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1. Which one of the following is the LEAST likely potential long-term adverse consequence of chronic PPI use?

A. Hip fracture B. Osteoarthritis C. Vitamin B12 deficiency D. Enteric infections (e.g. C. difficile)

2. A 65-year-old man who had a NSAID-related bleeding gastric ulcer (H. pylori-negative) three years ago has recently received two coronary stents and now is taking aspirin and clopidogrel. Which of the following statements regarding the use of a PPI in this patient is MOST correct?

A. All PPIs should be avoided as they may increase the risk of serious cardiovascular side effects B. PPIs can be given but there should be a 12 hour interval between taking the PPI and the clopidogrel C. Based on a risk/benefit analysis, PPI co-therapy is appropriate for this patient D. The patient should be given ranitidine 150 mg bid to prevent recurrent gastric ulcer bleeding

3. The FDA has advised against the concomitant use of clopidogrel and which ONE of the following PPIs?

A. Lansoprazole B. Pantoprazole C. Omeprazole D. Rabeprazole

4. Based on available evidence, which of the following statements is MOST true?

A. Multiple randomized trials have conclusively shown that all PPIs interact with clopidogrel B. Clopidogrel dose should be doubled to 75 mg po BID in all patients receiving concomitant PPIs C. Data regarding the safety of concomitant PPI and clopidogrel therapy remains inconclusive to date D. Patients older than 65 years should never take PPI and clopidogrel therapy together

5. Which of the following PPI formulations would be MOST preferred for use in a patient with GERD who is taking clopidogrel after undergoing angioplasty following a myocardial infarction?

A. Omeprazole B. Esomeprazole C. Pantoprazole D. Omeprazole with sodium bicarbonate

6. The COGENT trial found that:

A. Omeprazole treatment did not increase the risk for cardiovascular complications B. Omeprazole treatment significantly increased the risk for cardiovascular complications C. Omeprazole treatment increased the risk for stroke D. Omeprazole did not significantly affect any of the trial outcomes

7. Which one of the following PPIs is most likely to lead to an increase in the INR when started in a patient who is chronically receiving warfarin therapy?

A. Lansoprazole B. Rabeprazole C. Omeprazole D. Pantoprazole

8. A PPI is prescribed to a 60-year-old woman with a family history of osteoporosis and troublesome GERD symptoms. Which of the following statements is MOST correct?

A. More frequent (i.e., annual) bone density studies will need to be done because of the PPI use B. Extra calcium and Vitamin D therapy should be initiated because of the PPI use C. Osteoporosis monitoring and treatment practices do not need to be altered with the initiation of PPI therapy D. PPI therapy should be administered for a maximum of 6 months

9. What are the potential effects of PPIs on bone metabolism?

A. PPIs may reduce gastrointestinal calcium absorption B. PPIs may promote secondary hypoparathyroidism C. PPIs may promote reduced osteoclastic bone resorption D. PPIs may increase levels of circulating estrogen

10. Several observational studies have reported an association between long-term PPI therapy and fractures of the:

A. Wrist and ankle B. Wrist and leg C. Hip and spine D. There is an increased risk for all types of fractures associated with PPI therapy

11. Which of the following statements about clinical features of hypomagnesemia associated with PPI use is MOST correct?

A. Hypomagnesemia is defined as a serum magnesium level <2.0 mg/dL B. Hypomagnesemia is easy to recognize and is well-reported C. Symptoms of severe hypomagnesemia include tetany, seizures, and tremors D. Hypomagnesemia associated with PPI use has been reported only after 10 years or more treatment

12. Patients taking PPIs who may be at a higher risk of hypomagnesemia are:

A. Those also taking diuretics B. Those with a syndrome causing chronic diarrhea C. Those taking a PPI for >5 years D. All the above

13. Which of the following statements regarding the recognition and prevention of hypomagnesemia associated with PPI use is MOST correct?

A. Clinicians should check serum magnesium levels before prescribing short-term PPI treatment B. Clinicians should consider checking serum magnesium levels before prescribing PPIs if the patient is currently receiving a diuretic (e.g. furosemide) or digoxin C. The serum magnesium level should be checked every 6 months D. Omeprazole and esomeprazole are the only marketed PPIS that have been associated with hypomagnesemia

14. Which of the following variables is NOT a risk factor for C difficile infection?

A. Advanced age B. Antibiotic use C. Hospitalizations D. Contact with cattle

15. Which of the following statements regarding the co-administration of PPIs with methotrexate is MOST correct?

A. PPI therapy may increase methotrexate clearance leading to sub therapeutic levels B. PPI therapy may delay elimination of methotrexate, leading to supratherapeutic levels C. Evidence supporting a PPI-methotraxate drug interaction comes from well-designed randomized, controlled trials D. The FDA has not issued any guidance regarding PPI-methotraxate interaction

16. Vitamin B12 deficiency affects up to % of the elderly

A. 5% B. 10% C. 15% D. 20%

17. Which of the following mechanisms best describes the ability of a PPI to inhibit the absorption of vitamin B12 from the GI tract?

A. It increases the gastric pH thereby resulting in the degradation of available R-binders for vitamin B12 to bind B. It inhibits the gene transcription of intrinsic factor in the chief cells of the stomach C. It directly binds to intrinsic factor thereby inhibiting its ability to complex with vitamin B12 D. It increases the gastric pH thereby inhibiting release of B12 from dietary proteins

18. Which of the following statements about C difficile associated with PPI use is MOST correct?

A. C difficile has been reported with the use of prescription PPIs but not with the use of OTC PPIs B. Features of acute C difficile infection may include constipation, abdominal pain, and fever C. PPIs should be prescribed in the lowest dose and for the shortest duration that is appropriate for the condition being treated D. PPI use is associated with a 10-fold increase in risk of C difficile infection, both in the community setting as well as in hospitalized patients

19. A 44-year-old woman asks the pharmacist for assistance. She has been taking omeprazole for the past 5 years. A friend told her she should not take her PPI for too long because it increases her risk for infection. She wants to know if she should stop taking her medication. What is the BEST advice that the pharmacist can provide her?

A. The pharmacist should advise her to stop taking her PPI immediately as she is at high risk for infection B. The pharmacist should explain the possible association between PPI use and infection, including the risk factors associated with acquiring an infection, and advise her to take her medication as prescribed C. The pharmacist should tell her there is no risk for increased infection risk with PPI use and that she should not worry about this. D. The pharmacist should advise her to change the PPI she is taking from omeprazole to pantoprazole