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NBME 20 Answers

nbme20/Block 1/Question#24 (57.2 difficulty score)
A 50-year-old man comes to the physician ...

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submitted by justgettinby(22),
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Izacltnooaer iqeurser eth caidci ntneievmrno fo teh cotsmha to eb ebo.dabrs Ooepamezlr tsibihni het /+KH+ upmp of hte amsthco, ehteryb cgeidsarne eth cyidiat of the tomcsah. So whne eht patteni ktesa eelmaprOoz adn otoaaelnIrzc oegrhe,tt neooactaIrzl o'nwt be obabesrd onit eth oyd.b hs'taT hwy it sha on tfefec.

Ist' nmrdecoeedm to ktae cisndtoeima at steal 2 rouhs orrip to ganikt an atndci.a

necrotizingfasciitis  Just adding support to the above explanation: +3  
pakimd  do all azoles or just itraconazole only requires an acidic environment to be absorbed? +2  
chandlerbas  just itraconazole and posaconazole +5  
lilyo  @chandlerbas, where did you find this information? I was looking over this on FA but they do not mention it and I would like a bit more information. Thanks! +5  
chandlerbas  haha no stress! the article above submitted by @necrotizingfasciitis does a descent job explaining it, however its not good enough, I looked into a bit more on uptodate but wasn't fruitful in my endeavours. goodluck! +  
haozhier  How are we supposed to know this!! It is not in UWORLD or FA right? +10  
kevin  Someone said it on here, since there was no CYP inducer of the answer choices, the only way to even think about an answer to this question was to just go with a less acidic environment from the PPI affecting absorption. It was simply the only reasonable answer choice, I don't think there's any way we were expected to know of this exact interaction prior +1  
aoa05  Golan pharm book states the exact same thing. Cannot be given to patients with acholrhydria. +  

submitted by nadhq(7),

I highly doubt that writers of this question expect us to know the relation between itraconazole and PPI but rather if a patient has a multidrug regimen (including a PPI), if there is no p450 related stuff going and drug absorbtion is defective we should be suspicious of the PPIs. Like a general rule or something like that.

Otherwise, if they expect us to know the specific relation between the two... meh this question sucks really hard then.

submitted by stepwarrior(22),

this is clearly another one of those trap questions for overthinkers

submitted by andremosq(3),

The encapsulated formulation of itraconazole has been associated with wide variability in plasma concentrations due to variability in absorption from the gastrointestinal (GI) tract.

Encapsulated itraconazole requires an acidic pH in the stomach for the proper dissolution and absorption in the duodenum (small intestine).

Proton pump inhibitor medications can increase the gastric pH and thereby decrease the dissolution of the capsule and the amount of itraconazole available for absorption from the GI tract for systemic delivery.

by:Anthony J. Busti, MD, PharmD, FNLA, FAHA

submitted by strugglebus(165),
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This a PYC 045 rbiioihnt (SKMCFACICS.OE;) sti the O.

coccidioinmytitties  Azoles, as a class, are CYP450 inhibitors [fungal > human; to prevent conversion of lanosterol to ergosterol]. Justget is correct- a ↓pH is needed for absorption and PPI/H2RA/antacids are contraindicated. +  

submitted by hayayah(1079),
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dAd no ot eht rteoh mm:ncteo E.FSAKOCCMCSI en h(Iw Am kidingrn priutarfGe cjiue) si teh iomnnemc orf mrbrmeengie teh P0C4Y5 iIhobr:ints

  • S oduim atrlvpeoa
  • I sdiaznoi
  • C eiimdtein
  • K aezleotocon
  • F couzleanol
  • A utec holcoal abesu
  • C ploihacrmhleon
  • E i/trlhritmoynrncoyrimyccah
  • S uoslmfeiand
  • C anlipcrxfoio
  • O rpezeomla
  • M nezodtrleaio

  • A oraimoden

  • trrfGeiapu eciju
charcot_bouchard  Its not a cytochrome question. IK because i go t it wrong +  
waterloo  both azoles and PPI inhibit cytochrome P450. So one isn't causing the other's lack of effect. +8  
stepwarrior  Nope. Inhibiting CYP450 would enhance the effect of itraconazole, so that can't be the mechanism. +1