BCACP Board Certified Ambulatory Care Pharmacist
Exam 2026 Latest Study Guide with Practice Questions
Ambulatory Pharmacy Review, Detailed Rationales,
Verified Answers, Success Workbook
Key Pharmacotherapy Topics:
Diabetes, hypertension, dyslipidemia, anticoagulation, heart failure,
COPD/asthma, chronic kidney disease, mental health, pain management,
immunizations, MTM services, and evidence-based medicine .
SECTION 1: PATIENT-CENTERED CARE — CARDIOVASCULAR DISORDERS
(Questions 1-20)
This section covers hypertension, dyslipidemia, heart failure, and
anticoagulation — core topics that appear frequently on the exam .
Question 1
A 58-year-old patient with type 2 diabetes (HbA1c 8.2%, eGFR 45
mL/min/1.73m²) is currently on metformin 1,000 mg twice daily. According
to the 2024 ADA Standards of Care, what is the most appropriate next step?
A) Add glipizide 5 mg daily
B) Add empagliflozin 10 mg daily
C) Increase metformin to 2,000 mg twice daily
D) Add sitagliptin 100 mg daily
Answer: B) Add empagliflozin 10 mg daily
Rationale: Per 2024 ADA guidelines, for patients with type 2 diabetes and CKD
(eGFR ≥ 20 mL/min/1.73m²), an SGLT2 inhibitor with proven cardiovascular
or kidney benefits (empagliflozin, dapagliflozin, or canagliflozin) is
recommended to reduce progression of CKD and cardiovascular events .
Metformin should be reduced (not increased) when eGFR is below 45
mL/min/1.73m². Glipizide is not preferred due to hypoglycemia risk.
,Question 2
Which of the following is the preferred first-line agent for hypertension in a
patient with diabetes and albuminuria (UACR 350 mg/g)?
A) Amlodipine 5 mg daily
B) Lisinopril 10 mg daily
C) Hydrochlorothiazide 25 mg daily
D) Metoprolol succinate 50 mg daily
Answer: B) Lisinopril 10 mg daily
Rationale: Per ADA and KDIGO guidelines, ACE inhibitors (like lisinopril) or
ARBs are first-line for hypertension in patients with diabetes and albuminuria
(UACR ≥ 300 mg/g) due to proven renal protection benefits . They reduce
progression of diabetic kidney disease and cardiovascular events in this
population.
Question 3
A 65-year-old patient with HFrEF (LVEF 35%) is on lisinopril 20 mg daily and
metoprolol succinate 50 mg daily. Which medication should be added next per
GDMT guidelines?
A) Digoxin 0.125 mg daily
B) Spironolactone 25 mg daily
C) Hydralazine-isosorbide dinitrate
D) Ivabradine 5 mg twice daily
Answer: B) Spironolactone 25 mg daily
Rationale: Per 2022 AHA/ACC/HFSA guidelines, the four pillars of HFrEF
GDMT are: 1) ACEi/ARB/ARNI, 2) Evidence-based beta-blocker, 3)
Mineralocorticoid receptor antagonist (spironolactone or eplerenone), and 4)
SGLT2 inhibitor (empagliflozin or dapagliflozin) . Spironolactone is indicated
in patients with NYHA class II-IV HFrEF and LVEF ≤ 35%.
,Question 4
A 62-year-old patient with hypertension is currently on lisinopril 20 mg daily
and hydrochlorothiazide 25 mg daily. Home blood pressure readings average
148/92 mmHg. The patient reports a chronic cough. Which of the following is
the most appropriate next step?
A) Increase lisinopril to 40 mg daily
B) Switch lisinopril to losartan 50 mg daily
C) Add amlodipine 5 mg daily
D) Increase hydrochlorothiazide to 50 mg daily
Answer: B) Switch lisinopril to losartan 50 mg daily
Rationale: The patient is on two antihypertensives but still above goal (<
130/80 mmHg). The chronic cough is a common side effect of ACE inhibitors
due to bradykinin accumulation. Switching to an ARB (losartan) will eliminate
the cough while maintaining similar blood pressure control and renal
protection. Adding a third agent (amlodipine) would also be appropriate, but
addressing the medication intolerance is the priority.
Question 5
A patient is started on warfarin for atrial fibrillation. Which of the following
medications would most likely require a dose adjustment or increased
monitoring of INR?
A) Acetaminophen
B) Amiodarone
C) Levothyroxine
D) Metformin
Answer: B) Amiodarone
Rationale: Amiodarone is a potent inhibitor of CYP2C9 and CYP3A4, which
metabolizes warfarin. It significantly increases INR and the risk of bleeding.
The warfarin dose should be reduced by 30-50% when amiodarone is
initiated. Acetaminophen has minimal effect on INR at standard doses.
Levothyroxine and metformin do not significantly interact with warfarin.
, Question 6
A 55-year-old patient with a 10-year ASCVD risk score of 12% has an LDL of
145 mg/dL. What is the most appropriate statin therapy per 2018 ACC/AHA
guidelines?
A) Lifestyle modification only
B) Moderate-intensity statin (atorvastatin 20 mg or rosuvastatin 10 mg)
C) High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg)
D) Ezetimibe monotherapy
Answer: B) Moderate-intensity statin (atorvastatin 20 mg or
rosuvastatin 10 mg)
Rationale: Per 2018 ACC/AHA guidelines, patients with 10-year ASCVD risk ≥
7.5% to < 20% with LDL ≥ 70 mg/dL should be treated with a moderate-
intensity statin. High-intensity statin is reserved for patients with ASCVD, LDL
≥ 190, or diabetes with risk factors. Lifestyle modification is insufficient for
this risk level.
Question 7
A patient on apixaban 5 mg twice daily for atrial fibrillation is scheduled for a
colonoscopy with polypectomy. What is the recommended approach to
anticoagulation management?
A) Continue apixaban without interruption
B) Hold apixaban 48-72 hours before the procedure
C) Hold apixaban 24 hours before the procedure
D) Bridge with enoxaparin
Answer: B) Hold apixaban 48-72 hours before the procedure
Rationale: For patients on DOACs undergoing procedures with a high bleeding
risk (e.g., polypectomy), apixaban should be held for 48-72 hours before the
procedure, depending on renal function. For low-bleeding-risk procedures, 24
hours may be sufficient. Bridging with enoxaparin is not typically required for
DOACs.
Exam 2026 Latest Study Guide with Practice Questions
Ambulatory Pharmacy Review, Detailed Rationales,
Verified Answers, Success Workbook
Key Pharmacotherapy Topics:
Diabetes, hypertension, dyslipidemia, anticoagulation, heart failure,
COPD/asthma, chronic kidney disease, mental health, pain management,
immunizations, MTM services, and evidence-based medicine .
SECTION 1: PATIENT-CENTERED CARE — CARDIOVASCULAR DISORDERS
(Questions 1-20)
This section covers hypertension, dyslipidemia, heart failure, and
anticoagulation — core topics that appear frequently on the exam .
Question 1
A 58-year-old patient with type 2 diabetes (HbA1c 8.2%, eGFR 45
mL/min/1.73m²) is currently on metformin 1,000 mg twice daily. According
to the 2024 ADA Standards of Care, what is the most appropriate next step?
A) Add glipizide 5 mg daily
B) Add empagliflozin 10 mg daily
C) Increase metformin to 2,000 mg twice daily
D) Add sitagliptin 100 mg daily
Answer: B) Add empagliflozin 10 mg daily
Rationale: Per 2024 ADA guidelines, for patients with type 2 diabetes and CKD
(eGFR ≥ 20 mL/min/1.73m²), an SGLT2 inhibitor with proven cardiovascular
or kidney benefits (empagliflozin, dapagliflozin, or canagliflozin) is
recommended to reduce progression of CKD and cardiovascular events .
Metformin should be reduced (not increased) when eGFR is below 45
mL/min/1.73m². Glipizide is not preferred due to hypoglycemia risk.
,Question 2
Which of the following is the preferred first-line agent for hypertension in a
patient with diabetes and albuminuria (UACR 350 mg/g)?
A) Amlodipine 5 mg daily
B) Lisinopril 10 mg daily
C) Hydrochlorothiazide 25 mg daily
D) Metoprolol succinate 50 mg daily
Answer: B) Lisinopril 10 mg daily
Rationale: Per ADA and KDIGO guidelines, ACE inhibitors (like lisinopril) or
ARBs are first-line for hypertension in patients with diabetes and albuminuria
(UACR ≥ 300 mg/g) due to proven renal protection benefits . They reduce
progression of diabetic kidney disease and cardiovascular events in this
population.
Question 3
A 65-year-old patient with HFrEF (LVEF 35%) is on lisinopril 20 mg daily and
metoprolol succinate 50 mg daily. Which medication should be added next per
GDMT guidelines?
A) Digoxin 0.125 mg daily
B) Spironolactone 25 mg daily
C) Hydralazine-isosorbide dinitrate
D) Ivabradine 5 mg twice daily
Answer: B) Spironolactone 25 mg daily
Rationale: Per 2022 AHA/ACC/HFSA guidelines, the four pillars of HFrEF
GDMT are: 1) ACEi/ARB/ARNI, 2) Evidence-based beta-blocker, 3)
Mineralocorticoid receptor antagonist (spironolactone or eplerenone), and 4)
SGLT2 inhibitor (empagliflozin or dapagliflozin) . Spironolactone is indicated
in patients with NYHA class II-IV HFrEF and LVEF ≤ 35%.
,Question 4
A 62-year-old patient with hypertension is currently on lisinopril 20 mg daily
and hydrochlorothiazide 25 mg daily. Home blood pressure readings average
148/92 mmHg. The patient reports a chronic cough. Which of the following is
the most appropriate next step?
A) Increase lisinopril to 40 mg daily
B) Switch lisinopril to losartan 50 mg daily
C) Add amlodipine 5 mg daily
D) Increase hydrochlorothiazide to 50 mg daily
Answer: B) Switch lisinopril to losartan 50 mg daily
Rationale: The patient is on two antihypertensives but still above goal (<
130/80 mmHg). The chronic cough is a common side effect of ACE inhibitors
due to bradykinin accumulation. Switching to an ARB (losartan) will eliminate
the cough while maintaining similar blood pressure control and renal
protection. Adding a third agent (amlodipine) would also be appropriate, but
addressing the medication intolerance is the priority.
Question 5
A patient is started on warfarin for atrial fibrillation. Which of the following
medications would most likely require a dose adjustment or increased
monitoring of INR?
A) Acetaminophen
B) Amiodarone
C) Levothyroxine
D) Metformin
Answer: B) Amiodarone
Rationale: Amiodarone is a potent inhibitor of CYP2C9 and CYP3A4, which
metabolizes warfarin. It significantly increases INR and the risk of bleeding.
The warfarin dose should be reduced by 30-50% when amiodarone is
initiated. Acetaminophen has minimal effect on INR at standard doses.
Levothyroxine and metformin do not significantly interact with warfarin.
, Question 6
A 55-year-old patient with a 10-year ASCVD risk score of 12% has an LDL of
145 mg/dL. What is the most appropriate statin therapy per 2018 ACC/AHA
guidelines?
A) Lifestyle modification only
B) Moderate-intensity statin (atorvastatin 20 mg or rosuvastatin 10 mg)
C) High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg)
D) Ezetimibe monotherapy
Answer: B) Moderate-intensity statin (atorvastatin 20 mg or
rosuvastatin 10 mg)
Rationale: Per 2018 ACC/AHA guidelines, patients with 10-year ASCVD risk ≥
7.5% to < 20% with LDL ≥ 70 mg/dL should be treated with a moderate-
intensity statin. High-intensity statin is reserved for patients with ASCVD, LDL
≥ 190, or diabetes with risk factors. Lifestyle modification is insufficient for
this risk level.
Question 7
A patient on apixaban 5 mg twice daily for atrial fibrillation is scheduled for a
colonoscopy with polypectomy. What is the recommended approach to
anticoagulation management?
A) Continue apixaban without interruption
B) Hold apixaban 48-72 hours before the procedure
C) Hold apixaban 24 hours before the procedure
D) Bridge with enoxaparin
Answer: B) Hold apixaban 48-72 hours before the procedure
Rationale: For patients on DOACs undergoing procedures with a high bleeding
risk (e.g., polypectomy), apixaban should be held for 48-72 hours before the
procedure, depending on renal function. For low-bleeding-risk procedures, 24
hours may be sufficient. Bridging with enoxaparin is not typically required for
DOACs.
