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This patient’s BP is above goal (eg, ≥ 130/80 mmHg) despite his current treatment with a combined thiazide diuretic and angiotensin receptor blocker (ARB) [eg, Benicar HCT (olmesartan/hydrochlorothiazide)]. This is likely related to multiple modifiable risk factors (eg, NSAID use, limited physical activity) but warrants medication titration (eg, adding a drug from a different preferred drug class, increasing the dose of the current drug).

Preferred antihypertensive drug classes include thiazide diuretics, dihydropyridine calcium channel blockers (DHP CCBs), angiotensin-converting enzyme (ACE) inhibitors, and ARBs. Because this patient is already taking an ARB and a thiazide diuretic, adding a DHP CCB [eg, Procardia XL (nifedipine extended-release)] is recommended. Follow-up and medication adjustment should continue monthly until goal BP is achieved.

(Choice A) The addition of a thiazide diuretic (eg, chlorthalidone) is not appropriate because it is a duplication of the current hydrochlorothiazide therapy.

(Choice B) Direct vasodilators (eg, hydralazine) are not a preferred antihypertensive drug class due to adverse effects (eg, reflex tachycardia, peripheral edema); they are generally reserved for resistant hypertension and hypertensive crises.

(Choice C) Because beta-blockers [eg, Lopressor (metoprolol tartrate)] are less effective at lowering BP, their use should be limited to patients with specific comorbidities (eg, heart failure, coronary artery disease).

(Choice D) ACE inhibitors [eg, Lotensin (benazepril)] should not be used in combination with ARBs due to their overlapping mechanism of action (eg, renin-angiotensin-aldosterone system inhibition) and increased risk of hyperkalemia and renal impairment.

Things to remember:
Antihypertensive therapy should be titrated (eg, adding a drug from a different preferred drug class, increasing the dose of the current drug) to achieve a BP goal < 130/80 mmHg.

This patient has new signs of dementia, including forgetfulness and getting lost in a familiar place. Select drugs can worsen dementia symptoms or cause reversible confusion and are included on the Beers Criteria list of potentially inappropriate medications that should be avoided in most older adults.

Drugs that should be avoided in patients with dementia include:

• Central nervous system (CNS) depressants, which can cause sedation and confusion with short- and long-term use. This includes opioids (eg, morphine) and benzodiazepines (eg, alprazolam) (Choice A).

• Anticholinergics, such as antihistamines (eg, doxylamine) and antimuscarinic agents used for urinary incontinence (eg, tolterodine). These drugs antagonize acetylcholine, a neurotransmitter involved with memory, attention, and learning (Choices B and F).

• Antipsychotics (eg, haloperidol), which increase the rate of cognitive decline due to mechanisms that are not well defined. Antipsychotics may be used in select patients with dementia-related psychosis, but because of a boxed warning for increased mortality, they are reserved for use when nonpharmacologic strategies fail (Choice D).

(Choice C) Finasteride (a 5-alpha reductase inhibitor) is a treatment for benign prostatic hyperplasia. Its most common adverse effect is sexual dysfunction (eg, impotence, decreased libido); it does not cause CNS adverse effects.

(Choice E) Proton pump inhibitors (eg, pantoprazole) are not known to cause delirium or altered mental status, unlike histamine-2 receptor antagonists (eg, famotidine), which can impair cognition in elderly patients or patients with renal dysfunction.

Things to remember:
Antipsychotics, central nervous system depressants, and drugs with anticholinergic effects can impair cognition and should be avoided in patients with dementia.

Necrotizing fasciitis (NF) is a life-threatening skin and soft tissue infection that leads to the destruction of muscle fascia and overlying subcutaneous fat. The initial presentation is similar to cellulitis (eg, erythema, edema), but rapidly progresses to red-purple skin discoloration and necrosis. Other distinguishing characteristics include wooden-hard induration, pain that is more severe than expected based on the appearance, and systemic toxicity (eg, fever, hypotension).

NF requires urgent surgical debridement and broad-spectrum antibiotics. The infection can be monomicrobial or polymicrobial; possible pathogens include group A Streptococcus, Staphylococcus aureus [including methicillin-resistant S. aureus (MRSA)], Enterobacteriaceae, and anaerobes (gram-positive and gram-negative). Appropriate empiric treatment regimens to target these organisms include meropenem or piperacillin/tazobactam in combination with vancomycin or daptomycin. Clindamycin is often added empirically to inhibit streptococcal toxin production.

(Choice A) Cefepime (a fourth-generation cephalosporin) and vancomycin both lack the necessary activity against anaerobic organisms.

(Choices B and E) Piperacillin/tazobactam or ceftriaxone combined with metronidazole do not provide the needed activity against MRSA. Ceftriaxone (a third-generation cephalosporin) is also not a preferred beta-lactam for empiric NF treatment because its activity is too narrow. In addition, because piperacillin/tazobactam has intrinsic activity against anaerobes, there is no benefit to adding metronidazole.

(Choice D) Penicillin G aqueous is too narrow for initial empiric therapy but may be warranted for definitive therapy, with clindamycin, if cultures identify a monomicrobial infection with Streptococcus pyogenes or Clostridium spp.

Things to remember:
Necrotizing fasciitis is a rapidly progressing and life-threatening skin and soft tissue infection. Treatment requires urgent surgical debridement and broad-spectrum antibiotics (meropenem or piperacillin/tazobactam in combination with vancomycin or daptomycin). Clindamycin can be added empirically to suppress streptococcal toxin production.

2. Determine the best dosing regimen based on the patient’s CrCl

• CrCl ≥ 30 mL/min: 40 mg subcutaneously (SC) every 24 hours or 30 mg SC every 12 hours
• CrCl < 30 mL/min: 30 mg SC every 24 hours

(Choice A) Enoxaparin 30 mg SC every 12 hours would be correct if the patient’s CrCl was 30 mL/min or greater. The administration frequency should be every 24 hours based on this patient’s creatinine clearance (CrCl 19 mL/min).

(Choice C) Enoxaparin is administered subcutaneously, not intravenously, for VTE prophylaxis. In addition, it should be administered every 24 hours for a CrCl less than 30 mL/min.

(Choice E) This dose and frequency (1 mg/kg SC every 24 hours) would be correct for the treatment of a VTE in a patient with a CrCl < 30 mL/min, not for VTE prophylaxis.

Things to remember:
Enoxaparin is a renally eliminated medication that is preferred for VTE prophylaxis in most patients. The standard doses are 40 mg SC every 24 hours or 30 mg SC every 12 hours; the dose is 30 mg every 24 hours when the CrCl is less than 30 mL/min.

• Refer to the latest version of the RxPrep Course Book – Anticoagulation chapter, “Low Molecular Weight Heparins”, beginning on page 475.

• Low Molecular Weight Heparins

The current PN provides 1885 kcals, so 515 kcals must be provided by the 10% Intralipid. 515 kcals x 1 mL/1.1 kcals = 468.1818 mL of 10% Intralipid. Be sure to divide the volume of 10% Intralipid by 12 to get the 12-hr infusion rate. In many hospitals, lipids are infused over 8 or 12 hours.