoxicity
E) No significant interaction between methotrexate and omeprazole
Correct Answer: B) Omeprazole increases methotrexate levels, potentially leading to toxicity
Explanation: Omeprazole can increase methotrexate levels by inhibiting its renal clearance, potentially leading to increased toxicity. Close monitoring or an alternative treatment for gastrointestinal discomfort may be necessary.
Question 8
A 55-year-old woman with rheumatoid arthritis is receiving methotrexate therapy. After a few months, she reports fatigue, mouth ulcers, and dark urine. What is the most likely cause of these symptoms?
A) Methotrexate-induced hepatotoxicity
B) Methotrexate-induced pancytopenia
C) Methotrexate-induced nephrotoxicity
D) Methotrexate-induced gastrointestinal upset
E) Methotrexate-induced neuropathy
Correct Answer: A) Methotrexate-induced hepatotoxicity
Explanation: Methotrexate can cause hepatotoxicity, leading to symptoms such as fatigue, dark urine, and, in some cases, jaundice. Regular liver function tests are recommended to monitor for this potential side effect.
Question 9
A 63-year-old patient with rheumatoid arthritis is being treated with tofacitinib. He reports frequent infections, including urinary tract infections and bronchitis. What is the most likely explanation for these symptoms?
A) Tofacitinib-induced immunosuppression
B) Tofacitinib-induced liver toxicity
C) Tofacitinib-induced gastrointestinal toxicity
D) Tofacitinib-induced anemia
E) Tofacitinib-induced renal failure
Correct Answer: A) Tofacitinib-induced immunosuppression
Explanation: Tofacitinib, a JAK inhibitor, can cause immunosuppression, leading to an increased risk of infections. Patients on tofacitinib should be monitored for signs of infection, and treatment may need to be adjusted accordingly.
Question 10
A 60-year-old man with rheumatoid arthritis on hydroxychloroquine reports difficulty seeing and states that colors appear distorted. What is the most likely cause of these symptoms?
A) Hydroxychloroquine-induced retinopathy
B) Hydroxychloroquine-induced optic neuritis
C) Hydroxychloroquine-induced cataracts
D) Hydroxychloroquine-induced glaucoma
E) Hydroxychloroquine-induced conjunctivitis
Correct Answer: A) Hydroxychloroquine-induced retinopathy
Explanation: Hydroxychloroquine can cause retinopathy, particularly with long-term use. Patients should be screened regularly for retinal damage, as this can lead to irreversible vision loss.
Question 11
A 48-year-old patient with rheumatoid arthritis is being treated with etanercept. She presents to the clinic with fever, cough, and weight loss. A chest X-ray shows a cavitary lesion in the upper lobe of the lung. What serious side effect of etanercept should be considered?
A) Etanercept-induced interstitial lung disease
B) Etanercept-induced tuberculosis reactivation
C) Etanercept-induced lung cancer
D) Etanercept-induced pulmonary embolism
E) Etanercept-induced pneumonia
Correct Answer: B) Etanercept-induced tuberculosis reactivation
Explanation: TNF-α inhibitors like etanercept can lead to the reactivation of latent tuberculosis, as TNF-α is important for granuloma formation and maintenance. Patients should be screened for latent TB before starting therapy and monitored for signs of reactivation.
Question 12
A 52-year-old woman with rheumatoid arthritis is being treated with leflunomide. She develops numbness and tingling in her hands and feet. What is the most likely side effect associated with leflunomide?
A) Leflunomide-induced liver toxicity
B) Leflunomide-induced neuropathy
C) Leflunomide-induced nephrotoxicity
D) Leflunomide-induced pancytopenia
E) Leflunomide-induced gastrointestinal toxicity
Correct Answer: B) Leflunomide-induced neuropathy
Explanation: Peripheral neuropathy is a recognized but less common side effect of leflunomide. Patients should be monitored for symptoms such as numbness, tingling, or weakness in the extremities.
Question 13
A 70-year-old patient with rheumatoid arthritis on infliximab presents with elevated liver enzymes and jaundice. What is the most likely explanation for these symptoms?
A) Infliximab-induced hepatotoxicity
B) Infliximab-induced pancytopenia
C) Infliximab-induced nephrotoxicity
D) Infliximab-induced bone marrow suppression
E) Infliximab-induced retinopathy
Correct Answer: A) Infliximab-induced hepatotoxicity
Explanation: Hepatotoxicity is a potential side effect of infliximab, especially when combined with other hepatotoxic drugs like methotrexate. Monitoring liver function tests regularly is critical in patients on infliximab therapy.
Question 14
A 65-year-old patient with rheumatoid arthritis is receiving sulfasalazine. After several weeks, she develops a rash, fever, and difficulty breathing. What is the most likely side effect of sulfasalazine?
A) Sulfasalazine-induced Stevens-Johnson syndrome
B) Sulfasalazine-induced agranulocytosis
C) Sulfasalazine-induced gastrointestinal toxicity
D) Sulfasalazine-induced hepatotoxicity
E) Sulfasalazine-induced nephrotoxicity
Correct Answer: A) Sulfasalazine-induced Stevens-Johnson syndrome
Explanation: Sulfasalazine can cause severe hypersensitivity reactions such as Stevens-Johnson syndrome, characterized by a rash, fever, and mucosal involvement. It requires immediate discontinuation of the drug and prompt medical intervention.
Question 15
A patient on methotrexate therapy for rheumatoid arthritis develops severe gastrointestinal toxicity and bone marrow suppression. What is the role of leucovorin in this scenario?
A) Leucovorin is a synthetic folate that rescues normal cells from methotrexate toxicity by replenishing folate stores
B) Leucovorin neutralizes methotrexate’s effects by binding to it directly
C) Leucovorin should be given before methotrexate to prevent toxicity
D) Leucovorin is used to enhance methotrexate’s therapeutic effect in rheumatoid arthritis
E) Leucovorin should be avoided in methotrexate-induced toxicities
Correct Answer: A) Leucovorin is a synthetic folate that rescues normal cells from methotrexate toxicity by replenishing folate stores
Explanation: Leucovorin (a synthetic folate) is used as a rescue therapy to mitigate the toxic effects of methotrexate by replenishing folate stores in normal cells. It does not neutralize methotrexate but helps protect healthy tissues from the drug’s toxic effects.
Question 16
A 40-year-old woman with rheumatoid arthritis on methotrexate 25 mg weekly wants to become pregnant. What is the most appropriate course of action?
A) Continue methotrexate and monitor closely during pregnancy
B) Switch methotrexate to a biologic agent before conception
C) Discontinue methotrexate immediately due to its teratogenic effects and switch to an alternative therapy
D) Reduce the methotrexate dose to 10 mg weekly
E) Continue methotrexate but add leucovorin to prevent teratogenic effects
Correct Answer: C) Discontinue methotrexate immediately due to its teratogenic effects and switch to an alternative therapy
Explanation: Methotrexate is highly teratogenic and must be discontinued before conception. Alternative therapies should be considered for managing rheumatoid arthritis during pregnancy.
Question 17
A patient with rheumatoid arthritis on methotrexate therapy presents with shortness of breath and a dry cough. The chest X-ray shows diffuse interstitial infiltrates. What is the most likely diagnosis?
A) Methotrexate-induced pneumonitis
B) Infectious pneumonia
C) Congestive heart failure
D) Pulmonary embolism
E) Drug-induced lupus
Correct Answer: A) Methotrexate-induced pneumonitis
Explanation: Methotrexate-induced pneumonitis is a known side effect characterized by non-infectious inflammation of the lungs, leading to symptoms such as shortness of breath and diffuse interstitial infiltrates on imaging.
Question 18
A 58-year-old patient with rheumatoid arthritis is about to start therapy with infliximab. What screening must be completed before initiating treatment with a TNF-α inhibitor, and why is this step necessary?
A) Hepatitis C screening to prevent liver toxicity
B) Tuberculosis (TB) screening to prevent reactivation of latent TB
C) Echocardiogram to evaluate heart function and avoid heart failure
D) Complete blood count to monitor for cytopenias
E) Skin biopsy to rule out skin cancer before starting treatment
Correct Answer: B) Tuberculosis (TB) screening to prevent reactivation of latent TB
Explanation: TNF-α inhibitors impair the immune system’s ability to maintain granulomas, which can lead to the reactivation of latent TB. Screening for TB is mandatory before starting therapy, and prophylactic treatment is required if latent TB is detected.
Question 19
A 45-year-old woman with rheumatoid arthritis on etanercept presents with fatigue, a new rash, and joint pain resembling lupus. What is the most likely explanation for these symptoms, and what action should be taken?
A) Reactivation of latent TB; perform a TB test
B) Autoimmune reaction with a lupus-like syndrome; consider discontinuing etanercept
C) Drug-induced hepatotoxicity; monitor liver enzymes
D) Onset of heart failure; conduct a cardiac evaluation
E) Infection; initiate broad-spectrum antibiotics
Correct Answer: B) Autoimmune reaction with a lupus-like syndrome; consider discontinuing etanercept
Explanation: TNF-α inhibitors, including etanercept, can induce a lupus-like syndrome. The patient’s new rash and joint pain are consistent with this adverse effect, and discontinuation of the drug may be necessary.
Question 20
A patient on adalimumab for psoriatic arthritis presents with shortness of breath and leg swelling. The physician is concerned about heart failure. What should be considered regarding TNF-α inhibitors and heart failure, and what is the most appropriate action?
A) Continue adalimumab but monitor for worsening symptoms
B) Stop adalimumab immediately due to the risk of heart failure
C) Switch to another TNF-α inhibitor with a lower risk of heart failure
D) Reduce the dose of adalimumab and continue monitoring
E) Initiate diuretic therapy while continuing adalimumab
Correct Answer: B) Stop adalimumab immediately due to the risk of heart failure
Explanation: TNF-α inhibitors, including adalimumab, can worsen or precipitate heart failure. In patients developing heart failure symptoms, discontinuation of the drug is recommended.
Question 21
A 35-year-old patient on infliximab for Crohn’s disease reports persistent headaches, vision changes, and numbness in the legs. The physician is concerned about a demyelinating disorder. What is the most likely diagnosis, and how should therapy be managed?
A) Guillain-Barré syndrome; continue infliximab with supportive care
B) Drug-induced multiple sclerosis; discontinue infliximab immediately
C) Cytopenia; reduce the infliximab dose
D) Opportunistic infection; initiate antiviral therapy
E) Liver toxicity; monitor liver function tests closely
Correct Answer: B) Drug-induced multiple sclerosis; discontinue infliximab immediately
Explanation: TNF-α inhibitors, including infliximab, can induce or exacerbate demyelinating disorders such as multiple sclerosis. The patient’s neurological symptoms are suggestive of this adverse effect, and discontinuation of the drug is necessary.
Question 22
A 62-year-old man with rheumatoid arthritis on certolizumab reports fever, cough, and shortness of breath. Chest imaging shows signs of pneumonia, and blood cultures reveal a fungal infection. What is the most likely cause of his condition, and how should his treatment be managed?
A) Bacterial infection due to immunosuppression; continue certolizumab and treat with antibiotics
B) Fungal infection due to immunosuppression; discontinue certolizumab and treat with antifungal therapy
C) Opportunistic viral infection; add an antiviral agent and continue certolizumab
D) Reactivation of latent TB; initiate anti-tuberculosis therapy
E) Drug-induced pneumonitis; discontinue certolizumab and manage symptomatically
Correct Answer: B) Fungal infection due to immunosuppression; discontinue certolizumab and treat with antifungal therapy
Explanation: TNF-α inhibitors increase the risk of serious infections, including fungal infections. Discontinuation of the TNF-α inhibitor and initiation of appropriate antifungal therapy are necessary.
Question 23
A 25-year-old patient on golimumab for ankylosing spondylitis develops severe fatigue, jaundice, and dark urine. Lab results show significantly elevated liver enzymes. What is the most likely adverse effect of the TNF-α inhibitor, and what should be the next step?
A) Drug-induced cytopenia; perform a complete blood count
B) Hepatitis B reactivation; stop golimumab and initiate antiviral therapy
C) Drug-induced liver toxicity; discontinue golimumab and monitor liver function
D) Opportunistic infection; initiate broad-spectrum antibiotics
E) Heart failure; conduct an echocardiogram
Correct Answer: C) Drug-induced liver toxicity; discontinue golimumab and monitor liver function
Explanation: TNF-α inhibitors can cause severe liver toxicity, as indicated by the patient’s jaundice and elevated liver enzymes. Discontinuation of the drug and monitoring of liver function are necessary.
Question 24
A 60-year-old patient with rheumatoid arthritis on methotrexate presents with elevated liver enzymes and mild fatigue. What is the most likely cause of these findings?
A) Methotrexate-induced hepatotoxicity
B) Methotrexate-induced pancytopenia
C) Rheumatoid arthritis flare-up
D) Acute viral hepatitis
E) Methotrexate-induced nephrotoxicity
Correct Answer: A) Methotrexate-induced hepatotoxicity
Explanation: Hepatotoxicity is a potential adverse effect of methotrexate, especially with long-term use. Regular monitoring of liver function tests is important to detect early signs of liver damage.
Question 25
A 35-year-old woman recently started sulfasalazine for rheumatoid arthritis and notices her urine has become orange-yellow in color. She is concerned about this side effect. What is the most appropriate counseling point regarding this issue?
A) Stop sulfasalazine immediately and seek medical attention
B) The discoloration is a harmless side effect of sulfasalazine and does not indicate harm
C) The urine discoloration suggests liver toxicity and must be reported immediately
D) Increase hydration to resolve the urine discoloration
E) This is an indication of overdose and should be reported
Correct Answer: B) The discoloration is a harmless side effect of sulfasalazine and does not indicate harm
Explanation: Sulfasalazine can cause harmless orange-yellow discoloration of urine and possibly skin. Patients should be reassured that this is a common and benign side effect.
Question 26
A patient taking sulfasalazine for ulcerative colitis reports gastrointestinal discomfort including nausea and vomiting. What is the best advice to minimize this side effect?
A) Discontinue sulfasalazine and switch to another medication
B) Take the medication on an empty stomach to increase absorption
C) Take the medication after meals to reduce gastrointestinal distress
D) Increase the dose to build tolerance
E) Stop eating high-fiber foods while on the medication
Correct Answer: C) Take the medication after meals to reduce gastrointestinal distress
Explanation: Taking sulfasalazine after meals helps reduce gastrointestinal side effects like nausea and vomiting, ensuring proper passage of the medication into the intestine.
Question 27
A 45-year-old man with rheumatoid arthritis on sulfasalazine asks if there are any special precautions he should take while outdoors. What is the most appropriate counseling point?
A) Avoid any outdoor activity while on sulfasalazine
B) Sulfasalazine does not increase sensitivity to sunlight, so no precautions are needed
C) Use sunscreen and avoid excessive sun exposure due to photosensitivity caused by sulfasalazine
D) Stop taking sulfasalazine on days with prolonged sun exposure
E) Cover all exposed skin with clothing, as sunscreen is ineffective with sulfasalazine
Correct Answer: C) Use sunscreen and avoid excessive sun exposure due to photosensitivity caused by sulfasalazine
Explanation: Sulfasalazine increases photosensitivity, so patients should be advised to use sunscreen and avoid prolonged sun exposure to prevent skin reactions.
Question 28
A pregnant woman with rheumatoid arthritis is prescribed sulfasalazine. What is the most appropriate counseling point regarding the use of this medication during pregnancy?
A) Sulfasalazine is contraindicated during pregnancy
B) Sulfasalazine is safe during pregnancy when combined with folic acid supplementation to prevent folate deficiency
C) Sulfasalazine should only be used in the first trimester
D) Discontinue sulfasalazine and switch to a safer alternative
E) Sulfasalazine requires no adjustments during pregnancy
Correct Answer: B) Sulfasalazine is safe during pregnancy when combined with folic acid supplementation to prevent folate deficiency
Explanation: Sulfasalazine is considered safe during pregnancy when combined with folic acid supplementation, as it can interfere with folate metabolism. Adequate folic acid intake helps prevent folate deficiency and related complications.
Question 29
A 50-year-old patient on sulfasalazine therapy for ulcerative colitis complains that they are not seeing any improvement in their symptoms after one week of treatment. What is the most appropriate counseling point?
A) Discontinue the medication and switch to a faster-acting drug
B) Therapeutic effects of sulfasalazine may take several weeks, so patience is needed with treatment
C) Increase the dosage to accelerate symptom relief
D) Add an NSAID to enhance the effects of sulfasalazine
E) Stop sulfasalazine immediately and seek medical advice
Correct Answer: B) Therapeutic effects of sulfasalazine may take several weeks, so patience is needed with treatment
Explanation: Sulfasalazine can take several weeks to reach its full therapeutic effect. Patients should be counseled to continue treatment and be patient with the onset of symptom relief.
Question 30
A 60-year-old patient with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) is prescribed abatacept. Which serious side effect should the physician closely monitor for due to the patient’s pre-existing condition?
A) Progressive multifocal leukoencephalopathy (PML)
B) COPD exacerbation
C) Cardiac arrhythmias
D) Hepatitis B reactivation
E) Infusion reactions
Correct Answer: B) COPD exacerbation
Explanation: Abatacept can cause exacerbations of COPD, so patients with pre-existing COPD should be closely monitored for worsening respiratory symptoms during therapy.
Question 31
A 60-year-old patient with rheumatoid arthritis on methotrexate mistakenly takes the drug daily instead of weekly as prescribed. What is the pharmacist’s most immediate concern regarding this error?
A) The patient may experience an increase in rheumatoid arthritis symptoms
B) Methotrexate can cause severe toxicity if taken daily instead of weekly
C) Methotrexate will lose its effectiveness if taken daily
D) Methotrexate must be combined with folic acid when taken daily
E) There is no significant risk from this dosing error
Correct Answer: B) Methotrexate can cause severe toxicity if taken daily instead of weekly
Explanation: Methotrexate is prescribed once weekly for rheumatoid arthritis. Taking it daily can lead to severe toxicity, including liver damage, bone marrow suppression, and gastrointestinal toxicity.
Question 32
A 55-year-old patient with rheumatoid arthritis is started on leflunomide therapy. During a follow-up visit, he reports experiencing frequent diarrhea. What should the pharmacist inform the patient regarding this side effect?
A) Diarrhea is an uncommon side effect and should be reported to the doctor immediately
B) Diarrhea affects about 17% of patients on leflunomide and may persist
C) Diarrhea is a sign of serious toxicity, and leflunomide should be discontinued
D) Increasing water intake will reduce diarrhea caused by leflunomide
E) This side effect indicates that leflunomide is not working
Correct Answer: B) Diarrhea affects about 17% of patients on leflunomide and may persist
Explanation: Diarrhea is a common side effect of leflunomide, affecting approximately 17% of patients. It is typically mild but may persist, and patients should be informed of this possibility.
Question 33
A 47-year-old woman with rheumatoid arthritis is prescribed tofacitinib. How does this medication work, and what is its role in rheumatoid arthritis therapy?
A) It is a TNF-α inhibitor that reduces inflammation by blocking TNF-α activity
B) It is a Janus kinase (JAK) inhibitor that blocks cytokine signaling involved in inflammation
C) It is an IL-1 receptor antagonist that prevents IL-1-mediated inflammation
D) It is an immunosuppressant that inhibits B-cell proliferation
E) It is a T-cell activation blocker that reduces autoimmune activity
Correct Answer: B) It is a Janus kinase (JAK) inhibitor that blocks cytokine signaling involved in inflammation
Explanation: Tofacitinib is a Janus kinase (JAK) inhibitor that interferes with the activity of JAK enzymes, which are involved in cytokine signaling pathways that contribute to inflammation in rheumatoid arthritis.
Question 34
A 65-year-old patient with rheumatoid arthritis is taking hydroxychloroquine and azithromycin for a respiratory infection. What is the primary concern with this combination of medications?
A) Risk of severe gastrointestinal upset
B) Risk of QT prolongation, which could lead to serious heart arrhythmias
C) Risk of liver toxicity
D) Increased risk of infection due to combined immunosuppressive effects
E) Decreased effectiveness of both medications
Correct Answer: B) Risk of QT prolongation, which could lead to serious heart arrhythmias
Explanation: Both hydroxychloroquine and azithromycin can cause QT prolongation, increasing the risk of serious cardiac arrhythmias. This combination should be used cautiously, and patients should be monitored for signs of heart problems.
Question 35
A patient on long-term hydroxychloroquine therapy for rheumatoid arthritis reports a sudden decrease in vision during a refill request at the pharmacy. What should the pharmacist do next?
A) Refill the prescription and recommend using over-the-counter eye drops
B) Refill the prescription and advise the patient to monitor vision changes
C) Do not refill the prescription and advise the patient to see a doctor for an eye exam
D) Recommend reducing the hydroxychloroquine dose to minimize vision problems
E) Suggest switching to a different DMARD and refilling the prescription
Correct Answer: C) Do not refill the prescription and advise the patient to see a doctor for an eye exam
Explanation: Sudden vision changes in patients on long-term hydroxychloroquine therapy may indicate retinopathy, a serious side effect. The pharmacist should not refill the prescription and advise the patient to seek immediate medical attention for an eye exam.
Question 36
A 45-year-old woman with rheumatoid arthritis is about to start treatment with rituximab. What is the most critical screening that must be performed before initiating this therapy?
A) Complete blood count (CBC)
B) Liver function tests
C) Hepatitis B screening
D) Tuberculosis skin test
E) Serum lipid profile
Correct Answer: C) Hepatitis B screening
Explanation: Rituximab can cause reactivation of hepatitis B in patients who are chronic carriers. It is essential to screen for hepatitis B before starting therapy, as reactivation can lead to severe liver damage or death.
Question 37
A 60-year-old woman with long-standing rheumatoid arthritis has been on hydroxychloroquine for several years. During a routine visit, she mentions that she has been experiencing vision changes. What is the most appropriate action?
A) Continue hydroxychloroquine and schedule an ophthalmology appointment
B) Discontinue hydroxychloroquine immediately and refer her to an ophthalmologist
C) Lower the dose of hydroxychloroquine and monitor for improvement
D) Switch to a different DMARD and advise her to monitor her vision
E) Recommend over-the-counter eye drops and reassess in a few weeks
Correct Answer: B) Discontinue hydroxychloroquine immediately and refer her to an ophthalmologist
Explanation: Hydroxychloroquine can cause retinopathy, a serious long-term side effect. Any patient experiencing vision changes should discontinue the medication and be referred for further assessment.
Question 38
A 55-year-old man with rheumatoid arthritis is prescribed leflunomide. During his follow-up visit, he mentions that he drinks alcohol socially. What is the most important counseling point to discuss with this patient?
A) Alcohol should be avoided while taking leflunomide due to the risk of hepatotoxicity
B) Alcohol intake can be continued in moderation as long as liver function tests are normal
C) Increase hydration to counteract any potential liver toxicity from alcohol
D) Stop alcohol consumption only during the first week of leflunomide therapy
E) Alcohol can be safely consumed if combined with folic acid supplements
Correct Answer: A) Alcohol should be avoided while taking leflunomide due to the risk of hepatotoxicity
Explanation: Leflunomide can cause hepatotoxicity, and alcohol consumption increases this risk. Patients should be advised to avoid alcohol while taking leflunomide.
Question 39
A 50-year-old patient with rheumatoid arthritis is taking salicylates for pain and inflammation. He asks if this will reverse his disease. What is the most appropriate response?
A) Salicylates are effective in reversing the course of rheumatoid arthritis
B) Salicylates provide analgesic and anti-inflammatory effects but do not reverse the disease
C) Salicylates are not recommended for rheumatoid arthritis due to their limited effect
D) Salicylates should be combined with methotrexate to reverse the disease
E) Salicylates are only useful for short-term symptom relief and should not be used long-term
Correct Answer: B) Salicylates provide analgesic and anti-inflammatory effects but do not reverse the disease
Explanation: Salicylates are used for their analgesic and anti-inflammatory properties in rheumatoid arthritis, but they do not reverse the progression of the disease.
Question 40
A 45-year-old woman with rheumatoid arthritis is on hydroxychloroquine therapy. What routine monitoring is necessary to detect a potential serious side effect?
A) Liver function tests
B) Complete blood count
C) Renal function tests
D) Ophthalmologic examination
E) Blood pressure monitoring
Correct Answer: D) Ophthalmologic examination
Explanation: Hydroxychloroquine can cause retinopathy, so regular ophthalmologic examinations are recommended to monitor for any early signs of vision impairment.
Question 41
A 40-year-old man is about to start infliximab therapy for Crohn’s disease. What screening should be performed before initiating therapy to prevent a serious complication?
A) Hepatitis B screening
B) Tuberculosis screening
C) Complete blood count (CBC)
D) Liver function tests
E) Lipid profile
Correct Answer: B) Tuberculosis screening
Explanation: Infliximab, a TNF-α inhibitor, can reactivate latent tuberculosis. Screening for TB is mandatory before initiating therapy to prevent this serious complication.
Question 42
A 48-year-old woman with rheumatoid arthritis is receiving methotrexate and develops mucositis. What is the most appropriate adjunct therapy to manage this side effect?
A) Folic acid supplementation
B) Vitamin D supplementation
C) Increased hydration
D) Zinc supplementation
E) Corticosteroid therapy
Correct Answer: A) Folic acid supplementation
Explanation: Folic acid is commonly used to manage and reduce the risk of methotrexate-induced mucositis by replenishing folate levels in the body.
Question 43
A 50-year-old patient receiving infliximab for rheumatoid arthritis develops hypotension shortly after the infusion begins. What is the most likely explanation for this side effect?
A) Anaphylaxis
B) Infusion reaction
C) Delayed drug toxicity
D) Hepatotoxicity
E) Opportunistic infection
Correct Answer: B) Infusion reaction
Explanation: Hypotension is a common side effect of infliximab during or after infusion, often indicating an infusion reaction. These reactions may require discontinuation or pre-medication before future infusions.
Question 44
A 45-year-old woman with rheumatoid arthritis is being treated with methotrexate. She overdoses on the medication, and the physician decides to administer leucovorin. What is the purpose of using leucovorin in this scenario?
A) To enhance the effects of methotrexate
B) To treat methotrexate overdose by replenishing folate stores
C) To counteract methotrexate’s immunosuppressive effects
D) To reduce the gastrointestinal side effects of methotrexate
E) To prevent methotrexate-induced liver toxicity
Correct Answer: B) To treat methotrexate overdose by replenishing folate stores
Explanation: Leucovorin is used to treat methotrexate overdose by replenishing folate stores and mitigating the toxic effects of methotrexate on healthy cells.
Question 45
A 60-year-old woman with rheumatoid arthritis on methotrexate develops gingivitis and mucositis. Which of the following conditions is least likely associated with methotrexate toxicity?
A) Stomatitis
B) Liver enzyme elevation
C) Gingivitis
D) Mucositis
E) Pancreatitis
Correct Answer: E) Pancreatitis
Explanation: Pancreatitis is not commonly associated with methotrexate toxicity. Other conditions such as gingivitis, stomatitis, mucositis, and liver enzyme elevations are more typical adverse effects of methotrexate.
Question 46
A 62-year-old patient on methotrexate mistakenly takes it daily instead of the prescribed weekly dose. What is the most significant concern regarding this error?
A) Development of resistance to methotrexate
B) Fatal toxicity due to overdosage
C) Reduced efficacy of methotrexate
D) Prolonged drug action
E) Increased rheumatoid arthritis symptoms
Correct Answer: B) Fatal toxicity due to overdosage
Explanation: Methotrexate is dosed weekly for rheumatoid arthritis. Taking it daily can cause severe toxicity, and fatalities have been reported due to this dosing error.
Question 47
A 65-year-old woman with rheumatoid arthritis is concerned that her new prescription for alendronate might interact with her methotrexate treatment. She asks if alendronate is also used to treat rheumatoid arthritis. What is the most appropriate response?
A) Alendronate is commonly used in combination with methotrexate for rheumatoid arthritis
B) Alendronate is not used for rheumatoid arthritis; it is used to treat osteoporosis
C) Alendronate is a biologic agent that works alongside methotrexate
D) Alendronate treats both osteoporosis and rheumatoid arthritis
E) Alendronate should be discontinued if taking methotrexate
Correct Answer: B) Alendronate is not used for rheumatoid arthritis; it is used to treat osteoporosis
Explanation: Alendronate is a bisphosphonate used to treat osteoporosis, not rheumatoid arthritis. Methotrexate is the drug commonly used to treat rheumatoid arthritis.
Question 48
A 55-year-old man with rheumatoid arthritis is prescribed methotrexate at a dose of 25 mg once weekly. He asks why he is only taking the drug once a week instead of daily. What is the most appropriate explanation?
A) Methotrexate is used at low daily doses for rheumatoid arthritis
B) Methotrexate is an anticancer drug and should be taken daily to maintain its effects
C) Methotrexate is an immunosuppressant and cytotoxic agent, and at higher doses, it is given weekly to avoid toxicity
D) Methotrexate should only be taken when experiencing pain
E) Methotrexate is ineffective when taken weekly
Correct Answer: C) Methotrexate is an immunosuppressant and cytotoxic agent, and at higher doses, it is given weekly to avoid toxicity
Explanation: Methotrexate is typically dosed once weekly for rheumatoid arthritis to minimize toxicity. Daily dosing can lead to severe toxicity, including fatal outcomes.
Question 49
A 58-year-old patient with rheumatoid arthritis is receiving infliximab therapy but is considering adding adalimumab for additional symptom relief. What is the most appropriate advice regarding this combination?
A) Combining infliximab and adalimumab is standard practice for RA
B) Combining two biologics can increase the risk of serious adverse effects and should be avoided
C) Infliximab and adalimumab should be used together for better outcomes
D) Switching between infliximab and adalimumab is recommended every month
E) The patient can take both biologics if they are well-tolerated
Correct Answer: B) Combining two biologics can increase the risk of serious adverse effects and should be avoided
Explanation: Combining biologics such as infliximab and adalimumab can significantly increase the risk of serious adverse effects, including infections and malignancies. It is generally not recommended to combine biologic agents.
Question 50
A 53-year-old man with psoriatic arthritis is considering treatment with secukinumab. He has a history of latent tuberculosis that was treated 5 years ago. What is the most appropriate action before initiating therapy?
A) Begin secukinumab without further testing
B) Start secukinumab and monitor for signs of TB reactivation
C) Perform a TB test and initiate prophylactic therapy if positive
D) Choose a different biologic agent due to the risk of TB reactivation
E) Initiate treatment with antibiotics and secukinumab simultaneously
Correct Answer: C) Perform a TB test and initiate prophylactic therapy if positive
Explanation: Secukinumab can reactivate latent tuberculosis. It is crucial to screen for TB and provide prophylactic treatment if necessary before starting therapy to reduce the risk of reactivation.
Question 51
A 40-year-old woman with rheumatoid arthritis is started on tocilizumab. She presents 3 months later with abdominal pain and a significant drop in hemoglobin. What serious adverse effect related to tocilizumab should be considered?
A) Hepatotoxicity
B) Gastrointestinal perforation
C) Progressive multifocal leukoencephalopathy (PML)
D) Infusion reaction
E) Neutropenia
Correct Answer: B) Gastrointestinal perforation
Explanation: Tocilizumab is associated with a risk of gastrointestinal perforations, especially in patients with a history of diverticulitis or other GI conditions. The patient’s symptoms and drop in hemoglobin may indicate this serious adverse effect.
Question 52
A 65-year-old patient with chronic lymphocytic leukemia (CLL) is receiving rituximab therapy. They develop confusion and neurological deficits over several weeks. What serious complication related to rituximab should be considered?
A) Tuberculosis reactivation
B) Progressive multifocal leukoencephalopathy (PML)
C) Acute coronary syndrome
D) Demyelinating disease
E) Guillain-Barré syndrome
Correct Answer: B) Progressive multifocal leukoencephalopathy (PML)
Explanation: Rituximab is associated with a rare but serious risk of PML, a fatal viral infection of the brain caused by the JC virus, which can lead to neurological deficits and confusion.
Question 53
A 45-year-old man with rheumatoid arthritis on anakinra develops fever, chills, and a sore throat. What should the clinician’s primary concern be regarding the continuation of anakinra therapy?
A) Increased risk of demyelinating diseases
B) Immunosuppression leading to serious infections
C) Development of lupus-like syndrome
D) Drug-induced liver toxicity
E) Increased risk of cardiac arrhythmias
Correct Answer: B) Immunosuppression leading to serious infections
Explanation: Anakinra, as an IL-1 receptor antagonist, increases the risk of serious infections. Infections should be promptly investigated, and therapy may need to be interrupted in the presence of an active infection.