Student Resources

Guideline/Drug Updates and Errata

The RxPrep Course Book is published annually. Information in the Course Book is up to date at the time of publishing, but drug information can change rapidly. Refer to the Updates on this page for NAPLEX-relevant information that becomes available before the next RxPrep Course Book is published. Guideline updates that may be relevant to NAPLEX are included. If we find anything that needs a correction or clarification in the RxPrep Course Book it will be included in the Errata table on this page.

See "What to do When Guidelines Conflict" at the bottom of this page.

Guideline/Drug Updates: 2019 RxPrep Course Book
NAPLEX-relevant updates from August 2018-May 2019

Page Update Type Description
Chapter 18: Immunizations
p. 255 and 257 Labeling Change

The FDA expanded approval of Gardasil 9 to include women and men aged 27-45 years.

Chapter 23: Infectious Diseases IV: Opportunistic Infections
p. 343 Guideline Update

The Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents has updated recommendations for primary prophylaxis of Mycobacterium avium complex (MAC) infections:

  1. Primary prophylaxis is no longer recommended in patients newly diagnosed with HIV who are immediately started on antiretroviral therapy (ART).
  2. Primary prophylaxis is indicated in patients with a CD4+ count < 50 cells/mm3 if they are not taking ART.
    1. Azithromycin 1,200 mg PO weekly is still the preferred prophylaxis regimen.
  3. Criteria for discontinuing primary prophylaxis: patient is started on ART.

Guidelines for the Treatment and Prevention of Opportunistic Infections

Chapter 24: Human Immunodeficiency Virus
p. 348 and 360 Guideline Update

The Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV have been updated. Key points for testing include:

  1. Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide) and Stribild (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate) have been moved from the category of “Recommended Initial Regimens for Most People with HIV” to “Recommended Initial Regimens in Certain Clinical Situations.” This change is due to the risk of drug-drug interactions with cobicistat and a lower threshold for resistance with elvitegravir.
  2. Dolutegravir should not be used in women who are pregnant or who might become pregnant due to a risk for neural tube defects in the infant. A pregnancy test should be performed in women of childbearing potential before starting antiretroviral therapy (ART).

Panel on Antiretroviral Guidelines for Adults and Adolescents.

p. 353 New Drug Approvals

The FDA has approved the following new medications for the treatment of HIV:

  1. Pifeltro (doravirine) is a non-nucleoside reverse transcriptase inhibitor (NNRTI).
  2. Delstrigo (doravirine/lamivudine/tenofovir disoproxil fumarate) is a combination drug that is included in the guideline “Recommended Initial Regimens in Certain Clinical Situations.”
Chapter 25: Dyslipidemia
p. 374 - 375 Guideline Update

The AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on The Management of Blood Cholesterol was published. Key points for testing include:

Update to Determining Appropriate Statin Treatment Intensity Based on Patient Risk (p. 375)

  1. Secondary prevention: high-intensity or moderate-intensity statin is reasonable in patients age > 75 years.
  2. Primary prevention:
    1. Diabetes and age 40-75 years with LDL ≥ 70 mg/dL: moderate-intensity (calculation of ASCVD risk is no longer needed).
    2. No Diabetes and age 40-75 years with LDL ≥ 70 mg/dL:
      1. 10-year ASCVD risk ≥ 7.5%: moderate-intensity.
      2. 10-year ASCVD risk ≥ 20% (very high risk): high-intensity.

Non-Statin Treatments (p. 374)

  1. If LDL ≥ 70 mg/dL on maximally tolerated doses of a statin and patient high risk (e.g., clinical ASCVD or diabetes with ASCVD risk ≥ 20%):
    1. Add ezetimibe.
    2. PCSK9 inhibitors are recommended after ezetimibe due to cost.

Grundy SM, et al. J Am Coll Cardiol. 2018.

Chapter 32: Anticoagulation
p. 467-468 Guideline Update

The Chest Guideline for Antithrombotic Therapy for Atrial Fibrillation and the AHA/ACC/HRF Guideline for the Management of Patients with Atrial Fibrillation were updated. Key points for testing include:

  1. The CHA2DS2-VASc scoring system should be used to evaluate stroke risk:
    1. Score of 0 in males or 1 in females: no anticoagulation treatment.
    2. Score ≥ 1 in males or ≥ 2 in females: consider oral anticoagulation treatment.
    3. Score ≥ 2 in males or ≥ 3 in females: oral anticoagulation treatment indicated.
  2. General treatment principles:
    1. Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over warfarin. These include apixaban, rivaroxaban, edoxaban and dabigatran.
    2. If warfarin is used, the INR should be within the therapeutic range most of the time.
    3. Antiplatelet treatment with aspirin alone, or a combination of aspirin and clopidogrel, is no longer recommended for stroke prevention.

Lip GYH, et al. Chest. 2018.
January CT, et al. J Am Coll Cardiol. 2019.

Chapter 40: Chronic Obstructive Pulmonary Disease
p. 545 Guideline Update

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report was published. Key points for testing include:

  1. Eosinophil counts can be used to predict the benefit from inhaled corticosteroids (ICS). Eosinophils > 300 cells/µL indicate a good response to ICS treatment (reduced exacerbations). Eosinophils < 100 cells/µL indicate a poor response to treatment.
  2. Initial treatment recommendations stayed the same, except for Group D patients: can start LAMA, LAMA + LABA (if highly symptomatic/dyspneic) or LABA + ICS (if eosinophil count > 300 cells/µL).
  3. Titration of treatment is based on the presence of dyspnea or history of exacerbations (patients with both should follow the exacerbation treatment recommendations).
    1. Dyspnea: focus on bronchodilators and titrate to LAMA + LABA. ICS treatment is generally reserved for patients with exacerbations and high eosinophil counts.
    2. Exacerbations and eosinophils < 100 cells/µL: titrate to LAMA + LABA. If additional treatment is needed, roflumilast or azithromycin (in former smokers) can decrease exacerbations.
    3. Exacerbations and eosinophils > 300 cells/µL: titrate to LABA + ICS. If additional treatment is needed, titrate to LAMA + LABA + ICS before adding roflumilast or azithromycin.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 Report.

Chapter 42: Diabetes
p. 563 and 566 Guideline Update

The American Diabetes Association Standards of Medical Care in Diabetes – 2019 has been published. Key points for testing include:

Comprehensive Care (p. 563)

  1. Antiplatelet therapy: aspirin is no longer routinely recommended for primary prevention. It should continue to be recommended for secondary prevention in any patient with ASCVD (e.g., history of myocardial infarction, stable angina, stroke/TIA, peripheral arterial disease).
  2. Cholesterol control: any patient with diabetes and ASCVD or ASCVD risk > 20% should receive a high-intensity statin.
  3. Blood pressure control: a goal BP of < 130/80 mmHg is appropriate for patients with diabetes and ASCVD or ASCVD risk > 15%.

Treatment for Type 2 Diabetes (p. 566)

  1. Dual treatment can be initiated if patient A1C is ≥ 8.5% at baseline.
  2. Metformin and lifestyle modifications are still first-line. If A1C is not at target after 3 months, select a drug to add to metformin based on patient comorbid risks:
    1. Patient has ASCVD: choose a drug with cardiovascular benefit, either a GLP-1 agonist (liraglutide, semaglutide or exenatide extended release) or an SGLT2 inhibitor (empagliflozin or canagliflozin).
    2. Patient has heart failure or CKD (eGFR ≤ 60 mL/min/1.73 m2 or albuminuria): choose an SGLT2 inhibitor (empagliflozin or canagliflozin).
    3. Patient has no ASCVD, heart failure or CKD: choose a drug from any of the remaining medication classes.

ADA Standards of Medical Care in Diabetes - 2019

Chapter 66: Gout
p. 753-754 Labeling Change

The FDA is requiring a boxed warning for febuxostat (Uloric) due to an increased risk of death compared to allopurinol. Allopurinol is now considered first-line for chronic urate-lowering therapy. Febuxostat should be reserved for patients who have failed or do not tolerate allopurinol.

Errata: 2019 RxPrep Course Book
Corrections or clarifications for the RxPrep Course Book

Page Description
Chapter 5: Preparing IV Medications
p. 68

In the Vesicants are Safer with a Central Line section, the second sentence should say “Vesicants are preferentially administered through a central line because the line is less likely…”

Chapter 17: Hepatitis & Liver Disease
p. 235

The footnote at the bottom of the Direct Acting Antivirals Study Tip should say: fosamprenavir oral susp (without food in adults).

Chapter 18: Immunizations, Chapter 42: Diabetes
p. 254 and 565

Patients with diabetes should receive an annual influenza vaccine (not live), a hepatitis B series, Pneumovax 23 from ages 19-64 years, and both Prevnar 13 and Pneumovax 23 at ages ≥ 65 years. Wait 12 months after Prevnar 13 to give Pneumovax 23.

Chapter 20: Infectious Diseases I
p. 280

The word "methotrexate" is missing in the section on Penicillin Drug Interactions. It should say “Penicillins can increase the concentration of methotrexate, and...”

Chapter 32: Anticoagulation
p. 459

The Notes section of the drug table should say “Antidote for apixaban and rivaroxaban: andexanet alfa (Andexxa).”

Chapter 61: Oncology I: Overview & Side Effect Management
p. 763-764

The “N” on the legend for chemo person should say “Neurotoxic (crosses blood brain barrier)."

Download 2018 RxPrep Course Book Guideline/Other Updates & Errata

What to do When Guidelines Conflict!

Practice guidelines change frequently.

Guideline updates that may be relevant for NAPLEX are reviewed in the table at the top of this page.

Many guidelines are now updated throughout the year, as needed, to address rapidly changing information. Examples include the American Diabetes Association's Standards of Medical Care in Diabetes, Guidelines for Use of Antiretroviral Agents from the U.S. Department of Health and Human Services and many others.

This can make NAPLEX preparation seem confusing!

NABP writes the NAPLEX questions, and NABP states that the current guideline (for any condition) should be used to respond to questions.

You can follow this recommendation even when a new guideline is released a week before your exam date.

How can that be true? Because the questions are largely guideline-version independent. The quantity of pre-test questions helps, too. New questions do not count towards the NAPLEX score until they make their way through NABP's question validation process. This takes time. A question based on information that changed recently is unlikely to count until several months later.

Here are two examples of common question types. The response would stay the same, regardless of the guideline version:

HIV Guidelines
Atripla was a recommended initial treatment option for HIV infection until 2015. The specific drug information (what is in the drug, the side effects, warnings, monitoring) has not changed substantially, though Atripla is no longer recommended as first-line treatment for most patients with HIV.

HIV Question Example
A patient is taking Atripla 1 tablet daily to treat HIV infection. Select the components of Atripla (Select ALL that apply.)

  1. Tenofovir
  2. Abacavir
  3. Efavirenz
  4. Emtricitabine
  5. Maraviroc

Hypertension Guidelines
Most pharmacists have been taught to treat blood pressure to a goal of < 140/90 mmHg. JNC 8 recommended a goal of < 150/90 mmHg for patients ≥ 60 years old who do not have diabetes or renal disease. Recently, the ACC/AHA guidelines recommended a goal of < 130/80 mmHg for all patients.

Hypertension Question Example
JT is a 51-year-old Hispanic male taking aspirin 81 mg daily, simvastatin 20 mg QHS and Lantus 16 units QHS. He presents to the clinic for medication refills. JT has recorded his blood pressure readings since his last clinic visit. They ranged from 164-182/96-108 mmHg. His blood pressure is 168/110 mmHg today. Select the most appropriate treatment for the patient's blood pressure:

  1. Diovan HCT 160/12.5 mg once daily
  2. Catapres 0.1 mg twice daily
  3. Verapamil 120 mg three times daily
  4. Tenoretic 50/25 mg once daily
  5. Maxzide-25 once daily

RxPREP helps students preparing for pharmacist licensure. It's what we do best.

We have found that students who have difficulty when testing have lapses in drug knowledge rather than lapses in knowledge of guideline details. It is best to focus your study time on becoming a drug therapy expert.

Feel confident using the material in the current RxPrep Course Book and any updates we have posted under the Student Resources tab on the RxPrep website at and your studies will proceed nicely.

Best wishes from our Pharmacist team for your successful preparation!

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