🫁 Respiratory, Gastrointestinal, Rheumatology and Dermatology

1. What is the foundation of long-term asthma control in an adult with persistent symptoms?

1. An oral antihistamine taken every evening as the only maintenance therapy required through the whole of the year
2. A short-acting beta-2 agonist used alone, taken whenever symptoms appear during the day
3. An oral corticosteroid taken continuously at low dose for as long as symptoms persist
4. An inhaled corticosteroid, used regularly or as part of a combination reliever strategy

Asthma is an inflammatory disease, so inhaled corticosteroid therapy is the foundation of control, and reliever-only treatment leaves the underlying inflammation untreated while increasing the risk of severe exacerbations. Long-term oral steroids and antihistamines are not maintenance therapy. Source: Canadian Thoracic Society asthma guidelines.

2. What does frequent use of a short-acting reliever indicate?

1. A need to increase the reliever dose and to stop the inhaled corticosteroid
2. Excellent control, since the reliever is working exactly as the patient expects
3. Poor control and an increased risk of exacerbation, prompting review of the controller
4. An allergy to the propellant used in the metered-dose inhaler device to the inhaler propellant used

Reliever overuse is one of the strongest markers of poor control and of exacerbation and mortality risk, so it triggers review of adherence, technique, triggers and controller therapy rather than an increase in reliever use. Source: Canadian Thoracic Society asthma guidelines.

3. Why is the mouth rinsed after using an inhaled corticosteroid?

1. To remove the taste, which is the only reason the manufacturer suggests it after each inhaled dose is taken
2. To increase the amount of drug that reaches the lower airways with each dose
3. To prevent the systemic absorption of the corticosteroid from the stomach
4. To reduce oropharyngeal candidiasis and hoarseness caused by local deposition

Rinsing and spitting after inhaled corticosteroid use, and using a spacer with a pressurised inhaler, reduce local deposition and therefore oral candidiasis and dysphonia. It does not change lung delivery, and swallowed drug undergoes extensive first-pass metabolism. Source: Canadian Thoracic Society asthma guidelines.

4. Which inhaler technique error most reduces drug delivery from a pressurised metered-dose inhaler?

1. Rinsing the mouth after the dose has been inhaled and the breath released
2. Holding the breath for ten seconds after the inhalation has been completed
3. Shaking the inhaler before use as the product information instructs the patient
4. Actuating the canister before or after the inhalation instead of during it

Poor coordination between actuation and a slow deep inhalation is the classic error with pressurised inhalers, and it is largely solved by a spacer. Breath-holding, shaking and rinsing are correct steps rather than errors. Source: Canadian Thoracic Society asthma guidelines.

5. Why must a long-acting beta-2 agonist never be used alone in asthma?

1. Monotherapy causes an immediate and severe fall in blood pressure in most users
2. Monotherapy leaves inflammation untreated and has been linked to severe outcomes
3. Monotherapy is ineffective because the drug is destroyed in the airway lining before it can reach the airway
4. Monotherapy causes irreversible hearing loss when used for more than a week of regular daily inhaled therapy

Long-acting beta-2 agonist monotherapy in asthma masks worsening inflammation and was associated with an increased risk of severe exacerbation and death, so these agents are used only in combination with an inhaled corticosteroid. Source: Health Canada product monographs for the long-acting beta-2 agonists.

6. What is the purpose of a written asthma action plan?

1. It lists the pharmacies at which the patient's inhalers may legally be dispensed
2. It records the price of each inhaler for reimbursement by the provincial plan
3. It replaces the need for any inhaled corticosteroid in a well controlled patient
4. It tells the patient what to change, and when to seek help, as symptoms worsen

An action plan translates worsening symptoms or peak flow into specific steps, including increasing controller therapy, starting oral corticosteroid where prescribed and seeking urgent care, and it reduces hospital attendance. Source: Canadian Thoracic Society asthma guidelines.

7. Which patient with asthma should avoid acetylsalicylic acid and other NSAIDs?

1. A patient with nasal polyps and a history of respiratory reactions to these drugs
2. A patient whose asthma has been well controlled on an inhaled corticosteroid
3. A patient with mild intermittent symptoms occurring only during vigorous exercise
4. A patient with seasonal allergic rhinitis controlled by an intranasal corticosteroid

Aspirin-exacerbated respiratory disease combines asthma, chronic rhinosinusitis with nasal polyps and reactions to cyclooxygenase-1 inhibitors, so these drugs are avoided and acetaminophen or a selective agent is used with caution. Well controlled asthma alone is not a contraindication. Source: CPhA Therapeutic Choices, asthma chapter.

8. Which intervention most alters the course of chronic obstructive pulmonary disease?

1. An annual course of oral antibiotics taken during the winter months only
2. A long-acting bronchodilator, which reverses the structural airway damage
3. An inhaled corticosteroid, which restores lung function to its previous level
4. Smoking cessation, supported by pharmacotherapy and behavioural counselling

Stopping smoking is the only intervention that clearly slows the decline in lung function, alongside vaccination, pulmonary rehabilitation and long-term oxygen in selected patients. Bronchodilators and inhaled steroids improve symptoms and exacerbations without reversing damage. Source: Canadian Thoracic Society chronic obstructive pulmonary disease guidelines.

9. Which risk is increased by inhaled corticosteroid therapy in chronic obstructive pulmonary disease?

1. Severe hypoglycaemia requiring hospital admission within the first month of continuous inhaled therapy
2. Acute kidney injury, which occurs in the majority of treated patients
3. Pneumonia, which is why the class is reserved for patients with exacerbations
4. Irreversible loss of hearing developing after the first year of therapy of regular inhaled corticosteroid

Inhaled corticosteroids increase pneumonia risk in this population, so they are added where exacerbations persist despite bronchodilators or where eosinophil counts suggest benefit, and withdrawal is considered when they are not indicated. The other risks do not apply. Source: Canadian Thoracic Society chronic obstructive pulmonary disease guidelines.

10. Which device instruction is specific to a dry powder inhaler?

1. Inhale quickly and deeply, and do not exhale into the device before or after the dose
2. Inhale as slowly and gently as possible, exactly as with a pressurised inhaler
3. Shake the device vigorously for a full minute before every dose is taken to disperse the powder inside it
4. Use it with a spacer, which is required for every dry powder inhaler product to improve delivery to the lungs

Dry powder devices depend on the patient's inspiratory effort to disaggregate the powder, so a forceful deep inhalation is needed, and exhaling into the device introduces moisture that clumps the dose. Spacers are used with pressurised inhalers rather than dry powder devices. Source: Canadian Thoracic Society device guidance.

11. Which finding indicates that a patient with chronic obstructive pulmonary disease is having an exacerbation?

1. An acute worsening of breathlessness, cough or sputum beyond day-to-day variation
2. A stable exercise tolerance with no change in sputum volume or colour over months
3. A gradual improvement in breathlessness after starting pulmonary rehabilitation for the patient being reviewed
4. An unchanged requirement for the reliever inhaler over the previous three months of stable maintenance therapy

An exacerbation is defined by an acute worsening of respiratory symptoms beyond normal variation that leads to a change in therapy, and early recognition with an action plan reduces hospital admission. The other descriptions indicate stability or improvement. Source: Canadian Thoracic Society chronic obstructive pulmonary disease guidelines.

12. What is the most effective single therapy for moderate to severe allergic rhinitis?

1. An oral first-generation antihistamine taken at night for its sedative effect
2. An intranasal corticosteroid used regularly through the period of exposure
3. A topical nasal decongestant used continuously through the whole pollen season
4. An oral decongestant taken four times a day for as long as symptoms persist

Intranasal corticosteroids are the most effective single therapy for moderate to severe disease, working best with regular use and correct aiming away from the septum. Sedating antihistamines and prolonged topical decongestants are not appropriate maintenance therapy. Source: CPhA Therapeutic Choices, allergic rhinitis chapter.

13. Why must a topical nasal decongestant be limited to a few consecutive days?

1. Longer use causes the nasal mucosa to absorb no further medication at all
2. Longer use causes an immediate and permanent loss of the sense of smell
3. Longer use causes rebound congestion known as rhinitis medicamentosa
4. Longer use is limited only by the size of the bottle that is dispensed

Prolonged use of xylometazoline or oxymetazoline produces rebound vasodilatation and worsening congestion that perpetuates use, so the label limits treatment to a small number of consecutive days and an intranasal corticosteroid is used for longer treatment. Source: Health Canada product monographs for the topical nasal decongestants.

14. Which technique point applies to an intranasal corticosteroid spray?

1. Aim directly at the septum so that the drug is deposited where it is most needed
2. Aim away from the nasal septum with the opposite hand to reduce the risk of bleeding
3. Sniff as hard as possible so that the spray reaches the back of the throat so that the dose is not wasted
4. Tilt the head fully backwards so that the liquid runs down into the throat where the drug is best absorbed

Directing the spray away from the septum, using the opposite hand and avoiding a hard sniff reduce epistaxis and keep the drug on the nasal mucosa rather than in the throat, and regular daily use is required for full effect. Source: CPhA Therapeutic Choices, allergic rhinitis chapter.

15. Why are first-generation antihistamines avoided in older adults and drivers?

1. They cause an irreversible loss of the sense of taste after a single dose of the antihistamine tablet
2. They are ineffective against histamine and therefore do not treat any symptom
3. They cause a severe rise in blood pressure in the majority of treated patients who are prescribed the medicine
4. Sedation and anticholinergic effects impair cognition, coordination and driving

Diphenhydramine, chlorpheniramine and similar agents cross the blood-brain barrier, producing sedation and psychomotor impairment that can persist into the next day, alongside anticholinergic burden, so second-generation agents are preferred. Source: Beers Criteria and CPhA Therapeutic Choices, allergic rhinitis chapter.

16. When is a proton pump inhibitor taken for best effect?

1. Thirty to sixty minutes before a meal, so that active proton pumps are inhibited
2. At bedtime on an empty stomach, when no proton pumps are active in the stomach
3. Immediately after the largest meal of the day, once the stomach is already full when acid production is highest
4. At any time, since food and timing have no effect on the action of this class on the effect of the medicine

Proton pump inhibitors bind irreversibly to actively secreting pumps, so administration before a meal, when a meal will stimulate pump activity, gives the greatest acid suppression. Bedtime dosing on an empty stomach is less effective. Source: CPhA Therapeutic Choices, gastro-oesophageal reflux disease chapter.

17. Which symptom in a patient with reflux requires referral rather than self-care?

1. Difficulty swallowing, unintentional weight loss, vomiting blood or black stools
2. Occasional heartburn after a large late meal that settles with an antacid
3. Mild symptoms occurring twice a week that respond to lifestyle changes and lifestyle advice was given
4. Reflux that improves after raising the head of the bed and losing some weight over the preceding few months

Dysphagia, odynophagia, unintentional weight loss, gastrointestinal bleeding, persistent vomiting, anaemia or new symptoms in an older adult are alarm features requiring assessment rather than continued self-treatment. The other presentations fit uncomplicated reflux. Source: CPhA Therapeutic Choices, gastro-oesophageal reflux disease chapter.

18. Why is long-term proton pump inhibitor therapy periodically reassessed?

1. Proton pump inhibitors lose all effect after the first three months of therapy
2. Indefinite use without indication has been linked to several potential harms
3. Reassessment is required only for reimbursement rather than for clinical reasons
4. Long-term therapy is contraindicated in every patient after one year of treatment

Prolonged acid suppression has been associated with Clostridioides difficile infection, community-acquired pneumonia, hypomagnesaemia, vitamin B12 deficiency and fracture, so continuing need is reviewed and step-down or on-demand therapy considered. Source: CPhA Therapeutic Choices, deprescribing proton pump inhibitors.

19. What does a Helicobacter pylori eradication regimen typically contain?

1. An antacid alone taken as needed for symptoms over several months for symptomatic relief of pain
2. A single antibiotic given once, which reliably eradicates the organism
3. An acid suppressant with two or more antimicrobials for a defined course
4. A probiotic alone, which eradicates the organism without any antibiotic taken alongside the usual diet

Eradication requires acid suppression to allow antibiotic activity plus at least two antimicrobials, chosen with local resistance in mind, for the stated duration, and confirmation of eradication is recommended in many circumstances. Source: CPhA Therapeutic Choices, Helicobacter pylori chapter.

20. Which drug most commonly causes a peptic ulcer in ambulatory practice?

1. A topical emollient applied to the arms and legs for the treatment of dry skin during the winter and spring
2. A second-generation antihistamine taken once daily during the pollen season
3. An inhaled corticosteroid used twice daily with a spacer for persistent asthma for the management of asthma
4. A non-steroidal anti-inflammatory drug used regularly for musculoskeletal pain

NSAIDs, including low-dose acetylsalicylic acid, are the leading drug cause of peptic ulceration alongside Helicobacter pylori, with risk increased by age, previous ulcer, anticoagulants, antiplatelets and corticosteroids. The other products carry no ulcer risk. Source: CPhA Therapeutic Choices, peptic ulcer disease chapter.

21. Which laxative class is usually tried first for simple constipation in an adult?

1. A bulk-forming agent taken without any additional fluid intake at all taken with the evening meal
2. A stimulant laxative taken at maximum dose every day for an indefinite period
3. A rectal enema used daily as the first measure before any oral therapy is tried for the management of symptoms
4. An osmotic agent such as polyethylene glycol, alongside fluid, fibre and activity

Lifestyle measures with an osmotic laxative such as polyethylene glycol are the usual first pharmacological step, with stimulants added or used intermittently and rectal measures reserved for impaction. Bulk-forming agents require adequate fluid to be safe and effective. Source: CPhA Therapeutic Choices, constipation chapter.

22. Which laxative approach is used for opioid-induced constipation?

1. No treatment at all, because tolerance to the constipating effect develops quickly
2. A bulk-forming agent alone, which is the most effective option in this situation
3. A stimulant with or without an osmotic agent, started when the opioid is started
4. A single dose of a rectal preparation given at the end of each week of therapy

Opioids reduce propulsive motility, so bulk-forming agents are generally unhelpful and can worsen the problem, whereas a stimulant with or without an osmotic agent is started prophylactically, with peripherally acting antagonists reserved for refractory cases. Source: CPhA Therapeutic Choices, constipation chapter.

23. In which situation should loperamide be avoided?

1. Mild watery diarrhoea for a day in an otherwise well adult with no fever
2. Bloody diarrhoea with fever, or suspected Clostridioides difficile infection
3. Travellers' diarrhoea without blood or fever in a healthy adult traveller who is travelling for work
4. Diarrhoea caused by a change of diet on the first day of a holiday abroad taken during the holiday period

Antimotility agents can worsen invasive bacterial infection and precipitate toxic megacolon in Clostridioides difficile colitis, so they are avoided in dysentery, high fever and suspected inflammatory colitis. They are acceptable in non-dysenteric illness. Source: CPhA Therapeutic Choices, acute diarrhoea chapter.

24. What is the priority in managing acute gastroenteritis in a young child?

1. Complete withholding of all fluid until the vomiting has entirely stopped
2. A full-strength sports drink, which has the correct electrolyte composition
3. Oral rehydration solution in small frequent amounts to prevent dehydration
4. An immediate antibiotic course for every child with acute watery diarrhoea

Oral rehydration with a properly formulated solution, given in small frequent volumes, is the mainstay, with early resumption of feeding. Sports drinks have too much sugar and too little sodium, withholding fluid causes dehydration and antibiotics are rarely needed. Source: CPhA Therapeutic Choices, acute diarrhoea chapter.

25. Which class is used for maintenance of remission in mild to moderate ulcerative colitis?

1. A systemic corticosteroid continued indefinitely to maintain the remission achieved with the initial course
2. An aminosalicylate, given orally or rectally according to the extent of disease
3. An antibiotic given continuously for as long as the remission is maintained once the remission is established
4. A proton pump inhibitor taken before breakfast to suppress colonic inflammation to suppress the bowel inflammation

Aminosalicylates such as mesalamine maintain remission in ulcerative colitis, with the route chosen by disease extent, whereas corticosteroids are for induction only because of their adverse effects. Antibiotics and acid suppression have no maintenance role. Source: CPhA Therapeutic Choices, inflammatory bowel disease chapter.

26. Which assessment is required before starting a biologic agent for inflammatory bowel disease?

1. A bone density scan of the spine and hip repeated every six months thereafter
2. Screening for latent tuberculosis and hepatitis B, with vaccination reviewed
3. An audiogram and a formal visual field assessment before the first infusion
4. A twenty-four hour urinary cortisol collection before therapy is commenced

Tumour necrosis factor inhibitors and other biologics increase the risk of reactivating latent tuberculosis and hepatitis B, so screening and appropriate prophylaxis or treatment precede therapy, and live vaccines are given beforehand where needed. Source: CPhA Therapeutic Choices, inflammatory bowel disease chapter.

27. Which approach is used for irritable bowel syndrome with predominant constipation?

1. A long-term systemic antibiotic taken continuously to sterilise the whole bowel of the affected large intestine
2. Soluble fibre, an osmotic laxative and dietary review, with specific agents if needed
3. An opioid analgesic taken regularly to reduce the abdominal discomfort reported by the treated patient
4. A systemic corticosteroid tapered slowly over the course of several months under close medical supervision

Management combines dietary modification including soluble fibre and a low fermentable carbohydrate approach where appropriate, osmotic laxatives, antispasmodics for pain and specific secretagogues in refractory cases. Opioids and corticosteroids are inappropriate. Source: CPhA Therapeutic Choices, irritable bowel syndrome chapter.

28. Which antiemetic class is used for chemotherapy-induced nausea of high emetogenic risk?

1. A single dose of an antacid taken before the chemotherapy infusion begins
2. A serotonin antagonist with a neurokinin antagonist and a corticosteroid
3. An oral antihistamine used alone as the sole prophylaxis for every regimen
4. A proton pump inhibitor taken thirty minutes before each infusion session

Highly emetogenic regimens require combination prophylaxis with a serotonin receptor antagonist, a neurokinin-1 antagonist and dexamethasone, sometimes with olanzapine, given before the first dose rather than after symptoms appear. Source: CPhA Therapeutic Choices, nausea and vomiting chapter.

29. Which antiemetic is first-line for nausea and vomiting of pregnancy in Canada?

1. An oral cannabinoid preparation taken three times daily throughout the pregnancy
2. The combination of doxylamine with pyridoxine, which has the best safety record
3. A systemic corticosteroid given for the whole of the first trimester of pregnancy
4. A dopamine antagonist given at high dose from the first day of the symptoms

The delayed-release combination of doxylamine and pyridoxine is the recognised first-line pharmacological therapy for nausea and vomiting of pregnancy, with other agents added if symptoms persist. Cannabinoids and prolonged corticosteroids are not first-line. Source: CPhA Therapeutic Choices, nausea and vomiting of pregnancy chapter.

30. Which dosing error with methotrexate has caused deaths and is specifically guarded against?

1. Daily rather than weekly administration of the oral dose for inflammatory arthritis
2. Taking the weekly dose with folic acid on the same day of the week each time agreed with the treating team
3. Splitting the weekly dose into two administrations on the same day of the week to spread the exposure evenly
4. Taking the weekly dose with food rather than on an empty stomach in the morning to reduce gastric irritation

Methotrexate for inflammatory arthritis is dosed once weekly, and inadvertent daily administration causes severe myelosuppression, mucositis and death, which is why the day of the week is specified on the label and the dose is confirmed at every dispensing. Source: ISMP Canada medication safety bulletins on methotrexate.

31. Why is folic acid prescribed alongside methotrexate?

1. It prevents the weekly dose from being taken on the wrong day of the week that has been prescribed for them
2. It doubles the anti-inflammatory effect of methotrexate in every treated patient who is treated with the drug
3. It reduces gastrointestinal, mucosal and hepatic adverse effects without abolishing efficacy
4. It is required to activate methotrexate within the inflamed synovial tissue where the inflammation is greatest

Folic acid supplementation reduces stomatitis, nausea and transaminase elevation without meaningfully reducing efficacy, and it is standard practice with low-dose weekly methotrexate. It does not activate the drug or prevent dosing errors. Source: CPhA Therapeutic Choices, rheumatoid arthritis chapter.

32. Which monitoring accompanies long-term methotrexate therapy?

1. A twenty-four hour ambulatory electrocardiogram repeated every three months for the duration of the therapy
2. Complete blood count, liver enzymes and renal function on a defined schedule
3. An annual audiogram to detect the hearing loss caused by the medication caused by the medication itself
4. A monthly bone marrow aspiration for the duration of the treatment course while the therapy is continued

Myelosuppression, hepatotoxicity and accumulation in renal impairment are the principal risks, so blood counts, transaminases and renal function are monitored on a schedule, with alcohol intake and interacting drugs also reviewed. The other investigations are not required. Source: Health Canada product monograph for methotrexate.

33. Which monitoring is specific to long-term hydroxychloroquine therapy?

1. Retinal assessment at baseline and at intervals, because of a risk of retinopathy
2. Monthly measurement of the serum potassium for the whole treatment period for as long as therapy continues
3. Annual bone density scanning of the lumbar spine and the femoral neck during long-term continuous use
4. Weekly liver biopsy during the first three months of continuous therapy while the drug is being taken

Hydroxychloroquine can cause a dose and duration-related retinopathy, so baseline and periodic ophthalmological screening is recommended, with risk increased by higher weight-based doses, renal impairment and prolonged use. Source: Health Canada product monograph for hydroxychloroquine.

34. Which treatments are used for an acute gout flare?

1. An NSAID, colchicine or a corticosteroid, chosen according to comorbidity
2. Allopurinol at full dose, started on the first day of the acute attack
3. A urate-lowering agent alone, which resolves the flare within a few hours
4. A prolonged course of an oral antibiotic to treat the joint inflammation

Acute flares are treated with an NSAID, colchicine or a corticosteroid, selected on renal function, cardiovascular status, anticoagulation and other comorbidity. Urate-lowering therapy is not started at full dose during a flare, and gout is not an infection. Source: CPhA Therapeutic Choices, gout chapter.

35. Which measure is the foundation of osteoarthritis management?

1. Intra-articular corticosteroid injections given every week indefinitely
2. A long-acting opioid started at diagnosis and continued for the rest of life
3. Complete rest of the affected joint until all pain has permanently resolved
4. Exercise, weight management and education, with analgesia as an adjunct

Structured exercise, weight reduction where relevant and self-management education produce the most durable benefit, with topical and oral analgesia, intra-articular injection and surgery used as adjuncts. Rest causes deconditioning and frequent injections are harmful. Source: CPhA Therapeutic Choices, osteoarthritis chapter.