202022542 이동용 _ 약물치료학 3 과제

1. A 42-year-old man is receiving treatment for pulmonary TB. He has received 9 weeks of
daily rifampin, isoniazid, ethambutol, and pyrazinamide. His sputum smear and cultures
have been negative. Susceptibility results have just been made available and indicate the
isolate is resistant to isoniazid. Which of the following would be the most appropriate
recommendation for your patient at this time?

A. Discontinue isoniazid, continue rifampin, pyrazinamide, and ethambutol × 6

months.

B. Discontinue isoniazid, continue rifampin, pyrazinamide, ethambutol, and add

levofloxacin × 4 months.

C. Discontinue isoniazid and ethambutol, continue rifampin and pyrazinamide × 4

months.

D. Discontinue isoniazid, pyrazinamide and ethambutol, continue rifampin × 4

months.

답 : A. 중단해야 하는 유일한 약물은 이소니아지드입니다. 도말검사와 배양검사가 음성이고

환자가 반응을 보이고 있으므로 추가 제제를 추가할 필요는 없습니다. 치료는 최소 6 개월
동안 나머지 약물로 계속되어야 합니다.

2. TC is a 74-year-old-man recently diagnosed with multidrug-resistant (MDR)-TB. His

physician is thinking about starting a regimen of amikacin, levofloxacin, cycloserine,
and p-aminosalicylic acid, but is uncertain if this is correct. Therefore, he asks you to
evaluate this proposed regimen. You note that his susceptibility tests indicate his
organism is susceptible to: amikacin, ethambutol, levofloxacin, cycloserine, and p-
 aminosalicylic acid. His estimated creatinine clearance is 25 mL/min (0.42 mL/s); he has a
history of psychosis. From this information, you recommend the following:

A. Replace the planned cycloserine with ethambutol; make adjustments to amikacin

for renal dysfunction.

B. Continue the planned regimen, but make adjustments to amikacin for renal
dysfunction.

C. Replace p-aminosalicylic acid with ethambutol; make adjustments to amikacin for

renal dysfunction.

D. Treat with levofloxacin, cycloserine, and p-aminosalicylic acid.

답 : A. 크레아티닌 청소율이 30 mL/min (0.5 mL/s) 미만으로 추정되는 환자의 경우

피라진아미드와 에탐부톨을 매일 투여하는 것이 아닌 주 3 회 투여하는 것이 권장됩니다.

3. Which one of the following patients presenting with cough, fever, and weight loss would
be at greatest risk of having TB disease?

A. Joe who recently travelled to a resort in Cancun, Mexico

B. Emily who volunteers on holidays at a homeless shelter

C. Brian who works at a Vietnamese restaurant

D. Lisa who is on infliximab for rheumatoid arthritis

답 : D. 이들 환자 모두 위험이 어느 정도 증가하지만, TNF-알파 억제제를 복용하는 환자를

포함한 면역 저하 환자는 잠복 결핵의 재활성화 위험이 높습니다.
4. SL has been on antituberculosis treatment for 2 months, which of the following tests
would be most appropriate to determine her response to therapy?

A. Mantoux test

B. Nucleic acid amplification test

C. Acid fast baccili (AFB) culture

D. Interferon Gamma release assay (QuantiFERON®TB Gold)

답 : C. 치료에 대한 반응 및 지속 여부는 2 개월째의 객담 및 AFB 배양 결과와 치료 시작 시

흉부 X 선 검사에서 공동 질환의 유무에 따라 결정됩니다.
5. After being discharged from the hospital, LB comes to your pharmacy with prescriptions
to continue her antituberculosis regimen. Which of the following drugs would cause
pruritus and orange discoloration of her urine, sputum, sweat, and tears?

A. Isoniazid

B. Ethambutol

C. Rifampin

D. Pyrazinamide

답 : C. 리팜핀을 복용하는 환자는 일반적으로 체액이 주황색으로 변색되어 옷과 접촉면에

얼룩이 생길 수 있습니다. 리팜핀의 다른 일반적인 부작용으로는 가려움증, 독감 유사 증후군,
메스꺼움/설사, 두통, 혈액학적 영향 및 간 기능 검사 상승이 있습니다.
6. A 68-year-old Asian male with active TB has been on a four-drug antituberculosis
medication (rifampin, isoniazid, pyrazinamide, and ethambutol) regimen for 5 weeks. He
complains that his right big toe has been painful for 2 weeks, and recently, he has a hard
time walking around the house. On examination, the right big toe is tender and red.
Laboratory testing shows an elevated uric acid level and gout is suspected. Which of the
following antituberculosis medications is most likely associated with this side effect?

A. Isoniazid

B. Pyrazinamide

C. Rifampin

D. Ethambutol

답 : B. 피라진아미드는 종종 혈청 요산 수치를 증가시킵니다. 혈청 요산은 통풍 병력이 있는

환자, 특히 신부전증이 있거나 요산 분비를 감소시키는 약물을 사용하는 환자에서 얻을 수
있습니다.

7. An otherwise healthy 29-year-old Asian female with active TB has been improving
symptomatically after 6 weeks of antituberculosis medications (rifampin, isoniazid,
 pyrazinamide, and ethambutol). However, for the past 2 weeks, she has noticed trouble
reading phone numbers in the phonebook, and has had trouble reading the newspaper.

On examination, her visual acuity and red/green perception are diminished. The most
likely diagnosis is:

A. Ethambutol-associated optic neuritis

B. Isoniazid-induced hepatitis

C. Macular degeneration

D. TB dissemination to her eyes

답 : A. 시신경병증은 에탐부톨의 중요한 부작용이므로 특히 고용량 투여 시 모니터링해야

합니다. 에탐부톨을 복용하는 환자의 시력 변화가 나타나면 안과의사에게 의뢰해야 합니다.

8. BC is a 36-year-old patient severely immunocompromised with human immunodeficiency

virus (HIV) and TB coinfection. Which of the following is the most appropriate treatment
approach in this patient?

A. Defer antiretroviral therapy until after TB treatment.

B. Start antiretroviral therapy and then treat start TB treatment 4 weeks later.

C. Start TB therapy and then start antiretroviral therapy as soon as possible after.

D. Start both antiretroviral therapy and TB treatment together, as soon as possible.

 답 : C 중증 면역저하 폐결핵 HIV 환자는 결핵 치료를 시작해야 하며, 사망 위험과 면역
재구성 염증 증후군의 위험을 줄이기 위해 가능한 한 빨리 항레트로바이러스 치료를
시작해야 한다.

9. A 55-year-old emergency room nurse was exposed to TB 4 weeks ago. Susceptibility data
are pending for the patient’s isolate. Her current purified protein derivative (PPD) was read
as 8 mm induration. She has no symptoms and her chest x-ray is normal. Which of the
following is the best option in this patient?

A. No treatment needed at this time because the patient is asymptomatic

B. Rifampin daily for 12 months

C. Isoniazid daily for 9 months

D. Rifampin and pyrazinamide for 4 months

답 : C 해당 환자는 최근 활동성 결핵환자에게 노출된 바 있습니다. 그녀의 PPD 는 양성 T-Spot 검사

외에도 활성 전염 사례와 밀접하게 접촉했기 때문에 양성으로 간주됩니다. 분리균은 rifamycin 에
내성이 있었기 때문에 이 환자에게 가장 좋은 선택은 isoniazid 를 9 개월간 투여하는 것입니다.

10. Which of the following regimens would be the best option for a 26-year-old pregnant
female recently diagnosed with active TB?

A. Isoniazid, rifampin, and pyrazinamide

B. Isoniazid, rifampin, and ethambutol

 C. Isoniazid, ethambutol, and pyrazinamide

D. Isoniazid, rifampin, and streptomycin

답 : B 치료받지 않은 결핵질환은 치료보다 산모와 태아에게 더 높은 위험을 가져온다. 미국에서 임신

중 약물 감수성 활동성 결핵으로 추정되는 경험적 치료를 위한 선택 요법은 이소니아지드, 리팜핀,
에탐부톨을 2 개월간 투여한 후 이소니아지드와 리팜핀을 7 개월간 투여하여 총 9 개월간 치료하는
것입니다.

11. A 67-year-old man has received 8 weeks of therapy with rifampin, isoniazid, ethambutol,
and pyrazinamide. His sputum was negative for AFB within 2 weeks of initiating therapy.
Laboratory tests are drawn and liver function tests are reported as: AST 166 IU/L (8-48
IU/L) and ALT 96 IU/L (7-55 IU/L) (or AST 2.77 µkat/L [0.13-0.80 µkat/L] and ALT 1.60
µkat/L [0.12-0.92 µkat/L]). Which of the following would be the best option for the patient
at this time?

A. Discontinue isoniazid and rifampin and start pyrazinamide, levofloxacin, and

ethionamide.

B. Discontinue isoniazid and rifampin and add moxifloxacin and check serum
concentrations of his TB drugs.

C. Discontinue all TB drugs, continue to recheck liver function tests, and restart same
treatment when liver function returns to normal.

D. Continue current treatment and continue to monitor for continued elevation of

liver function tests.

답 : D. 이소니아지드 및 리팜핀 치료 첫 몇 주 동안 간 기능 검사의 일시적인 상승이 발생할

수 있습니다. 간 기능 검사가 계속해서 정상 상한치의 5 배를 초과하는 경우, 중단을 고려해야
합니다.
 12. A 23-year-old Hispanic male with HIV infection and active TB is receiving highly active
antiretroviral therapy and antituberculous treatment with rifabutin, isoniazid, pyrazinamide,
and ethambutol by directly observed treatment (DOT). He reports that his right eye has
been hurting him for 3 days and is now red. What is the most likely medication for TB,
when she has been on four-drug antituberculosis-induced condition?

A. Ethambutol-induced optic neuritis

B. Isoniazid-induced peripheral neuropathy

C. Pyrazinamide-induced acidosis leading to optic neuritis

D. Rifabutin-related uveitis

답 : D 시클로세린은 발작 장애의 병력이 있는 환자에서는 사용을 피해야 하며, 기존의 정신 건강

문제가 있는 환자에게는 신경정신과적 이상반응과 연관되므로 주의해서 사용해야 한다.

13. Which of the following regimens is not an option for treatment of latent TB infection?

A. Rifampin daily × 4 months

 B. Isoniazid and rifapentine DOT once weekly × 3 months

C. Isoniazid and rifampin daily for 6 months

D. Isoniazid DOT twice weekly for 6 months

답 : C. 리팜핀 기반 요법은 기간이 짧고 우수한 내약성과 효능을 제공하므로 현재

선호됩니다. 대체 요법으로, 잠복결핵 치료제로 이소니아지드를 6 개월 또는 9 개월 동안 매일
투여할 수 있습니다.

14. TS is a 58-year-old woman with drug-susceptible TB. She has been on four-drug
antituberculosis treatment for 6 weeks and is still smear positive. Which of the following
options below would be the most appropriate to do at this time?

A. Add streptomycin to her regimen and check serum concentrations of her TB

drugs.

B. Continue treatment; M. tuberculosis is slow growing and 6 weeks is not enough

time to convert to smear-negative.

C. Inform the patient that her treatment will need to be extended to 12 months.

D. Continue current treatment and check serum concentrations of her TB drugs.

답 : D 항결핵치료 3 개월 후 객담배양이 양성인 경우 감수성검사, 혈청농도 등 치료실패 원인에

대한 검토가 필요하다. 추가 약물을 추가해야 하며, 실패한 요법에 단일 약물을 추가하지 마십시오.

15. Rifabutin should be chosen over rifapentine or rifampin when a patient is on certain
combined antiretroviral combinations because it:
 A. Has a better side effect profile in HIV-positive patients.

B. Is less likely to induce hepatic clearance of the antiretroviral drugs.

C. It has a lower risk of uveitis.

D. Serum concentration monitoring is available for rifabutin.

답 : B. 리파마이신은 프로테아제 억제제와 일부 비뉴클레오시드 역전사 억제제의 대사를

가속화할 수 있는 간 CYP3A4 효소를 유도합니다. 리파부틴은 리팜핀보다 덜 강력한
유도제입니다. 리파부틴은 CYP3A4 의 기질이기도 하기 때문에 병용 투여되는 약물에 따라
용량 조정이 필요할 수 있습니다.