Treatments in Specific Patient Populations

Medical board exams include a high percentage of treatment-focused questions, since appropriate treatment is what patients seek from physicians. Specialty board exams test three aspects of treatment:

• Details of specific treatment interventions
• Treatments in specific patient populations and by disease variants
• Treatment algorithms

This post focuses on choosing the right treatment for a patient based on that patient’s specific population or disease variant. Board exam question writers test your ability to know which treatment interventions apply to particular forms of the disease and within special patient populations. Such specificity is reserved for conditions or disease states that have well-established treatment guidelines or recommendations.

For example, in patients with diabetes mellitus who have elevated albumin-to-creatinine ratios as measured on at least three tests conducted over a six-month period, the addition of an ACE inhibitor is recommended at doses that achieve normalization of albumin excretion. (American Diabetes Association Standards of Medical Care in Diabetes, 2014)

Another example: a woman with anorexia nervosa who has been amenorrhoeic for six months or longer should receive a bone densitometry test since extended amenorrhea places her at a high risk of osteoporosis. (American Psychiatric Association Practice Guideline for the Treatment of Eating Disorders, Third Edition, 2005)

Example Exam Question from Psychiatry

Question: A 17 year old female presents in her 9^th week of pregnancy. She is diagnosed with an episode of severe major depressive disorder. Which antidepressant would be least safe to prescribe?

1. Bupropion
2. Clozapine
3. Fluoxetine
4. Paroxetine
5. Venlafaxine

Question Explanation

If a pregnant patient needs treatment with an antidepressant, the medication to most clearly avoid from among the available response options is paroxetine. It’s the only medication in Pregnancy Category D because of its associated teratogenic risk of cardiac abnormality. Further, the fetal heart is most susceptible to teratogenic insults in the first trimester. (Note that recent research indicates that heart development occurs later into gestation than previously thought; the heart muscle is not fully organized until the 20^th week of gestation).

Let’s review the other response options: Bupropion and clozapine are Pregnancy Category B, the safest category presented, although, as an antipsychotic, clozapine is not indicated for this patient’s condition. Fluoxetine and venlafaxine, both antidepressants and appropriate treatment for depression, are in Pregnancy Category C.

One could argue about the limited meaningfulness of the currently assigned Pregnancy Categories, but this is a real world concern and not necessarily an exam-world concern. Exams test you on treatment appropriateness based on some established standard, even if that standard at some later point is revised, as inevitably happens.

 

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