NRNP 6566 ss
Key Concepts Week 1 to 5 WITH COMPLETE SOLUTION 2026, 100%CORRECT
ss ss ss ss ss ss ss ss ss ss
Week 1
ss
1. Describe the cytochrome P450 system. Describe how inducers and inhibitors affect
ss ss ss ss s s ss ss ss ss ss
the cytochrome system and how that affects the half-life of medications.
ss ss ss ss ss ss ss ss ss ss ss
a. Cytochrome p450 system is a series of enzymes used to metabolize medications. ss ss ss ss ss ss ss ss ss ss ss
b. Drugs that cause CYP450 metabolic drug interactions are referred to as either inhibitors
ss ss ss ss ss ss ss ss ss ss ss ss
or inducers. Inducers increase CYP450 enzyme activity by increasing enzyme
ss ss ss ss ss ss ss ss ss ss
synthesis ss
c. Inhibitors block the metabolic activity of one or more CYP450 enzymes ss ss ss ss ss ss ss ss ss ss
2. Describe the affect on low and high albumin levels on active drug levels especially for drugs
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
that are highly protein bound.
ss ss ss ss ss
a. Albumin is the plasma protein with the greatest capacity for binding drugs.
ss ss ss ss ss ss ss ss ss ss ss
i. Binding to plasma proteins affects drug distribution into tissues, because only ss ss ss ss ss ss ss ss ss ss
drug that is not bound is available to penetrate tissues, bind to receptors, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
exert activity. As free drug leaves the bloodstream, more bound drug is released
ss ss ss ss ss ss ss ss ss ss ss ss ss
from binding sites. ss ss ss
b. Highly protein bound drugs, low albumin levels (w/ malnutrition, or chronic illness)
ss ss ss ss ss ss ss ss ss ss ss
may lead to toxicity because there are fewer than the normal sites for the drug to bind
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
3. Describe ways to lessen the hepatic first pass effect: metabolism during first pass through the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
liver
ss
a. Alternative routes (suppository, intravenous, intramuscular, inhalational aerosol, ss ss ss ss ss ss
transdermal, and sublingual) avoid the first-pass effect allow drugs to be absorbed
ss ss ss ss ss ss ss ss ss ss ss ss ss
directly into the systemic circulation
ss ss ss ss ss
4. Be able to calculate creatinine clearance using the Cockgraft Gault equiation:
ss ss ss ss ss ss ss ss ss ss
a. Male = ([140-age] × weight in kg)/(serum creatinine × 72)
ss s s ss ss ss ss ss ss ss ss
b. Female = CrCl (male) × 0.85 ss ss ss ss ss ss
5. Describe what determines the frequency of drug administration:
ss ss ss ss ss ss ss
a. Drug half-life, plasma concentration ss ss ss
6. Be familiar with the Beers criteria and how to use it:
ss ss ss ss ss ss ss ss ss ss
a. Potentially Inappropriate Medication Use in Older Adults ss ss ss ss ss ss
i. to call attention to medications that are commonly problematic, and thus should
ss ss ss ss ss ss ss ss ss ss ss
be avoided in most older adults ss ss ss ss ss ss
7. Describe factors that affect absorption, distribution, metabolism and excretion:
ss ss ss ss ss ss ss ss
a. Absorption low blood state (shock or arrest); contact time with GI tract too fast ss ss ss ss ss ss ss ss ss ss ss ss ss ss
(diarrhea = can’t absorb); delayed stomach emptying (large meal = delayed
ss ss ss ss ss ss ss ss ss ss ss
absorption); drug-drug or drug-food interactions
ss ss ss ss ss
b. Metabolism genetics, age, organ function ss ss ss ss ss
c. Distribution low albumin levels, body composition, cardiac decomp (HF), and age ss ss ss ss ss ss ss ss ss ss ss
d. Excretion affected by abnormal kidney or liver function; age, drug interactions ss ss ss ss ss ss ss ss ss ss ss
8. Define narrow therapeutic index How would you monitor a patient with a narrow
ss ss ss s s ss ss ss ss ss ss ss ss
therapeutic index?
ss ss
, a. Therapeutic index: dose range where efficacy of med is optimized while side effects
ss ss ss ss ss ss ss ss ss ss ss ss
minimized
ss
b. Narrow therapeutic index (NTI) drugs are defined as those drugs where small
ss ss ss ss ss ss ss ss ss ss ss
differences in dose or blood concentration may lead to dose and blood
ss ss ss ss ss ss ss ss ss ss ss ss
concentration dependent, serious therapeutic failures or adverse drug reactions.
ss ss ss ss ss ss ss ss ss
c. Blood tests to monitor blood concentrations and dose adjustments accordingly
ss ss ss ss ss ss ss ss ss
9. Describe how aging affect absorption, distribution, metabolism, and excretion
ss ss ss ss ss ss ss ss
a. Decreased organ function, poorly tolerate drugs that require metabolism, lower rates of
ss ss ss ss ss ss ss ss ss ss ss
excretion
ss
b. decrease in small-bowel surface area, slowed gastric emptying, and an increase in
ss ss ss ss ss ss ss ss ss ss ss
gastric pH, changes in drug absorption
ss ss ss ss ss ss
c. With age, body fat generally increases and total body water decreases. Increased fat
ss ss ss ss ss ss ss ss ss ss ss ss
increases the volume of distribution for highly lipophilic drugs
ss ss ss ss ss ss ss ss ss
(eg, diazepam, chlordiazepoxide) and may increase their elimination half-lives.
ss ss ss ss ss ss ss ss
d. Serum albumin decreases and alpha 1-acid glycoprotein increases
ss ss ss ss ss ss ss
i. Phenytoin and warfarin are examples of drugs with a higher risk of toxic effects ss ss ss ss ss ss ss ss ss ss ss ss ss
when the serum albumin level decreases
ss ss ss ss ss ss
e. hepatic metabolism of many drugs through the cytochrome P-450 enzyme system
ss ss ss ss ss ss ss ss ss ss
decreases with age. For drugs with decreased hepatic metabolism clearance
ss ss ss ss ss ss ss ss ss ss
typically decreases 30 to 40%.
ss ss ss ss ss
i. Drugs metabolized in phase 1 reactions likely prolonged ss ss ss ss ss ss ss
ii. First-pass metabolism (metabolism, typically hepatic, that occurs before a drug ss ss ss ss ss ss ss ss ss
reaches systemic circulation) decreasing by about 1%/yr after age 40.
ss ss ss ss ss ss ss ss ss ss
1. Thus, for a given oral dose, older adults may have higher circulating drug ss ss ss ss ss ss ss ss ss ss ss ss
concentrations. ss
f. Decreased renal elimination ss ss
Week 2 and 3
ss ss ss
1. Identify and describe 12 lead EKGs that demonstrate:
ss ss ss ss ss ss ss
a. 1st, 2nd, and 3rd degree AV blocks
ss ss ss ss ss ss
i. 1st degree HB cards consult ss ss ss
ii. 2nd degree HB type 1 & 2 ss ss ss ss ss ss ss
1. Type 1: Echo (r/o structural dx), Thyroid levels, meds, lytes to identify and ss ss ss ss ss ss ss ss ss ss ss ss
treat cause ss ss
2. Type 2: PPM, continuous tele with transcutaneous pacing if needed, ss ss ss ss ss ss ss ss ss
determine cause; IV atropine if poor perfusion s/s q 3-5m with max 3mgss ss ss ss ss ss ss ss ss ss ss ss ss
if s/s poor perfusion; ss ss ss ss
3. If no response to atropine dopa, epi, isoproterenol ss ss ss ss ss ss ss
rd
iii. 3 degree/ complete HB: PPM; tele and transcutaneous pace if neded; identify
ss ss ss ss ss ss ss ss ss ss ss
cause; IV atropine if s/s poor perfusion; If no response to atropine dopa, epi,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
isoproterenol ss
b. STEMI in any lead (know what area of the heart is affected based on lead location)
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
c. Atrial fibrillation: ss
, i. Stable Rate control vs rhythm control strategy (AV nodal blockers, ss ss ss ss ss ss ss ss ss ss
antiarrhythmics, anticoagulation); ablation if no response to meds;
ss ss ss ss ss ss ss ss
ii. unstable DCC/CV ss ss
d. Atrial flutter ss
i. CV; rate control not as responsive as afib ss ss ss ss ss ss ss
e. Ventricular fibrillation: ss
i. Defibrillate and CPR ss ss
f. VT: stable ss
i. Stable/nonsustained BB ss ss
ii. Amiodarone, sotalol, mexiletine to reduce # shocks ss ss ss ss ss ss
iii. Mg if torsades ss ss
iv. EPS/ablation
v. Unstable CPR, epi vaso (2nd dose), amio, lidocaine, mg, airway management ss ss ss ss ss ss ss ss ss ss ss
g. Tachycardia:
i. Vagal maneuver, adenosine (6/12mg), BB or Ca channel; ablation;ss ss ss ss ss ss ss ss
antiarrhythmics if no response to BB or don’t want ablation
ss ss ss ss ss ss ss ss ss ss
h. Asystole: CPR ss
2. Distinguish between dihydropyridine and non-dihydropyridine calcium channel blocker.
ss ss ss ss ss ss ss
Know what conditions each class would be used to treat.
s s ss ss ss ss ss ss ss ss ss
a. dihydropyridine calcium channel blocker: (e.g., nifedipine, amlodipine) primarily act on ss ss ss ss ss ss ss ss ss
vascular smooth muscles
ss ss ss
i. use for HTN ss ss
b. non-dihydropyridine calcium channel blocker: (diltiazem < verapamil) primarily act on ss ss ss ss ss ss ss ss ss
the heart
ss ss
i. use for CP, SVT (verap); controlling irregular rapid HR and lowering BP
ss ss ss ss ss ss ss ss ss ss ss
(Diltiazem) ss
3. Describe the medications to treat atrial fibrillation (rate, rhythm, and embolus prevention).
ss ss ss ss ss ss ss ss ss ss ss
Know the side effects, needed monitoring, and interaction for each of these
ss ss ss ss ss ss ss ss ss ss ss ss
medications.
ss
a.
4. Calculate a CHADS2 score and describe treatment based on the score:
ss ss ss ss ss ss ss ss ss ss
a. 1 point for the following h/o: HF, HTN, DM, stroke/TIA (2 pt) and age >/= 75
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
i. 0 = low risk, 1-2 = mod risk, >3 = high risk start anticoag
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
5. Calculate a HASBLED score and describe treatment based on the score:
ss ss ss ss ss ss ss ss ss ss
a. 1 point for each of the following:
ss ss ss ss ss ss
i. Hypertension
ii. Uncontrolled, >160 mmHg systolic ss ss ss
iii. Renal disease (Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L)
ss ss ss ss ss ss ss ss ss
iv. Liver disease (Cirrhosis or bilirubin >2x normal with AST/ALT/AP >3x normal)
ss ss ss ss ss ss ss ss ss ss
v. Stroke history ss
vi. Prior major bleeding or predisposition to bleeding ss ss ss ss ss ss
vii. Labile INR (Unstable/high INRs, time in therapeutic range <60%) ss ss ss ss ss ss ss ss
viii. Age >65 ss
ix. Medication usage predisposing to bleeding (Aspirin, clopidogrel, NSAIDs) ss ss ss ss ss ss ss
x. Alcohol use (≥8 drinks/week) ss ss ss
b. Risk of major bleeding in one year:
ss ss ss ss ss ss
Key Concepts Week 1 to 5 WITH COMPLETE SOLUTION 2026, 100%CORRECT
ss ss ss ss ss ss ss ss ss ss
Week 1
ss
1. Describe the cytochrome P450 system. Describe how inducers and inhibitors affect
ss ss ss ss s s ss ss ss ss ss
the cytochrome system and how that affects the half-life of medications.
ss ss ss ss ss ss ss ss ss ss ss
a. Cytochrome p450 system is a series of enzymes used to metabolize medications. ss ss ss ss ss ss ss ss ss ss ss
b. Drugs that cause CYP450 metabolic drug interactions are referred to as either inhibitors
ss ss ss ss ss ss ss ss ss ss ss ss
or inducers. Inducers increase CYP450 enzyme activity by increasing enzyme
ss ss ss ss ss ss ss ss ss ss
synthesis ss
c. Inhibitors block the metabolic activity of one or more CYP450 enzymes ss ss ss ss ss ss ss ss ss ss
2. Describe the affect on low and high albumin levels on active drug levels especially for drugs
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
that are highly protein bound.
ss ss ss ss ss
a. Albumin is the plasma protein with the greatest capacity for binding drugs.
ss ss ss ss ss ss ss ss ss ss ss
i. Binding to plasma proteins affects drug distribution into tissues, because only ss ss ss ss ss ss ss ss ss ss
drug that is not bound is available to penetrate tissues, bind to receptors, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
exert activity. As free drug leaves the bloodstream, more bound drug is released
ss ss ss ss ss ss ss ss ss ss ss ss ss
from binding sites. ss ss ss
b. Highly protein bound drugs, low albumin levels (w/ malnutrition, or chronic illness)
ss ss ss ss ss ss ss ss ss ss ss
may lead to toxicity because there are fewer than the normal sites for the drug to bind
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
3. Describe ways to lessen the hepatic first pass effect: metabolism during first pass through the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
liver
ss
a. Alternative routes (suppository, intravenous, intramuscular, inhalational aerosol, ss ss ss ss ss ss
transdermal, and sublingual) avoid the first-pass effect allow drugs to be absorbed
ss ss ss ss ss ss ss ss ss ss ss ss ss
directly into the systemic circulation
ss ss ss ss ss
4. Be able to calculate creatinine clearance using the Cockgraft Gault equiation:
ss ss ss ss ss ss ss ss ss ss
a. Male = ([140-age] × weight in kg)/(serum creatinine × 72)
ss s s ss ss ss ss ss ss ss ss
b. Female = CrCl (male) × 0.85 ss ss ss ss ss ss
5. Describe what determines the frequency of drug administration:
ss ss ss ss ss ss ss
a. Drug half-life, plasma concentration ss ss ss
6. Be familiar with the Beers criteria and how to use it:
ss ss ss ss ss ss ss ss ss ss
a. Potentially Inappropriate Medication Use in Older Adults ss ss ss ss ss ss
i. to call attention to medications that are commonly problematic, and thus should
ss ss ss ss ss ss ss ss ss ss ss
be avoided in most older adults ss ss ss ss ss ss
7. Describe factors that affect absorption, distribution, metabolism and excretion:
ss ss ss ss ss ss ss ss
a. Absorption low blood state (shock or arrest); contact time with GI tract too fast ss ss ss ss ss ss ss ss ss ss ss ss ss ss
(diarrhea = can’t absorb); delayed stomach emptying (large meal = delayed
ss ss ss ss ss ss ss ss ss ss ss
absorption); drug-drug or drug-food interactions
ss ss ss ss ss
b. Metabolism genetics, age, organ function ss ss ss ss ss
c. Distribution low albumin levels, body composition, cardiac decomp (HF), and age ss ss ss ss ss ss ss ss ss ss ss
d. Excretion affected by abnormal kidney or liver function; age, drug interactions ss ss ss ss ss ss ss ss ss ss ss
8. Define narrow therapeutic index How would you monitor a patient with a narrow
ss ss ss s s ss ss ss ss ss ss ss ss
therapeutic index?
ss ss
, a. Therapeutic index: dose range where efficacy of med is optimized while side effects
ss ss ss ss ss ss ss ss ss ss ss ss
minimized
ss
b. Narrow therapeutic index (NTI) drugs are defined as those drugs where small
ss ss ss ss ss ss ss ss ss ss ss
differences in dose or blood concentration may lead to dose and blood
ss ss ss ss ss ss ss ss ss ss ss ss
concentration dependent, serious therapeutic failures or adverse drug reactions.
ss ss ss ss ss ss ss ss ss
c. Blood tests to monitor blood concentrations and dose adjustments accordingly
ss ss ss ss ss ss ss ss ss
9. Describe how aging affect absorption, distribution, metabolism, and excretion
ss ss ss ss ss ss ss ss
a. Decreased organ function, poorly tolerate drugs that require metabolism, lower rates of
ss ss ss ss ss ss ss ss ss ss ss
excretion
ss
b. decrease in small-bowel surface area, slowed gastric emptying, and an increase in
ss ss ss ss ss ss ss ss ss ss ss
gastric pH, changes in drug absorption
ss ss ss ss ss ss
c. With age, body fat generally increases and total body water decreases. Increased fat
ss ss ss ss ss ss ss ss ss ss ss ss
increases the volume of distribution for highly lipophilic drugs
ss ss ss ss ss ss ss ss ss
(eg, diazepam, chlordiazepoxide) and may increase their elimination half-lives.
ss ss ss ss ss ss ss ss
d. Serum albumin decreases and alpha 1-acid glycoprotein increases
ss ss ss ss ss ss ss
i. Phenytoin and warfarin are examples of drugs with a higher risk of toxic effects ss ss ss ss ss ss ss ss ss ss ss ss ss
when the serum albumin level decreases
ss ss ss ss ss ss
e. hepatic metabolism of many drugs through the cytochrome P-450 enzyme system
ss ss ss ss ss ss ss ss ss ss
decreases with age. For drugs with decreased hepatic metabolism clearance
ss ss ss ss ss ss ss ss ss ss
typically decreases 30 to 40%.
ss ss ss ss ss
i. Drugs metabolized in phase 1 reactions likely prolonged ss ss ss ss ss ss ss
ii. First-pass metabolism (metabolism, typically hepatic, that occurs before a drug ss ss ss ss ss ss ss ss ss
reaches systemic circulation) decreasing by about 1%/yr after age 40.
ss ss ss ss ss ss ss ss ss ss
1. Thus, for a given oral dose, older adults may have higher circulating drug ss ss ss ss ss ss ss ss ss ss ss ss
concentrations. ss
f. Decreased renal elimination ss ss
Week 2 and 3
ss ss ss
1. Identify and describe 12 lead EKGs that demonstrate:
ss ss ss ss ss ss ss
a. 1st, 2nd, and 3rd degree AV blocks
ss ss ss ss ss ss
i. 1st degree HB cards consult ss ss ss
ii. 2nd degree HB type 1 & 2 ss ss ss ss ss ss ss
1. Type 1: Echo (r/o structural dx), Thyroid levels, meds, lytes to identify and ss ss ss ss ss ss ss ss ss ss ss ss
treat cause ss ss
2. Type 2: PPM, continuous tele with transcutaneous pacing if needed, ss ss ss ss ss ss ss ss ss
determine cause; IV atropine if poor perfusion s/s q 3-5m with max 3mgss ss ss ss ss ss ss ss ss ss ss ss ss
if s/s poor perfusion; ss ss ss ss
3. If no response to atropine dopa, epi, isoproterenol ss ss ss ss ss ss ss
rd
iii. 3 degree/ complete HB: PPM; tele and transcutaneous pace if neded; identify
ss ss ss ss ss ss ss ss ss ss ss
cause; IV atropine if s/s poor perfusion; If no response to atropine dopa, epi,
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
isoproterenol ss
b. STEMI in any lead (know what area of the heart is affected based on lead location)
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
c. Atrial fibrillation: ss
, i. Stable Rate control vs rhythm control strategy (AV nodal blockers, ss ss ss ss ss ss ss ss ss ss
antiarrhythmics, anticoagulation); ablation if no response to meds;
ss ss ss ss ss ss ss ss
ii. unstable DCC/CV ss ss
d. Atrial flutter ss
i. CV; rate control not as responsive as afib ss ss ss ss ss ss ss
e. Ventricular fibrillation: ss
i. Defibrillate and CPR ss ss
f. VT: stable ss
i. Stable/nonsustained BB ss ss
ii. Amiodarone, sotalol, mexiletine to reduce # shocks ss ss ss ss ss ss
iii. Mg if torsades ss ss
iv. EPS/ablation
v. Unstable CPR, epi vaso (2nd dose), amio, lidocaine, mg, airway management ss ss ss ss ss ss ss ss ss ss ss
g. Tachycardia:
i. Vagal maneuver, adenosine (6/12mg), BB or Ca channel; ablation;ss ss ss ss ss ss ss ss
antiarrhythmics if no response to BB or don’t want ablation
ss ss ss ss ss ss ss ss ss ss
h. Asystole: CPR ss
2. Distinguish between dihydropyridine and non-dihydropyridine calcium channel blocker.
ss ss ss ss ss ss ss
Know what conditions each class would be used to treat.
s s ss ss ss ss ss ss ss ss ss
a. dihydropyridine calcium channel blocker: (e.g., nifedipine, amlodipine) primarily act on ss ss ss ss ss ss ss ss ss
vascular smooth muscles
ss ss ss
i. use for HTN ss ss
b. non-dihydropyridine calcium channel blocker: (diltiazem < verapamil) primarily act on ss ss ss ss ss ss ss ss ss
the heart
ss ss
i. use for CP, SVT (verap); controlling irregular rapid HR and lowering BP
ss ss ss ss ss ss ss ss ss ss ss
(Diltiazem) ss
3. Describe the medications to treat atrial fibrillation (rate, rhythm, and embolus prevention).
ss ss ss ss ss ss ss ss ss ss ss
Know the side effects, needed monitoring, and interaction for each of these
ss ss ss ss ss ss ss ss ss ss ss ss
medications.
ss
a.
4. Calculate a CHADS2 score and describe treatment based on the score:
ss ss ss ss ss ss ss ss ss ss
a. 1 point for the following h/o: HF, HTN, DM, stroke/TIA (2 pt) and age >/= 75
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
i. 0 = low risk, 1-2 = mod risk, >3 = high risk start anticoag
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
5. Calculate a HASBLED score and describe treatment based on the score:
ss ss ss ss ss ss ss ss ss ss
a. 1 point for each of the following:
ss ss ss ss ss ss
i. Hypertension
ii. Uncontrolled, >160 mmHg systolic ss ss ss
iii. Renal disease (Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L)
ss ss ss ss ss ss ss ss ss
iv. Liver disease (Cirrhosis or bilirubin >2x normal with AST/ALT/AP >3x normal)
ss ss ss ss ss ss ss ss ss ss
v. Stroke history ss
vi. Prior major bleeding or predisposition to bleeding ss ss ss ss ss ss
vii. Labile INR (Unstable/high INRs, time in therapeutic range <60%) ss ss ss ss ss ss ss ss
viii. Age >65 ss
ix. Medication usage predisposing to bleeding (Aspirin, clopidogrel, NSAIDs) ss ss ss ss ss ss ss
x. Alcohol use (≥8 drinks/week) ss ss ss
b. Risk of major bleeding in one year:
ss ss ss ss ss ss
