Iraqi Board Clinical Pharmacy cheat sheet

Vancomycin AUC24/MIC target 400–600 (mg·h/L) for serious MRSA infection; trough-only monitoring (10–15 mg/L) is an accepted surrogate when AUC cannot be calculated.

Aminoglycoside extended-interval dosing: peak/MIC ≥8–10 for efficacy; trough <1 mg/L (gentamicin/tobramycin) or <2 mg/L (amikacin) to limit nephrotoxicity.

Cockcroft-Gault: CrCl (mL/min) = [(140 − age) × weight kg] ÷ (72 × SCr mg/dL) × 0.85 if female; use actual, ideal, or adjusted body weight per drug's labeling.

Loading dose depends on volume of distribution (LD = Vd × target concentration); maintenance dose depends on clearance (MD = CL × target concentration × dosing interval).

Half-life relates to volume and clearance: t½ = 0.693 × Vd / CL; steady state is reached in ~4–5 half-lives, independent of dose size.

Phenytoin follows saturable (Michaelis-Menten) kinetics: rate of elimination = Vmax × C / (Km + C); small dose increases can raise levels disproportionately.

First-order elimination: C = C0 × e^(−kt); constant fraction removed per unit time, so clearance and half-life are dose-independent.

Therapeutic index = TD50/ED50; narrow-index drugs (digoxin, lithium, warfarin, phenytoin, vancomycin) require TDM and individualized dosing.

Heart failure with reduced EF: quadruple therapy (ARNI/ACEi/ARB, evidence-based beta-blocker, MRA, SGLT2 inhibitor) unless contraindicated; diuretics for congestion only.

Acute decompensated HF: IV loop diuretic for congestion; avoid routine beta-blocker initiation during decompensation; treat precipitants (ischemia, infection, arrhythmia, nonadherence).

Hypertension in chronic kidney disease with albuminuria: ACEi or ARB is preferred, with monitoring of creatinine and potassium within 1–2 weeks of initiation or dose change.

Statin intensity: high-intensity = atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily; add ezetimibe then PCSK9 inhibitor if LDL goals are unmet.

Atrial fibrillation stroke risk: CHA2DS2-VASc score guides anticoagulation; DOACs preferred over warfarin except mechanical valves or moderate-severe mitral stenosis.

Warfarin: target INR 2–3 for most indications (2.5–3.5 for mechanical mitral valve); bridge with heparin when INR is subtherapeutic in high-risk patients.

Hyperkalemia with RAAS inhibitors: do not reflexively stop therapy; correct diet, review interacting drugs, use potassium binders, and reduce dose if K >5.5 mmol/L.

Contrast-induced nephropathy prevention: isotonic saline volume expansion and minimizing contrast volume; hold nephrotoxins; statins do not substitute for hydration.

Sepsis: broad-spectrum antibiotics within 1 hour of recognition; obtain cultures before antibiotics when this does not delay therapy; de-escalate based on culture and susceptibility.

Beta-lactam allergy: true IgE-mediated anaphylaxis is rare; obtain detailed history and use direct oral challenge or graded challenge for low-risk penicillin-labeled patients rather than broad alternatives.

Community-acquired pneumonia: severity scoring (CURB-65/PSI) determines site of care; typical regimens cover Streptococcus pneumoniae and atypical pathogens.

MRSA bacteremia: vancomycin or daptomycin for ≥14 days from first negative blood culture; repeat cultures until clearance; echocardiography to exclude endocarditis.

Antimicrobial de-escalation: narrow spectrum, stop redundant agents, and convert IV to oral when the patient is clinically stable and the oral agent has adequate bioavailability.

Antibiotic lock or prolonged infusion strategies: extended/continuous beta-lactam infusion improves time above MIC for resistant gram-negative organisms with high MICs.

Antimicrobial resistance mechanisms: beta-lactamases (ESBL, carbapenemases), efflux pumps, porin loss, and target modification; carbapenem-sparing options depend on local susceptibility.

Surgical prophylaxis: single preoperative dose within 60 minutes of incision (vancomycin/fluoroquinolones within 120 minutes); redose for prolonged procedures or major blood loss; discontinue within 24 hours.

Type 2 diabetes: metformin first-line unless contraindicated; add SGLT2 inhibitor or GLP-1 receptor agonist when ASCVD, heart failure, or CKD is present regardless of A1c.

Hypoglycemia in a conscious patient: 15–20 g fast-acting oral carbohydrate, recheck glucose in 15 minutes, repeat if still <70 mg/dL; IV dextrose or glucagon if unconscious.

DKA management: isotonic fluid resuscitation, IV insulin infusion after potassium is ≥3.3 mmol/L, and potassium replacement; bicarbonate only if pH <6.9.

Thyroid replacement: levothyroxine on an empty stomach, separated 4 hours from calcium, iron, and PPIs; titrate by TSH every 6–8 weeks; pregnancy requires dose increase.

Antithyroid drugs: methimazole preferred for most Graves disease; PTU preferred in first trimester and thyroid storm; monitor for agranulocytosis and hepatotoxicity.

Corticosteroid equivalence: hydrocortisone 20 mg = prednisone 5 mg = methylprednisolone 4 mg = dexamethasone 0.75 mg; taper after prolonged use to avoid adrenal insufficiency.

Osteoporosis: bisphosphonates first-line; check calcium and vitamin D before treatment, ensure dental review, and use drug holidays after 3–5 years for oral agents in moderate-risk patients.

Nutrition support: start enteral feeding early when the gut works; refeeding syndrome risk requires thiamine before feeding and cautious caloric advancement with electrolyte monitoring.

Asthma step-up: low-dose ICS-formoterol as reliever and controller (MART) is preferred; SABA-only treatment is no longer recommended.

COPD: LABA or LAMA first; add ICS only for frequent exacerbations with elevated eosinophils or coexisting asthma; smoking cessation is the only intervention that slows decline.

Gastroesophageal reflux disease: 8-week trial of once-daily PPI taken 30–60 minutes before a meal; double-dose or bedtime addition only for partial response.

Helicobacter pylori eradication: PPI-based quadruple therapy (PPI + bismuth + tetracycline + metronidazole) for 14 days is preferred where clarithromycin resistance is high.

Inflammatory bowel disease: 5-ASA for mild ulcerative colitis; corticosteroids for induction only, not maintenance; biologics and immunomodulators for moderate-severe disease.

Cirrhosis complications: nonselective beta-blockers for variceal prophylaxis; lactulose and rifaximin for hepatic encephalopathy; avoid NSAIDs, aminoglycosides, and sedatives.

Acetaminophen hepatotoxicity: N-acetylcysteine is most effective within 8 hours of ingestion; use the Rumack-Matthew nomogram for acute single ingestions.

Drug-induced liver injury: check R ratio (ALT/ULN ÷ ALP/ULN); R ≥5 suggests hepatocellular, R ≤2 cholestatic, and 2–5 mixed injury; stop the suspected agent.

Depression: SSRIs are first-line; full effect takes 4–6 weeks; continue 4–9 months after remission and longer for recurrent episodes.

Serotonin syndrome: clonus, hyperreflexia, agitation, and hyperthermia after serotonergic agents; stop offending drugs, use benzodiazepines, and cyproheptadine in severe cases.

Bipolar disorder: mood stabilizer (lithium, valproate, or atypical antipsychotic) for maintenance; antidepressant monotherapy risks inducing mania.

Lithium monitoring: target trough 0.6–1.0 mmol/L; check levels 12 hours after dose, plus renal and thyroid function every 6 months; toxicity is exacerbated by dehydration and NSAIDs.

Opioid prescribing: start low, reassess, use the lowest effective dose; co-prescribe naloxone for high-risk patients; screen for opioid use disorder and check prescription monitoring data.

Acute pain: multimodal analgesia (acetaminophen, NSAIDs, regional blocks, adjuvants) reduces opioid requirements; NSAIDs are avoided in renal impairment and peptic ulcer disease.

Neuropathic pain: gabapentinoids, tricyclic antidepressants, and SNRIs are first-line; opioids are not first-line for chronic neuropathic pain.

Alcohol withdrawal: benzodiazepines are first-line, symptom-triggered with CIWA-Ar scoring; give thiamine before glucose to prevent Wernicke encephalopathy.

Chemotherapy-induced nausea and vomiting: 5-HT3 antagonist + dexamethasone + NK1 antagonist for highly emetogenic regimens; olanzapine is a useful adjunct.

Febrile neutropenia: start empiric antipseudomonal beta-lactam within 1 hour; add vancomycin for line infection, skin infection, or hemodynamic instability.

Tumor lysis syndrome: prevention with hydration and allopurinol for low risk; rasburicase for high risk or established hyperuricemia; monitor potassium, phosphate, calcium, and uric acid.

Methotrexate toxicity: leucovorin rescue after high-dose therapy; glucarpidase for toxic methotrexate levels with renal impairment; monitor renal and hepatic function.

Immunosuppression after transplant: calcineurin inhibitors (tacrolimus, cyclosporine) have narrow therapeutic indices; monitor troughs and watch for nephrotoxicity and drug interactions.

Biologic therapy screening: test for latent tuberculosis and hepatitis B before anti-TNF agents; live vaccines are contraindicated during immunosuppression.

Anemia of chronic kidney disease: iron studies first; erythropoiesis-stimulating agents target hemoglobin 10–11 g/dL, with attention to hypertension and thromboembolic risk.

Heparin-induced thrombocytopenia: stop heparin, start a non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux), and avoid platelet transfusions.

Anion gap = Na⁺ − (Cl⁻ + HCO3⁻); normal 8–12 mmol/L; high anion gap acidosis suggests ketoacidosis, lactic acidosis, renal failure, or toxins.

Corrected sodium for hyperglycemia: add 1.6 mmol/L to measured Na⁺ for every 100 mg/dL glucose above 100 mg/dL (or 2.4 mmol/L per 100 mg/dL using a factor of 2.4 in some references).

Corrected calcium = measured Ca²⁺ + 0.8 × (4.0 − albumin g/dL); ionized calcium is preferred in critical illness.

Liver enzymes: ALT is more liver-specific than AST; an AST/ALT ratio >2 suggests alcohol-related liver disease.

Blood gas interpretation: pH determines acidemia or alkalemia; pCO2 reflects respiratory component; HCO3⁻ reflects metabolic component; check compensation adequacy.

CBC interpretation: MCV classifies anemia as microcytic (<80 fL), normocytic (80–100 fL), or macrocytic (>100 fL); reticulocyte count distinguishes hypo- from hyperproliferative anemia.

Renal function: eGFR is preferred for chronic staging; Cockcroft-Gault CrCl is used for drug dosing; AKI is defined by KDIGO creatinine and urine output criteria.

Coagulation: INR reflects extrinsic pathway (PT); aPTT reflects intrinsic pathway; mixing studies help distinguish factor deficiency from inhibitor.

Medication reconciliation: obtain the best possible medication history at admission, transitions, and discharge; compare against orders and document intentional changes.

ADverse drug reaction reporting: report serious, unexpected, and new-drug reactions to the national pharmacovigilance center; causality assessment tools include Naranjo and WHO-UMC scales.

High-alert medications (insulin, heparin, concentrated electrolytes, chemotherapy, opioids) require independent double-checks, standardized concentrations, and clear labeling.

LASA (look-alike/sound-alike) drugs: use tall-man lettering, separate storage, and read-back verification to prevent selection errors.

Medication error analysis: distinguish prescribing, transcribing, dispensing, administration, and monitoring errors; use root cause analysis for sentinel events.

Pharmacovigilance signal detection: disproportionality methods (PRR, ROR, BCPNN) identify possible new adverse reactions from spontaneous reports.

Anticoagulant safety: warfarin requires INR monitoring and patient education; DOACs require renal function and interaction review; never overlap heparin and LMWH unnecessarily.

Patient counseling: use teach-back, plain language, and written instructions; assess adherence barriers and health literacy before discharge.

Levels of evidence: systematic reviews/meta-analyses of RCTs > individual RCTs > cohort studies > case-control studies > case series > expert opinion.

Relative risk reduction vs absolute risk reduction: ARR = control event rate − treatment event rate; NNT = 1/ARR; relative measures can exaggerate benefit.

Confidence interval interpretation: 95% CI means if the study were repeated, 95% of intervals would contain the true effect; it is not a 95% probability that the true value lies within.

p value: probability of observing data as extreme or more extreme if the null hypothesis is true; it is not the probability that the null is true.

Sensitivity = TP/(TP + FN); specificity = TN/(TN + FP); positive predictive value depends on prevalence.

Intention-to-treat analysis preserves randomization and estimates real-world effect; per-protocol analysis can overestimate efficacy.

Meta-analysis heterogeneity: I² >50% suggests substantial heterogeneity; use random-effects models and explore sources of inconsistency.

Drug information sources: primary literature (original studies), secondary (indexing/abstracting databases), tertiary (textbooks, compendia); appraise primary literature before relying on tertiary summaries.

Iraqi pharmacy practice is regulated by the Iraqi Pharmacists Syndicate and the Ministry of Health; registration and licensure are required to practice.

Controlled substances: dispensing requires a valid prescription, secure storage, and record-keeping; narcotics are subject to stricter documentation and reporting requirements.

Prescription requirements: prescriber identity, patient identity, drug name, strength, dosage form, quantity, directions, and date; verify legality and authenticity before dispensing.

Pharmacist ethics: respect patient autonomy and confidentiality, avoid conflicts of interest, maintain competence, and report impaired practice or unsafe conditions.

Generic substitution: permitted where legally authorized and with consideration of bioequivalence, patient consent, and prescriber communication.

Adverse event and medication error reporting: pharmacists have a professional duty to report serious events through institutional and national systems.

Patient confidentiality: disclose health information only with consent or when required by law (e.g., notifiable diseases, court order, imminent harm).

Continuing education and professional development: pharmacists must maintain competence through accredited CPD and adhere to scope-of-practice rules.