Pharmacotherapy and Clinical Pharmacy
What the exam tests
Pharmacotherapy and Clinical Pharmacy tests guideline-based drug selection, patient-specific dose adjustment, monitoring, and interactions in common diseases.
Core rules
- Renal dosing often uses Cockcroft–Gault CrCl = (140 − age) × weight/(72 × SCr), ×0.85 for women. eGFR and CrCl are not interchangeable for drugs labeled with CrCl.
- Hypertension: ACE inhibitors or ARBs are preferred with diabetes or albuminuria; add a thiazide-like diuretic or calcium-channel blocker. Do not combine an ACE inhibitor with an ARB.
- Heart failure with reduced ejection fraction: foundational therapy includes an ARNI, ACE inhibitor, or ARB; an evidence-based beta-blocker; an MRA; and an SGLT2 inhibitor, titrated with renal function and potassium monitoring.
- Anticoagulation: use CHA2DS2-VASc for stroke risk in atrial fibrillation; check renal function, weight, age, and interacting drugs before choosing a DOAC dose.
Worked example
A 68-year-old woman weighs 60 kg and has SCr 1.1 mg/dL. CrCl = (140 − 68) × 60/(72 × 1.1) = 4320/79.2 = 54.5 mL/min. For a DOAC whose label uses CrCl, this value belongs to the moderate-renal-impairment band, not the severe band. However, DOAC dose reduction also depends on age and weight criteria; a single CrCl result does not automatically justify a lower dose. Document the calculation and the label criteria used.
Traps
Do not use actual body weight in obese patients without checking the label; do not confuse mg/kg/day with mg/kg/dose; do not start an MRA when potassium is above 5.0 mEq/L; and do not treat asymptomatic bacteriuria in most patients.