Seuenth Edition Appleton & Lange's Review of PHARMACY Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in ac- cord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to ad- minister to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindica- tions for administration. This recommendation is of particular importance in con- nection with new or infrequently used drugs. Seuenth Edition Appleton & Lange's Review of PHA Cy Gary D. Hall, MS Professor of Pharmaceutics Albany College of Pharmacy Union University Albany, New York Barry S. Reiss, PhD Professor Emeritus Albany College of Pharmacy Union University Albany, New York Appleton & Lange Reviews/McGraw-Hill Medical Publishing Division New York St. Louis San Francisco Auckland Bogota Caracas Lisbon London Madrid Mexico City Milan Montreal New Delhi San Juan Singapore Sydney Tokyo Toronto McGraw-Hill l!Z A Division ofTheMcGraw-Hill Companies Appleton & Lange's Review of Pharmacy, Seventh Edition Copyright © 2001 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permis- sion of the publisher. Previous editions copyright © 1997,1993,1990,1985 by Appleton & Lange; © 1980, 1976 by Arco Publishing, Inc. 1234567890 QPD/QPD 09876543210 ISBN 0-07-136088-3 (domestic) This book was set in Palatino by Rainbow Graphics. The editor was Patricia Casey. The production supervisor was MinaI Bopaiah. Project management was provided by Rainbow Graphics. The cover designer was Elizabeth Schmitz. Quebecor Printing/Dubuque was printer and binder. This book is printed on acid-free paper. NAPLEX is a federally registered trademark owned by the National Association of Boards of Pharmacy (NABP) and this review guide is in no way authorized or sponsored by the NABP. Library of Congress Cataloging-in-Publication Data Hall, Gary D. Appleton & Lange's review of pharmacy / Gary D. Hall, Barry S. Reiss.-7th ed. p.;cm. Includes bibliographical references and index. ISBN 0-07-136088-3 (pbk.) 1. Pharmacy-Examinations, questions, etc. 1. Title: Appleton and Lange's review of pharmacy. 11. Title: Review of pharmacy. Ill. Title: Pharmacy. IV. Reiss, Barry S., 1944- V. Title. [DNLM: 1. Pharmacy-Examination Questions. QV 18.2 H176a 2000] RS97 .H35 2000 615' .1'076-dc21 00-041838 ISBN 0-07-118224-1 (international edition) Exclusive rights by The McGraw-Hill Companies, Inc. for manufacture and export. This book cannot be re-exported from the country to which it is consigned by McGraw-Hill. The International Edition is not available in North America. Contents Preface vii Acknowledgments .ix How to Use This Book xi Professional Competence in Pharmacy xi Computer-Based Examination xii Helpful Hints xii References xvii 1. Pharmacology 1 Questions 2 Answers and Explanations 23 2. Pharmaceutical Calculations 39 Questions 40 Answers and Explanations 49 3. Pharmacy 59 Questions 60 Answers and Explanations 90 4. Pharmaceutical Compounding 117 Questions 118 Answers and Explanations 133 5. Biopharmaceutics and Pharmacokinetics 145 Questions 146 Answers and Explanations 158 6. Pharmaceutical Care 169 Questions 170 Answers and Explanations 196 7. Patient Profiles 215 Questions 216 Answers and Explanations 293 v vi Contents 8. Practice Test 321 Questions 322 Answers 334 Appendix A-Frequently Dispensed Drugs 335 Appendix B-Brand Names (Trade Names) Versus Generic Names .343 Preface Pharmacy licensing examinations are designed to determine whether a candidate has the requisite ability to enter and then carry out the responsibili- ties of the profession. A candidate preparing for the licensing examination must be prepared to demon- strate competence in many areas, anyone of which may be the subject for in-depth questioning. This book is designed as a self-testing tool for the pharmacy student to identify individual areas of strength and weakness, to suggest areas for fur- ther review, and to impart new concepts and other information useful to both the student and the practicing pharmacist. The book consists of three major sections: Chapters 1 through 6 concentrate on specific disciplines in order to improve the stu- dent's competence in each. Within each chapter, some questions dealing with related subject matter have been grouped together, whereas others have intentionally not been categorized, necessitating a return to certain areas of study in later questions to reinforce prior learning. In each chapter, questions are followed by an Answers and Explanations sec- tion, which we think is the keystone of our book. Some comments are quite extensive and represent miniature reviews, whereas others are limited to brief specifics. In every instance, the cited refer- ences offer a way for more extensive review. Chapter 7 consists of patient profiles, each ac- companied by a series of related questions. Infor- mation obtained from the questions and commen- taries in Chapters 1 through 6 will probably aid in answering questions in Chapter 7. The final section, Chapter 8, is a practice exami- nation to test the reader who has faithfully com- pleted all of the previous material. A self-assessment disk is included in the Sev- enth Edition and helps in preparing you for the computerized format of the NAPLEX. A descrip- tion of the computer-based examination is pro- vided on page xii. There are also two appendices: the first lists more than 200 drugs by generic names that the au- thors consider most likely to be dispensed by phar- macists. Included in the table are trade or brand names, manufacturing companies, a brief descrip- tion of therapeutic uses, and common dosage forms and strengths. It is NOT necessary to memorize the name of the company manufacturing a certain product, especially with the numerous company name changes. However, many individuals find it easier to relate a trade name to a company. To com- plete the cycle, the second appendix serves as a cross-reference of trade names with generic names. We trust that this book will not be viewed as simply a means to review material for the licensing examination. Passing this examination does not guarantee continued competence throughout a long professional career. Practicing pharmacists must not only retain their previously acquired knowledge and skill, but must remain up to date on contemporary modes of practice. We hope that this book will serve both as a means for self- assessment of competence to practice as well as a valuable guided review. A statement listing professional competency in pharmacy originally prepared by the California State Board of Pharmacy appears on page xi. Many of the test items in this book relate to these competencies. vii Acknowledgments We would like to thank Trish Casey, Editor, at Mc- Graw-Hill for her editorial guidance throughout the development of this newly revised edition. We would also like to thank all pharmacy students, past, present, and future, who aspire to excel in their chosen profession. Gary D. Hall, MS Barry S. Reiss, PhD ix How to Use This Book Professional Competence in Pharmacy A competent pharmacist is one who is able to con- fer with a physician about the care and treatment of his or her patient. The pharmacist should appreci- ate the essentials of the clinical diagnosis and un- derstand the medical management of the patient. He or she should also be informed about the drugs that may be used in the treatment of the patient- their mechanism of action; their combinations and dosage forms; the fate and disposition of the drugs (if known); the factors that may influence the phys- iological availability and biological activity of the drugs from their dosage forms; how age, sex, or secondary disease states might influence the course of treatment; and how other drugs, foods, and di- agnostic procedures may interact to modify the ac- tivity of the drug. A competent pharmacist is one whose overall function is to ensure optimum drug therapy. He or she should know the appropriate indications and dosage regimen for the drug therapy being under- taken as well as the contraindications and potential untoward reactions that may result during therapy. He or she should also be informed as to the propri- etary products that might interact adversely with or be useful adjuncts to drug therapy, facilitating administration or improving overall patient care. A competent pharmacist must be aware of the proposed therapeutic actions of proprietary med- ications, their composition, and any unique appli- cations or potential limitations of their dosage forms. He or she should be able to objectively ap- praise advertising claims. At the patient's request, he or she should be able to ascertain the probable therapeutic usefulness of a certain drug in resolv- ing the patient's complaints. A competent pharmacist should be able to re- view a scientific publication and summarize the practical implications of the findings as they may relate to the clinical use of drugs. He or she should be able to analyze a published report of a clinical trial in terms of the appropriateness of the study design and the validity of the statistical analysis, and should be able to prepare an objective sum- mary of the significance of the data and the au- thors' conclusions. A competent pharmacist is a specialist as to the stability characteristics and storage requirements of drugs and drug products, the factors that influence the release of drugs from dosage forms, and the ef- fect of the site of administration or its environment within the body on the absorption of a drug from the administered dosage form. Most importantly, the pharmacist understands the effect of the inter- action of all these factors on the onset, intensity or duration of therapeutic action. A competent pharmacist should be precisely in- formed as to the legal limitations on procurement, storage, distribution, and sale of drugs; the ap- proved use of a drug as specified by federal author- ities and acceptable medical practice; and his or her legal responsibilities to the patient when drugs are used in experimental therapeutic procedures. A competent pharmacist should be able to rec- ommend the drug and dosage form that are most likely to fulfill a particular therapeutic need, sup- porting his or her choice objectively with appropri- ate source material. In addition, he or she should be capable of identifying a drug, within a reasonable period of time, on the basis of its color, shape, and proposed use, as described in reference books or other sources. On the basis of symptoms described in an inter- view with the patient, a competent pharmacist should know what additional information he or she must obtain from the patient. Based on this in- xi xii How to Use This Book formation, he or she should be able to refer the pa- tient to the proper medical practitioner, specialist, or agency that would be of most help. A competent pharmacist should be aware of drug toxicities, as well as the most effective means of treatment for them. A competent pharmacist should be able to in- struct patients on the proper administration of pre- scription and proprietary drugs. He or she should know which restrictions should be placed on food intake, other medication, and physical activity. A competent pharmacist should be able to com- municate with other healthcare professionals or laymen on appropriate subjects, ensuring that the recipient understands the contents of the message being communicated. A competent pharmacist should be capable of compounding appropriate drugs or drug combina- tions in acceptable dosage forms. Finally, a competent pharmacist is a person who takes appropriate measures to maintain his or her level of competency in each of the areas de- scribed above. Computer-Based Examinations Following the lead of the nursing profession, many professions have reorganized their entry-level pro- fessional examinations to a computer-adaptive test (CAT) format. Qualified candidates have the op- portunity to take their exam almost anytime during the year. The actual exam format is similar to previ- ous examinations. For pharmacy, this involves the use of patient profiles followed by a series of ques- tions that mayor may not require reviewing the patient's profile. Using the computer keyboard or mouse, the candidate can scroll back to the profile for any needed information to answer a specific question. The questions will be presented one at a time and must be answered in sequence-that is, one may not skip or skim questions with the inten- tion of returning to them later. Also, once the candi- date has selected an answer and entered it into the computer, it is NOT possible to retrieve the answer and make changes. Be sure that you are satisfied with your answer before entering it into the com- puter. Once entered, forget about that question even if later questions lead you to believe that you gave a wrong answer. Remember that no one is expected to answer all questions correctly. Instead, the examining body has set reasonable goals based on both easy and more difficult questions or concepts. The examina- tion is designated as a "computer-adaptive" test because the system evaluates each individual can- didate by varying the question difficulty depend- ing on the candidate's response to previous ques- tions. Thus, different candidates at the same testing site may be answering different questions of vary- ing difficulty. The scoring will be based at least par- tially on the number of questions answered cor- rectly and the relative level of question difficulty. When preparing for computer-based exams, the candidate should review material in the exact man- ner as for any other examination. It is suggested that the candidate participate in any tutorial ses- sion offered at the exam site just prior to the actual examination. These sessions will include instruc- tion in the mechanics of operating the computer system being used. However, any anxiety about the use of the computer will soon be overcome once the exam has started. In addition, you are likely to benefit by receiving your grade and pharmacist li- cense much earlier! Helpful Hints There are several ways to maximize learning from this review book. For example, the reader could an- swer a short series of questions before looking for the answers at the end of each chapter. Keeping score will make these chapters function as minia- ture tests. Unfortunately, when challenged by mul- tiple-choice questions, even in the nonthreatening environment of a self-learning program, our behav- ioral response is often predictable. When more than 75% of the questions are answered correctly, satis- faction and confidence dominate. As the percent- age of missed questions increases, frustration and even panic develop. Such reactions lead to a self- limiting response: namely, the quick memorization of answers. Keep in mind, however, that although you may have increased your knowledge by one fact, you may not have maximized your learning experience. Do you really expect to see the same question on another examination? Do you realize why the other answer choices are not correct? Have you read the explanations of all the questions, even those you answered correctly? Hopefully, these ex- planations will contain additional tidbits of infor- mation that will increase your knowledge base. If the question mentions a drug with which you are not familiar, be sure to look up the drug in one of the reference sources at your disposal. The next time you see that drug may be when it is the sub- ject of a question. Some questions may concern top- ics with which you are not familiar. This is a perfect opportunity for learning! How to Use This Book xiii Rather than blindly guessing at the answers, seek information in the cited reference or other sources and then attempt to answer the question. If your answer does not agree with the one given in this book, check further in another source. Keep digging-learning cannot be passive. Recognize that a question stating "which of these does NOT" or "all of these EXCEPT" gives you four positive facts or statements. These, in themselves, have ex- panded your knowledge base. xiii References The references listed represent a small number of source material that is available in most pharmacy libraries or represent a collection that any pharma- cist or pharmacy student could accumulate during a career in pharmacy. Because of the increasing costs and frequent issuing of new editions, the au- thors of Appleton & Lange's Review ofPharmacy have attempted to limit the total number of books but re- alize that there are many other textbooks contain- ing similar material. To maintain an up-to-date per- sonal library, the reader should obtain at least a general pharmaceutical science book (eg, Ref. 1 or 24), a pharmacology book (Ref. 6 being the classic), a book with a clinical pharmacy orientation, and a book devoted to discussions of drug therapy in managing certain disease states (Refs. 5 and 16). To keep current with new drugs, drug products, and recent developments in drug therapy, it is neces- sary to have publications that are updated periodi- cally (monthly for Ref. 3 and yearly for Refs. 9 and 25.) Notice that the last line of each explanation of answers includes a number identifying the refer- ence source used for each question. The first num- ber in the cited reference indicates the reference source used and usually the second number pro- vides the exact page. For example (1:825; 23:84) refers to page 825 in Ref. 1, Remington: The Science and Practice of Pharmacy, and page 84 in Ref. 23, Stoklosa's Pharmaceutical Calculations. The USP/DI has been cited as three sources (18a, 18b, and 18c), reflecting the three volumes that make up this se- ries. Reference 4 (Thompson) has been cited as 4:22.5 in which 22 represents the chapter and 5 the page in that chapter. 1. Gennaro AR. Remington: The Science and Prac- tice of Pharmacy. 19th ed. Easton, PA: Mack Publishing Co., 1995. 2a. American Pharmaceutical Association. Hand- book of Nonprescription Drugs. 11th ed. Wash- ington, DC: American Pharmaceutical Associ- ation, 1996. 2b. American Pharmaceutical Association. Non- prescription Products: Formulations & Features '98-99. Washington, DC: American Pharma- ceutical Association, 1998. 3. Kastrup EK, Olin BR. Facts and Comparisons. Philadelphia, PA: Facts and Comparisons Di- vision, JB Lippincott Co, 2000. 4. Thompson JE. A Practical Guide to Contempo- rary Pharmacy Practice. Baltimore, MD: Williams & Wilkins, 1998. 5. Dipiro JT, et al. Pharmacotherapy. 4th ed. Stam- ford, CT: Appleton & Lange, 1999. 6. Hardman JG, Limbird LE. Goodman and Gilman's Pharmacological Basis of Therapeutics. 9th ed. New York, NY: McGraw-Hill, 1996. 7. Katzung BG. Basic & Clinical Pharmacology. 7th ed. Norwalk, CT: Appleton & Lange, 1997. 8. Tatro DS. Drug Interactions Facts. JB Lippincott Co, 1998. 9. AHFS Drug Information 99. Bethesda, MD: American Society of Health-System Pharma- cists, 1999. 10. Product literature drug package inserts cur- rent in 2000. 11. Pray WS. Nonprescription Product Therapeutics. Philadelphia, PA: Lippincott Williams & Wilkins, 1999. 12. Martin A. Physical Pharmacy. 4th ed. Philadel- phia, PA: Lea & Febiger, 1993. 13. Turco SJ. Sterile Dosage Forms. 4th ed. Philadel- phia, PA: Lea & Febiger, 1994. xv