The liver is a central metabolic organ, and its dysfunction presents complex challenges in medication management. Hepatic disease encompasses a wide range of conditions, from viral hepatitis to the end-stage complications of cirrhosis. As detailed in the Patient Care 4 curriculum, a pharmacist’s expertise is critical in managing these patients. This includes understanding the pharmacology of hepatitis antivirals, managing the severe complications of portal hypertension and hepatic encephalopathy, and applying pharmacokinetic principles to dose medications safely in patients with liver impairment. This quiz will test your knowledge on the multifaceted management of hepatic disease.
1. Which of the following lab tests is a true marker of the liver’s synthetic function?
- a. Alanine aminotransferase (ALT)
- b. Aspartate aminotransferase (AST)
- c. Alkaline Phosphatase (Alk Phos)
- d. Albumin and Prothrombin Time/INR
Answer: d. Albumin and Prothrombin Time/INR
2. In a patient with cirrhosis, portal hypertension is the primary driver of which of the following complications?
- a. Esophageal varices and ascites
- b. Drug-induced liver injury
- c. Acute viral hepatitis
- d. Hepatocellular carcinoma
Answer: a. Esophageal varices and ascites
3. What is the primary goal of therapy with Direct-Acting Antivirals (DAAs) for Hepatitis C?
- a. To decrease AST/ALT to the normal range.
- b. To achieve a Sustained Virologic Response (SVR), which is considered a cure.
- c. To suppress the virus without eliminating it.
- d. To prevent transmission to others.
Answer: b. To achieve a Sustained Virologic Response (SVR), which is considered a cure.
4. Which class of medication is used for the primary prophylaxis of esophageal variceal bleeding?
- a. Proton Pump Inhibitors (PPIs)
- b. Non-selective beta-blockers (e.g., nadolol, propranolol)
- c. ACE Inhibitors
- d. Loop diuretics
Answer: b. Non-selective beta-blockers (e.g., nadolol, propranolol)
5. The first-line treatment for managing ascites due to cirrhosis involves:
- a. Sodium restriction and diuretic therapy with spironolactone and furosemide.
- b. Fluid restriction to less than 1 liter per day.
- c. A high-dose loop diuretic alone.
- d. Weekly large-volume paracentesis.
Answer: a. Sodium restriction and diuretic therapy with spironolactone and furosemide.
6. Lactulose is used to treat hepatic encephalopathy (HE). What is its mechanism of action?
- a. It kills ammonia-producing bacteria in the gut.
- b. It converts ammonia (NH3) to the non-absorbable ammonium ion (NH4+) and promotes its excretion.
- c. It increases the synthesis of urea in the liver.
- d. It directly counteracts the effects of ammonia in the brain.
Answer: b. It converts ammonia (NH3) to the non-absorbable ammonium ion (NH4+) and promotes its excretion.
7. The Child-Pugh score is used to:
- a. Diagnose cirrhosis.
- b. Assess the severity of liver dysfunction and help guide drug dosing.
- c. Determine the cause of viral hepatitis.
- d. Calculate the risk of developing portal hypertension.
Answer: b. Assess the severity of liver dysfunction and help guide drug dosing.
8. Which of the following is a common cause of chronic liver disease and cirrhosis in the United States?
- a. Chronic Hepatitis C infection
- b. Alcoholic liver disease
- c. Non-alcoholic fatty liver disease (NAFLD)
- d. All of the above
Answer: d. All of the above
9. A patient with cirrhosis and ascites develops a fever and abdominal pain. A diagnostic paracentesis is performed. What finding would confirm a diagnosis of Spontaneous Bacterial Peritonitis (SBP)?
- a. Ascitic fluid albumin > 2.5 g/dL
- b. Ascitic fluid PMN count > 250 cells/mm³
- c. A negative ascitic fluid culture
- d. A low serum-ascites albumin gradient (SAAG)
Answer: b. Ascitic fluid PMN count > 250 cells/mm³
10. Why is it challenging to create a simple formula for drug dosing in hepatic dysfunction, similar to the Cockcroft-Gault for renal dysfunction?
- a. The liver has only one metabolic pathway.
- b. No single lab test accurately reflects the liver’s diverse metabolic and synthetic capabilities.
- c. All drugs are metabolized by the kidneys.
- d. The liver’s function does not decline with age.
Answer: b. No single lab test accurately reflects the liver’s diverse metabolic and synthetic capabilities.
11. The “Management of Viral Hepatitis” and “Management of Portal Hypertension & Cirrhosis” are specific modules within the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
12. When using diuretics for ascites, what is the recommended starting dose ratio of spironolactone to furosemide?
- a. 25 mg to 40 mg
- b. 50 mg to 20 mg
- c. 100 mg to 40 mg
- d. 40 mg to 100 mg
Answer: c. 100 mg to 40 mg
13. Which antibiotic is commonly added to lactulose for the secondary prevention of hepatic encephalopathy?
- a. Vancomycin
- b. Metronidazole
- c. Rifaximin
- d. Ciprofloxacin
Answer: c. Rifaximin
14. What is the goal of therapy with non-selective beta-blockers in a patient with esophageal varices?
- a. To reduce the heart rate to less than 50 bpm.
- b. To reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction.
- c. To increase blood pressure.
- d. To heal the varices completely.
Answer: b. To reduce portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction.
15. A patient with severe, decompensated cirrhosis may have a low serum albumin level. How does this affect the pharmacokinetics of highly protein-bound drugs?
- a. It decreases the free (active) fraction of the drug.
- b. It increases the free (active) fraction of the drug, potentially increasing its effect and toxicity.
- c. It has no effect on protein binding.
- d. It increases the drug’s metabolism.
Answer: b. It increases the free (active) fraction of the drug, potentially increasing its effect and toxicity.
16. Which of the following hepatitis viruses is transmitted primarily through the fecal-oral route and does not cause chronic infection?
- a. Hepatitis A
- b. Hepatitis B
- c. Hepatitis C
- d. Hepatitis D
Answer: a. Hepatitis A
17. “PK Dosing in hepatic dysfunction” is a transcending concept covered in the Patient Care 4 course.
- a. True
- b. False
Answer: a. True
18. What is the mechanism of action of octreotide in the management of an acute variceal bleed?
- a. It is a potent diuretic.
- b. It causes splanchnic vasoconstriction, which reduces portal blood flow and pressure.
- c. It directly causes clot formation at the site of bleeding.
- d. It is a non-selective beta-blocker.
Answer: b. It causes splanchnic vasoconstriction, which reduces portal blood flow and pressure.
19. A patient with cirrhosis presents with asterixis (a flapping tremor of the hands). This is a classic physical exam finding for which condition?
- a. Spontaneous Bacterial Peritonitis (SBP)
- b. Ascites
- c. Hepatic Encephalopathy (HE)
- d. Esophageal varices
Answer: c. Hepatic Encephalopathy (HE)
20. Which class of Hepatitis C Direct-Acting Antivirals (DAAs) has a suffix of “-previr”?
- a. NS5B Polymerase Inhibitors
- b. NS5A Replication Complex Inhibitors
- c. NS3/4A Protease Inhibitors
- d. All of the above
Answer: c. NS3/4A Protease Inhibitors
21. A patient with ascites should be counseled to restrict their dietary intake of:
- a. Protein
- b. Potassium
- c. Sodium
- d. Fiber
Answer: c. Sodium
22. Which of the following is NOT a component of the Child-Pugh score?
- a. Serum bilirubin
- b. Serum albumin
- c. Serum creatinine
- d. Presence of ascites
Answer: c. Serum creatinine
23. The pharmacology of hepatitis antivirals is a topic covered in the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
24. The first-line treatment for Spontaneous Bacterial Peritonitis (SBP) is typically:
- a. An oral first-generation cephalosporin.
- b. An IV third-generation cephalosporin like ceftriaxone.
- c. IV vancomycin.
- d. Oral rifaximin.
Answer: b. An IV third-generation cephalosporin like ceftriaxone.
25. For drugs with a high extraction ratio (high first-pass metabolism), how will severe liver disease affect their oral bioavailability?
- a. It will decrease the bioavailability.
- b. It will have no effect.
- c. It will increase the bioavailability, potentially leading to toxicity.
- d. It will slow the rate of absorption but not the extent.
Answer: c. It will increase the bioavailability, potentially leading to toxicity.
26. Hepatitis B can be prevented with a safe and effective:
- a. Antiviral medication.
- b. Vaccine.
- c. Probiotic.
- d. Diet.
Answer: b. Vaccine.
27. What is a common side effect of lactulose therapy?
- a. Constipation
- b. Diarrhea, flatulence, and abdominal cramping
- c. Headache
- d. Hypertension
Answer: b. Diarrhea, flatulence, and abdominal cramping
28. What is the goal of diuretic therapy in ascites?
- a. To achieve a rapid weight loss of 5 kg per day.
- b. To achieve a gradual weight loss (e.g., ~0.5 kg/day) and relieve symptoms without causing renal dysfunction.
- c. To cure the underlying cirrhosis.
- d. To increase serum sodium levels.
Answer: b. To achieve a gradual weight loss (e.g., ~0.5 kg/day) and relieve symptoms without causing renal dysfunction.
29. A patient with cirrhosis has an elevated INR of 2.0 in the absence of warfarin therapy. This indicates:
- a. The patient is at high risk for clotting.
- b. Impaired synthetic function of the liver.
- c. An active infection.
- d. The lab result is an error.
Answer: b. Impaired synthetic function of the liver.
30. The management of drug interactions is a key topic in the hepatic disease module.
- a. True
- b. False
Answer: a. True
31. Which of the following drugs is known to have significant potential for drug-induced liver injury (DILI), especially in overdose?
- a. Penicillin
- b. Acetaminophen
- c. Metformin
- d. Lisinopril
Answer: b. Acetaminophen
32. The term “SVR12” in Hepatitis C treatment means:
- a. The patient’s virus is resistant.
- b. Sustained Virologic Response (undetectable HCV RNA) at 12 weeks post-treatment.
- c. The treatment course lasts 12 months.
- d. The patient’s Child-Pugh score is 12.
Answer: b. Sustained Virologic Response (undetectable HCV RNA) at 12 weeks post-treatment.
33. In a patient with ascites, what is the rationale for the specific 100:40 ratio of spironolactone to furosemide?
- a. It is easier to remember.
- b. It helps maintain normokalemia by balancing the potassium-sparing effect of spironolactone with the potassium-wasting effect of furosemide.
- c. It minimizes the risk of renal failure.
- d. This ratio provides the most potent diuresis.
Answer: b. It helps maintain normokalemia by balancing the potassium-sparing effect of spironolactone with the potassium-wasting effect of furosemide.
34. A patient with a history of hepatic encephalopathy should be counseled to avoid:
- a. A high-protein diet.
- b. Constipation.
- c. Sedating medications like benzodiazepines and opioids.
- d. All of the above.
Answer: d. All of the above.
35. An elevated AST and ALT in the thousands is most characteristic of:
- a. Chronic, stable cirrhosis.
- b. Acute liver injury (e.g., from a virus or drug overdose).
- c. Cholestatic liver disease.
- d. Normal liver function.
Answer: b. Acute liver injury (e.g., from a virus or drug overdose).
36. A patient with Child-Pugh Class C cirrhosis has:
- a. Mild, well-compensated liver disease.
- b. Moderate liver disease.
- c. Severe, decompensated liver disease.
- d. Normal liver function.
Answer: c. Severe, decompensated liver disease.
37. The “-asvir” suffix is characteristic of which class of Hepatitis C DAAs?
- a. NS3/4A Protease Inhibitors
- b. NS5B Polymerase Inhibitors
- c. NS5A Replication Complex Inhibitors
- d. All of the above
Answer: c. NS5A Replication Complex Inhibitors
38. The serum-ascites albumin gradient (SAAG) is used to:
- a. Diagnose SBP.
- b. Determine the cause of ascites (portal hypertension vs. other causes).
- c. Guide diuretic dosing.
- d. Assess a patient’s nutritional status.
Answer: b. Determine the cause of ascites (portal hypertension vs. other causes).
39. All patients diagnosed with cirrhosis should be screened for what complication?
- a. Gallstones
- b. Peptic ulcer disease
- c. Esophageal varices
- d. Pancreatitis
Answer: c. Esophageal varices
40. A facilitated case discussion on cirrhosis is part of the Patient Care 4 course.
- a. True
- b. False
Answer: a. True
41. Which of the following is NOT a complication of portal hypertension?
- a. Ascites
- b. Varices
- c. Hepatic encephalopathy
- d. Acute cholecystitis
Answer: d. Acute cholecystitis
42. For patients who have survived an episode of SBP, what is recommended?
- a. No further treatment is needed.
- b. Long-term antibiotic prophylaxis (e.g., with ciprofloxacin or TMP/SMX).
- c. A liver transplant within 30 days.
- d. Daily paracentesis.
Answer: b. Long-term antibiotic prophylaxis (e.g., with ciprofloxacin or TMP/SMX).
43. The “-buvir” suffix is characteristic of which class of Hepatitis C DAAs?
- a. NS3/4A Protease Inhibitors
- b. NS5B Polymerase Inhibitors
- c. NS5A Replication Complex Inhibitors
- d. All of the above
Answer: b. NS5B Polymerase Inhibitors
44. The most important intervention to prevent the progression of alcoholic liver disease is:
- a. Starting a non-selective beta-blocker.
- b. A low-sodium diet.
- c. Complete abstinence from alcohol.
- d. A course of DAAs.
Answer: c. Complete abstinence from alcohol.
45. What is the role of albumin infusion during a large-volume paracentesis (>5 liters)?
- a. To provide nutrition.
- b. To prevent post-paracentesis circulatory dysfunction and renal impairment.
- c. To treat the underlying cirrhosis.
- d. To increase the patient’s blood pressure.
Answer: b. To prevent post-paracentesis circulatory dysfunction and renal impairment.
46. Which hepatitis virus requires co-infection with Hepatitis B to replicate?
- a. Hepatitis A
- b. Hepatitis E
- c. Hepatitis D
- d. Hepatitis C
Answer: c. Hepatitis D
47. The primary goal of managing chronic Hepatitis B is:
- a. Complete eradication of the virus (cure).
- b. Lifelong suppression of HBV DNA to undetectable levels to prevent disease progression.
- c. To boost the immune system.
- d. To prevent co-infection with Hepatitis C.
Answer: b. Lifelong suppression of HBV DNA to undetectable levels to prevent disease progression.
48. A patient on a non-selective beta-blocker for variceal prophylaxis should have their dose titrated to a goal:
- a. Systolic blood pressure >140 mmHg.
- b. Diastolic blood pressure >90 mmHg.
- c. Heart rate of 55-60 beats per minute, as tolerated.
- d. Heart rate >100 beats per minute.
Answer: c. Heart rate of 55-60 beats per minute, as tolerated.
49. An active learning session on cirrhosis and hepatitis is part of the Patient Care 4 course.
- a. True
- b. False
Answer: a. True
50. The pharmacist’s role in managing hepatic disease is crucial for:
- a. Dosing adjustments of medications.
- b. Screening for drug-drug interactions.
- c. Counseling patients on complex regimens and lifestyle modifications.
- d. All of the above.
Answer: d. All of the above.