North American Pharmacist Licensure Examination (NAPLEX) Pharmacotherapy and Disease State Management Syllabus

Which patients with hospitalized acute medical illness should receive pharmacologic VTE prophylaxis, and with what agents?

Acutely ill patients with elevated VTE risk and low bleeding risk; use low-dose unfractionated heparin, LMWH (enoxaparin), or fondaparinux.

What is the standard treatment-dose enoxaparin regimen for acute VTE?

$1$ mg/kg subcutaneously every $12$ hours, or $1.5$ mg/kg subcutaneously once daily.

How long is anticoagulation typically continued for a first provoked VTE versus an unprovoked VTE?

Provoked VTE (transient risk factor): $3$ months. Unprovoked VTE: at least $3$ months, often indefinite if bleeding risk is low.

How must enoxaparin be dose-adjusted in severe renal impairment (CrCl $< 30$ mL/min)?

Reduce treatment dosing to $1$ mg/kg subcutaneously once daily because enoxaparin is renally cleared and accumulates.

What is the Cockcroft-Gault equation used for estimating creatinine clearance?

$$\text{CrCl} = \frac{(140 - \text{age}) \times \text{weight (kg)}}{72 \times \text{SCr}} \times (0.85 \text{ if female})$$ where SCr is serum creatinine in mg/dL.

How are the CKD G (GFR) stages defined by eGFR?

G1 $\geq 90$, G2 $60$–$89$, G3a $45$–$59$, G3b $30$–$44$, G4 $15$–$29$, G5 $< 15$ mL/min/$1.73\,\text{m}^2$.

Which oral diabetes agents should be avoided or stopped in advanced CKD, and at what eGFR is metformin contraindicated?

Metformin is contraindicated at eGFR $< 30$ mL/min/$1.73\,\text{m}^2$ (do not initiate $< 45$); avoid most sulfonylureas like glyburide due to hypoglycemia from accumulation.

What HbA1c value defines diabetes, and what range defines prediabetes?

Diabetes: HbA1c $\geq 6.5\%$. Prediabetes: HbA1c $5.7$–$6.4\%$.

What is the first-line pharmacologic agent for type 2 diabetes, and what serious adverse effect must be monitored?

Metformin; monitor for lactic acidosis (especially in renal impairment, hypoxia, or contrast use) and vitamin $B_{12}$ deficiency with long-term use.

Which two diabetes drug classes have proven cardiovascular and renal benefit and are preferred in patients with ASCVD, HF, or CKD?

SGLT2 inhibitors (e.g., empagliflozin) and GLP-1 receptor agonists (e.g., semaglutide, liraglutide).

What fasting plasma glucose and 2-hour OGTT values establish a diagnosis of diabetes?

Fasting plasma glucose $\geq 126$ mg/dL, or 2-hour OGTT glucose $\geq 200$ mg/dL, or random glucose $\geq 200$ mg/dL with symptoms.

What is the mechanism of SGLT2 inhibitors and a characteristic adverse effect?

They block glucose reabsorption in the proximal tubule, increasing urinary glucose excretion; characteristic adverse effects include genital mycotic infections and euglycemic DKA.

What laboratory triad defines diabetic ketoacidosis (DKA)?

Hyperglycemia (usually $> 250$ mg/dL), anion-gap metabolic acidosis (pH $< 7.30$, $\ce{HCO3-} < 18$ mEq/L), and ketonemia/ketonuria.

How does HHS (hyperosmolar hyperglycemic state) differ from DKA in glucose, ketones, and osmolality?

HHS shows much higher glucose (often $> 600$ mg/dL), minimal ketones, no significant acidosis (pH $> 7.30$), and serum osmolality $> 320$ mOsm/kg.

Why must potassium be monitored and often replaced before insulin therapy in DKA?

Insulin drives $\ce{K+}$ intracellularly; if serum $\ce{K+} < 3.3$ mEq/L, hold insulin and replace potassium first to prevent fatal hypokalemia and arrhythmia.

What is the role of basal-bolus insulin in type 1 diabetes management?

Type 1 patients require exogenous insulin: a long-acting basal insulin (e.g., glargine, degludec) plus rapid-acting bolus insulin (e.g., lispro, aspart) at meals to mimic physiologic secretion.

What laboratory pattern is seen in primary hypothyroidism?

Elevated TSH with low free $T_4$. The free $T_4$ is low because reduced thyroid output triggers compensatory TSH rise.

What is the first-line treatment for hypothyroidism and how should it be administered?

Levothyroxine ($T_4$), taken on an empty stomach $30$–$60$ minutes before breakfast, separated from calcium, iron, and antacids that impair absorption.

What laboratory pattern characterizes primary hyperthyroidism (e.g., Graves disease)?

Suppressed (low) TSH with elevated free $T_4$ and/or $T_3$.

Which antithyroid drug is preferred in the first trimester of pregnancy and which in later pregnancy?

Propylthiouracil (PTU) is preferred in the first trimester; methimazole is preferred in the second and third trimesters (avoid PTU later due to hepatotoxicity).

What is the cortisol/biochemical hallmark of primary adrenal insufficiency (Addison disease)?

Low cortisol with high ACTH, often with hyponatremia and hyperkalemia; confirmed by an inadequate cortisol rise on the cosyntropin (ACTH) stimulation test.

Using corticosteroid equivalence, how many mg of prednisone equal 20 mg of hydrocortisone?

$5$ mg prednisone $=$ $20$ mg hydrocortisone (both anti-inflammatory equivalents); $0.75$ mg dexamethasone is also equivalent.

Rank hydrocortisone, prednisone, and dexamethasone by mineralocorticoid (sodium-retaining) activity.

Hydrocortisone has high mineralocorticoid activity, prednisone has low, and dexamethasone has essentially none.

What FRAX-based or T-score criteria define osteoporosis and warrant pharmacologic therapy?

Osteoporosis is a DXA T-score $\leq -2.5$, a fragility hip/vertebral fracture, or osteopenia (T-score $-1.0$ to $-2.5$) with high FRAX 10-year fracture probability.

What are the administration instructions for oral bisphosphonates to maximize absorption and prevent esophagitis?

Take on an empty stomach with a full glass of plain water, then remain upright and fasting for at least $30$ minutes (60 for ibandronate).

What is the mechanism of denosumab and a key counseling point about discontinuation?

Denosumab is a RANK ligand inhibitor that decreases osteoclast activity; abrupt discontinuation causes rapid bone loss and rebound vertebral fractures, so transition to another agent is needed.

Which oral antibiotics provide reliable coverage of MRSA for skin and soft tissue infections?

Trimethoprim-sulfamethoxazole, doxycycline, clindamycin, and linezolid.

What is the empiric IV agent of choice for serious MRSA infections, and what therapeutic monitoring parameter is used?

Vancomycin, monitored by an AUC/MIC ratio target of $400$–$600$ (or trough $15$–$20$ mcg/mL) to balance efficacy and nephrotoxicity.

Which antibiotic classes cover Pseudomonas aeruginosa?

Antipseudomonal beta-lactams (piperacillin-tazobactam, cefepime, ceftazidime, meropenem), aztreonam, fluoroquinolones (cipro/levofloxacin), and aminoglycosides.

What is the recommended empiric outpatient regimen for community-acquired pneumonia in a previously healthy adult with no comorbidities?

Amoxicillin high-dose, OR doxycycline, OR a macrolide (azithromycin) where pneumococcal macrolide resistance is low.

What is the first-line oral agent for uncomplicated cystitis, and what is a key contraindication?

Nitrofurantoin; it is contraindicated when CrCl $< 30$ mL/min due to inadequate urinary concentration and toxicity risk. Other options are TMP-SMX and fosfomycin.

In sepsis management, within what time window should broad-spectrum antibiotics be administered, and what is the initial fluid resuscitation?

Antibiotics within $1$ hour of recognition; initial crystalloid bolus of $30$ mL/kg for sepsis-induced hypotension or lactate $\geq 4$ mmol/L.

Which vasopressor is first-line for septic shock unresponsive to fluids?

Norepinephrine is the first-line vasopressor for septic shock.

What is the drug of choice for invasive candidiasis/candidemia in most hospitalized patients?

An echinocandin (caspofungin, micafungin, or anidulafungin).

What is the mechanism of azole antifungals and a major clinical caution?

Azoles inhibit fungal CYP450 ($14\alpha$-demethylase), blocking ergosterol synthesis; caution is needed because they are potent CYP3A4 inhibitors causing many drug interactions, plus QT prolongation and hepatotoxicity.

Which antiviral is first-line for herpes simplex and varicella-zoster infections, and what is its key toxicity?

Acyclovir (or valacyclovir); key toxicity is crystalline nephropathy, prevented with adequate hydration and slow IV infusion.

What is the preferred first-line antiretroviral regimen class combination for treatment-naive HIV patients?

An integrase strand transfer inhibitor (INSTI, e.g., bictegravir or dolutegravir) plus two NRTIs (e.g., tenofovir alafenamide/emtricitabine).

What regimens are used for HIV pre-exposure prophylaxis (PrEP)?

Oral tenofovir/emtricitabine (TDF/FTC or TAF/FTC) daily, or long-acting injectable cabotegravir every $2$ months.

What is the standard four-drug intensive-phase regimen (RIPE) for active tuberculosis?

Rifampin, Isoniazid, Pyrazinamide, and Ethambutol for the initial $2$ months, followed by rifampin + isoniazid for $4$ months.

Why is pyridoxine (vitamin $B_6$) co-administered with isoniazid?

Isoniazid increases pyridoxine excretion and can cause peripheral neuropathy; supplemental pyridoxine prevents it.

What are two preferred shorter regimens for latent tuberculosis infection?

Once-weekly isoniazid plus rifapentine for $12$ weeks (3HP), or daily rifampin for $4$ months (4R); isoniazid alone for $6$–$9$ months is an alternative.

What characteristic adverse effect distinguishes ethambutol among the anti-TB drugs?

Optic neuritis causing decreased visual acuity and red-green color discrimination loss; visual function must be monitored.