QUESTION: 33

LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.
His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.
What is the reason for holding metformin in patients with reduced renal function?

Metformin can cause acute renal failure
Metformin can cause lactic acidosis
Metformin can build up neurotoxin
Metformin can cause hyperglycemia
Metformin can cause hyperkalemia

Answer(s): B

Explanation:

Metformin is held in patients with reduced renal function due to an increased risk of lactic acidosis. Metformin has a Boxed Warning for lactic acidosis, which is a rare but serious metabolic complication. Lactic acidosis can occurs due to an accumulation of metformin (5 mcg/mL or more). It is fatal in about 50% of cases. Lactic acidosis has also been reported to occur in those with diabetes who have significant renal function impairment. Lactic acidosis occurs when there are elevated blood lactate levels of 5 mmol/L or more, decreased blood pH, electrolyte disturbances with an increased anion gap, and an increased lactate/pyruvate ratio. Normal lactic acid level <2.0 mmol/L.

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QUESTION: 34

LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.
His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.
It is recommended to monitor complete blood count in patients on chronic metformin because of what reason?

Metformin may decrease erythropoietin level
Metformin may decrease platelet count
Metformin may decrease vitamin B12 levels
Metformin may cause leukocytosis
Metformin may decrease iron absorption

Answer(s): C

Explanation:

Metformin may impair the absorption of vitamin B12, especially in those with inadequate vitamin b12 or calcium intake/absorption. Vitamin b12 deficiency can be treated with discontinuation of therapy or supplementation. Vitamin b12 serum concentrations should be monitored periodically with long-term therapy.

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QUESTION: 35

LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.
His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.
LN used 5 on-demand bolus doses from the hydromorphone PCA, how much hydromorphone did the patient get in 24 hours?

10mg
5.3mg
4.8mg
0.5mg
52.8mg

Answer(s): B

Explanation:

0.2 mg/hour basal rate = 0.2mg/hour (24 hours) = 4.8 mg Demand dose of 0.1 mg × 5 = 0.5 mg 4.8 mg + 0.5 mg = 5.3 mg

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QUESTION: 36

LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and NKDA.
His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing, Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram 20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for constipation, Famotidine 20mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS with 20K at 125mls/hour and Hydromorphone PCA at 0.2mg/hour of basal rate, demand dose 0.1mg. lock-out every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg 1.5mg/ dl, K 5.0mmol/L, Na 135mmol/L.
Which of the following medication’s dose are adjusted for poor renal function?

Famotidine
Metoclopramide
Lisinopril
Citalopram
Ondansetron

Answer(s): B

Explanation:

Famotidine and Metoclopramide would need to be adjusted for poor renal function. Since his CrCl is less than 50, famotidine would need to be adjusted by decreasing the dose by 50% or increasing the interval to every 36 to 48 hours. Metoclopramide would also need to be adjusted by 50% of the normal dose since his CrCl is less than 40. ACEInhibitors and ARBs should be held if serum K is greater than 5.6 or there is a rise in serum creatinine greater than 30% after initiation.

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