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Prescription Regulations And Safety Warnings - NAPLEX

  1. A 38-year-old female (66 kg) presents for migraine prophylaxis. Current medications: ethinyl estradiol/norgestimate 1 tablet daily. Allergies: none. Medical history: migraine with aura. Labs: serum creatinine 0.8 mg/dL. A new prescription is written for valproic acid 250 mg by mouth twice daily. What safety warning should be addressed for this medication?
    Answer: Valproic acid is contraindicated in pregnancy due to major teratogenicity; ensure counseling on pregnancy prevention and discuss alternatives This question examines teratogenicity warnings for valproic acid in women of childbearing potential. The key patient-specific factor is the female patient's age of 38 and contraceptive use, necessitating pregnancy prevention counseling. Choice A is the best because valproic acid is contraindicated in pregnancy due to teratogenicity, ensuring counseling and alternatives discussion for safety. Choice B is incorrect as it has no iPLEDGE requirement; choice C is wrong because Medication Guides are required broadly; choice D is suboptimal as the warning is for hepatotoxicity, not agranulocytosis. Counsel on contraception with teratogenic drugs. A framework involves assessing reproductive status and risks for high-alert medications.
  2. A 28-year-old woman (62 kg) presents with severe nodulocystic acne and a new prescription for isotretinoin 40 mg by mouth twice daily. Current medications: ethinyl estradiol/levonorgestrel 1 tablet daily, doxycycline 100 mg by mouth twice daily, and a multivitamin containing vitamin A daily. Allergies: none. Medical history: depression (stable). Labs: AST 22 U/L, ALT 19 U/L, triglycerides 110 mg/dL, pregnancy test negative today. Which action should the pharmacist take to ensure patient safety?
    Answer: Hold dispensing until iPLEDGE requirements are verified and counsel to stop doxycycline and vitamin A supplements This question tests knowledge of iPLEDGE REMS requirements for isotretinoin dispensing. The patient is a woman of childbearing potential starting isotretinoin, which requires strict adherence to the iPLEDGE program due to severe teratogenicity. The correct answer (C) is best because isotretinoin cannot be dispensed until all iPLEDGE requirements are verified (including registration, two forms of contraception, negative pregnancy tests, and counseling), and the patient must discontinue vitamin A supplements (which can cause additive toxicity) and doxycycline (which can increase intracranial pressure when combined with isotretinoin). Option A is incorrect because a general pregnancy warning form is insufficient - iPLEDGE has specific requirements that must be met before dispensing. Option B is dangerous because St. John's wort can reduce oral contraceptive effectiveness, potentially leading to pregnancy while on isotretinoin. Option D is incorrect because isotretinoin is not contraindicated in all women of childbearing potential - it can be used with proper iPLEDGE compliance. The clinical pearl is that isotretinoin dispensing requires verification of iPLEDGE registration and compliance before any doses can be dispensed, and pharmacists must counsel on drug interactions that could compromise contraception or increase toxicity.
  3. A 70-year-old male (75 kg) with chronic obstructive pulmonary disease presents for an inhaler refill. Current medications: tiotropium 18 mcg inhaled daily, albuterol inhaler as needed. Allergies: none. Medical history: chronic obstructive pulmonary disease. Labs: not available. A prescription is written for albuterol 2.5 mg/3 mL nebulizer solution, use 1 vial every 4 hours as needed, dispense 90 vials, refills 12. Which regulatory requirement applies to this prescription?
    Answer: Refills are permitted, but the pharmacist should ensure the prescription includes directions and quantity; excessive refills may warrant clinical follow-up for overuse This question evaluates regulatory requirements for non-controlled medications like albuterol, focusing on refill appropriateness. The key patient-specific factor is the patient's COPD and potential overuse with 12 refills, signaling possible poor control. Choice B is the best because refills are allowed but require complete prescriptions, with follow-up for excessive use to ensure safety. Choice A is incorrect as albuterol is not Schedule III; choice C is wrong because it has no REMS; choice D is suboptimal as tamper-resistant paper is for controlled substances. Monitor refill frequency for rescue inhalers. A framework is to assess clinical appropriateness beyond legal validity for chronic therapies.
  4. A 58-year-old male (82 kg) with type 2 diabetes presents for a new neuropathy medication. Current medications: metformin 1000 mg twice daily, insulin glargine 20 units nightly. Allergies: none. Medical history: type 2 diabetes, peripheral neuropathy. Labs: serum creatinine 1.3 mg/dL, estimated glomerular filtration rate 55 mL/min/1.73 m2^2. New prescription: pregabalin 150 mg by mouth three times daily, quantity 90, refills 5. Which prescription adjustment is necessary for this patient?
    Answer: Recommend renal dose adjustment because pregabalin is primarily renally eliminated at estimated glomerular filtration rate 55 mL/min/1.73 m2^2 This question tests renal dosing safety for pregabalin, which is renally cleared. The key patient-specific factor is the patient's eGFR of 55 mL/min/1.73 m², indicating moderate impairment. Choice B is the best because dose adjustment prevents accumulation and toxicity, ensuring safety. Choice A is incorrect as pregabalin is renally eliminated; choice C is wrong because increasing dose worsens risks; choice D is suboptimal as ER form crushing is inappropriate. Adjust pregabalin based on eGFR. A framework is to calculate renal function and apply dosing guidelines for excreted drugs.
  5. A 29-year-old male (72 kg) presents to the pharmacy with a prescription for buprenorphine/naloxone sublingual film 8 mg/2 mg, dissolve 1 film under the tongue daily, quantity 30, refills 1. Current medications: none. Allergies: none. Medical history: opioid use disorder. Labs: not available. Which regulatory requirement applies to this prescription?
    Answer: Ensure the prescription meets controlled substance requirements for a Schedule III medication (e.g., refills allowed within federal limits) and verify prescriber legitimacy This question evaluates regulatory requirements for Schedule III opioids like buprenorphine/naloxone for opioid use disorder. The key patient-specific factor is the patient's OUD, requiring prescriber verification for legitimacy. Choice C is the best because it ensures compliance with controlled substance rules, allowing refills while verifying authenticity. Choice A is incorrect as any pharmacy can dispense; choice B is wrong because it is Schedule III, not II; choice D is suboptimal as no iPLEDGE is needed. Verify prescriber waivers for buprenorphine. A framework involves confirming schedule, refills, and prescriber qualifications.
  6. A 45-year-old female (74 kg) presents for smoking cessation. Current medications: bupropion sustained-release 150 mg twice daily. Allergies: none. Medical history: major depressive disorder, tobacco use disorder. Labs: serum creatinine 0.9 mg/dL. A new prescription is written for varenicline 1 mg by mouth twice daily. What is the most critical safety consideration for this medication?
    Answer: Counsel on possible neuropsychiatric symptoms and advise the patient to report mood or behavior changes This question assesses safety warnings for varenicline, including neuropsychiatric effects. The key patient-specific factor is the patient's depression history and bupropion use, potentially amplifying mood risks. Choice A is the best because counseling on reporting changes ensures early intervention and safety. Choice B is incorrect as varenicline has no iPLEDGE; choice C is wrong because it is not Schedule II; choice D is suboptimal as it requires no freezing. Monitor for psychiatric symptoms with smoking cessation aids. A framework is to review boxed warnings and counsel on monitoring signs.
  7. A 41-year-old man (90 kg) with acute bacterial sinusitis presents a prescription for amoxicillin/clavulanate 875/125 mg by mouth twice daily for 10 days. Allergies: history of anaphylaxis (throat swelling, hypotension) to penicillin as a child. Current medications: cetirizine 10 mg daily. Medical history: seasonal allergies. Labs: serum creatinine 0.9 mg/dL, AST/ALT within normal limits. Which action should the pharmacist take to ensure patient safety?
    Answer: Contact the prescriber to change therapy because amoxicillin/clavulanate is contraindicated with a history of penicillin anaphylaxis This question tests understanding of cross-reactivity and contraindications in patients with severe penicillin allergies. The patient has a documented history of anaphylaxis to penicillin, which is an absolute contraindication to amoxicillin/clavulanate use. The correct answer (C) requires contacting the prescriber because amoxicillin (a penicillin) shares the beta-lactam ring structure and would likely cause another anaphylactic reaction. Option A is dangerously incorrect - clavulanate does not reduce allergic potential and the patient remains at high risk for anaphylaxis. Option B is inappropriate because diphenhydramine cannot prevent or adequately treat anaphylaxis, and the medication should not be dispensed at all. Option D is wrong on multiple levels - pharmacists cannot change antibiotics without prescriber authorization, and more importantly, cephalosporins have approximately 1-2% cross-reactivity with penicillins in patients with anaphylaxis history. The clinical pearl is that patients with IgE-mediated penicillin allergies (anaphylaxis, angioedema) should avoid all penicillins and use cephalosporins cautiously; non-beta-lactam antibiotics like fluoroquinolones or macrolides are safer alternatives.
  8. A 41-year-old female (63 kg) presents for a urinary tract infection. Current medications: none. Allergies: sulfonamides (hives). Medical history: recurrent urinary tract infections. Labs: serum creatinine 0.8 mg/dL. New prescription: trimethoprim/sulfamethoxazole double strength (160 mg/800 mg) 1 tablet by mouth twice daily for 3 days. What is the most critical safety consideration for this medication?
    Answer: Do not dispense; contact the prescriber for an alternative due to the patient's sulfonamide allergy history This question assesses allergy-related safety warnings for sulfonamides like trimethoprim/sulfamethoxazole. The key patient-specific factor is the patient's documented sulfa allergy with hives, signaling potential hypersensitivity. Choice B is the best because avoiding dispensing and suggesting alternatives prevents allergic reactions, prioritizing safety. Choice A is incorrect as hives indicate true allergy; choice C is wrong because cross-reactivity exists; choice D is suboptimal as dose reduction does not mitigate allergy. Confirm allergy details before dispensing. A framework involves verifying allergy history and assessing cross-reactivity risks.
  9. A 46-year-old male (92 kg) presents with severe constipation and requests a refill. Current medications: methadone 80 mg daily from an opioid treatment program, docusate 100 mg twice daily. Allergies: none. Medical history: opioid use disorder, chronic constipation. Labs: serum creatinine 0.9 mg/dL, alanine aminotransferase 28 U/L. A prescription is presented for methadone 10 mg tablets, take 8 tablets daily, quantity 240, written by an urgent care prescriber. Which regulatory requirement applies to this prescription?
    Answer: Methadone for opioid use disorder maintenance is generally restricted to opioid treatment programs; verify indication and prescriber/setting appropriateness before dispensing This question evaluates regulatory restrictions on methadone dispensing for opioid use disorder maintenance. The key patient-specific factor is the patient's opioid use disorder and existing methadone from an opioid treatment program, indicating a controlled setting. Choice B is the best because methadone for OUD is restricted to certified programs, requiring verification to prevent improper dispensing and ensure compliance. Choice A is incorrect as outpatient pharmacies cannot dispense it for OUD without restrictions; choice C is wrong because methadone is Schedule II; choice D is suboptimal as it misapplies identification requirements. Verify prescriber and setting for restricted opioids. A framework involves confirming indication and regulatory allowances for controlled substances in addiction treatment.
  10. A 79-year-old man (64 kg) is brought to the pharmacy after being treated for a urinary tract infection and has a prescription for trimethoprim-sulfamethoxazole (TMP-SMX) double strength 1 tablet by mouth twice daily for 7 days. Current medications: warfarin 5 mg daily (most recent INR 2.4), amiodarone 200 mg daily, atorvastatin 20 mg nightly. Allergies: none. Medical history: atrial fibrillation. Labs: serum creatinine 1.1 mg/dL, AST/ALT within normal limits. Which prescription adjustment is necessary for this patient?
    Answer: Recommend an alternative antibiotic or coordinate closer INR monitoring and warfarin dose adjustment due to increased bleeding risk This question tests recognition of a major drug interaction between trimethoprim-sulfamethoxazole and warfarin that significantly increases bleeding risk. The patient is on warfarin with a therapeutic INR, and TMP-SMX can increase INR through multiple mechanisms including CYP2C9 inhibition and displacement from protein binding sites. The correct answer (B) appropriately recommends either an alternative antibiotic or closer INR monitoring with likely warfarin dose reduction, as this interaction commonly causes supratherapeutic INRs and bleeding. Option A is incorrect and dangerous - skipping warfarin doses is never appropriate and doesn't address the pharmacokinetic interaction. Option C is wrong because TMP-SMX increases (not decreases) INR through enzyme inhibition, not induction. Option D is inappropriate because prophylactic vitamin K would antagonize warfarin's therapeutic effect and doesn't address the need for monitoring. The clinical pearl is that TMP-SMX is one of the most significant warfarin interactions, often requiring empiric warfarin dose reduction of 25-50% and INR checks within 3-5 days of starting therapy.
  11. A 30-year-old woman (58 kg) with opioid use disorder presents with a prescription for buprenorphine/naloxone 8 mg/2 mg sublingual films: dissolve 1 film under the tongue twice daily; quantity #60; refills: 3. Current medications: none. Allergies: none. Medical history: opioid use disorder. Labs: AST 18 U/L, ALT 16 U/L, pregnancy test negative. Which regulatory requirement applies to this prescription?
    Answer: It is a Schedule III controlled substance and may be refilled up to 5 times within 6 months under federal law This question tests knowledge of federal controlled substance regulations for buprenorphine/naloxone prescriptions. Buprenorphine/naloxone is a Schedule III controlled substance used for opioid use disorder treatment. The correct answer (C) identifies that as a Schedule III controlled substance, it may be refilled up to 5 times within 6 months from the date written under federal law. Option A is incorrect because the DATA 2000 X-waiver requirement was eliminated in January 2023 - prescribers no longer need a special waiver number to prescribe buprenorphine for opioid use disorder. Option B is wrong because Schedule III medications do not require triplicate forms (this applies to Schedule II in some states). Option D is incorrect because buprenorphine/naloxone can be e-prescribed like other controlled substances with appropriate security measures. The clinical pearl is that recent regulatory changes have removed the X-waiver requirement to increase access to buprenorphine treatment, but standard controlled substance regulations still apply including refill limitations and prescription monitoring program requirements.
  12. A 64-year-old female (60 kg) with rheumatoid arthritis presents for a new start. Current medications: folic acid 1 mg daily, prednisone 5 mg daily. Allergies: penicillin (rash). Medical history: rheumatoid arthritis. Labs: alanine aminotransferase 55 U/L (high; normal 7–35), aspartate aminotransferase 49 U/L (high; normal 10–40), serum creatinine 0.8 mg/dL. New prescription: methotrexate 2.5 mg tablets, take 6 tablets by mouth daily. Which prescription adjustment is necessary for this patient?
    Answer: Change to take 6 tablets by mouth once weekly and clarify monitoring due to toxicity risk with daily dosing This question assesses safety warnings for methotrexate dosing in rheumatoid arthritis to prevent toxicity. The key patient-specific factor is the patient's elevated liver enzymes, increasing hepatotoxicity risk with improper dosing. Choice A is the best because changing to weekly dosing aligns with standard RA regimens, reducing toxicity while clarifying monitoring needs. Choice B is incorrect as increasing the dose worsens risks; choice C is wrong because daily 25 mg is excessive; choice D is suboptimal as daily dosing is inappropriate for RA. Weekly dosing is a key pearl for methotrexate in autoimmune conditions. Use a framework of confirming indication-specific dosing to avoid errors in high-risk drugs.
  13. A 45-year-old woman (68 kg) with chronic pain presents a new prescription for transdermal fentanyl 50 mcg/hour patch: apply 1 patch every 72 hours; quantity #10. Current medications: oxycodone immediate-release 5 mg by mouth every 6 hours as needed (uses 1–2 tablets per week), acetaminophen 1,000 mg as needed. Allergies: none. Medical history: osteoarthritis. Labs: serum creatinine 0.8 mg/dL, AST/ALT within normal limits. What is the most critical safety consideration for this medication?
    Answer: Transdermal fentanyl should be initiated only in opioid-tolerant patients due to risk of fatal respiratory depression This question tests knowledge of the FDA boxed warning for transdermal fentanyl regarding opioid tolerance requirements. The patient is essentially opioid-naïve, using only 1-2 tablets of immediate-release oxycodone 5 mg per week, which falls far below the opioid tolerance threshold. The correct answer (B) identifies that transdermal fentanyl should only be initiated in opioid-tolerant patients (defined as ≥60 mg oral morphine equivalents daily for ≥1 week) due to risk of fatal respiratory depression. Option A is incorrect because transdermal fentanyl is contraindicated in opioid-naïve patients regardless of pain chronicity. Option C is dangerous advice because fentanyl patches should never be cut as this can cause dose dumping and fatal overdose. Option D is incorrect regarding both safety (doesn't address the opioid-naïve issue) and dosing frequency (patches are changed every 72 hours, not 24 hours). The clinical pearl is that transdermal fentanyl carries a boxed warning restricting use to opioid-tolerant patients only, and pharmacists must verify opioid tolerance before dispensing to prevent fatal respiratory depression in opioid-naïve patients.
  14. A 59-year-old male (88 kg) presents with fever and cough; a prescription is sent from an urgent care clinic. Current medications: simvastatin 40 mg nightly, tamsulosin 0.4 mg daily. Allergies: none. Medical history: hyperlipidemia, benign prostatic hyperplasia. Labs: serum creatinine 1.0 mg/dL, alanine aminotransferase 30 U/L. New prescription: clarithromycin 500 mg by mouth twice daily for 10 days. Which action should the pharmacist take to ensure patient safety?
    Answer: Recommend holding simvastatin and contacting the prescriber to consider an alternative antibiotic due to increased risk of myopathy/rhabdomyolysis This question tests drug interaction safety between clarithromycin and simvastatin, risking myopathy. The key patient-specific factor is the patient's simvastatin use for hyperlipidemia, compounded by normal but potentially vulnerable renal function. Choice B is the best because recommending to hold simvastatin and suggest alternatives prevents rhabdomyolysis, prioritizing safety. Choice A is incorrect as the CYP3A4 interaction is significant; choice C is wrong because clarithromycin needs no renal adjustment here; choice D is suboptimal as automatic substitution violates regulations. Screen for statin-macrolide interactions routinely. A framework is to evaluate enzyme inhibition and recommend holding or alternatives for severe interactions.
  15. A 56-year-old male (83 kg) presents with a new prescription for erectile dysfunction. Current medications: nitroglycerin 0.4 mg sublingual as needed for chest pain, metoprolol tartrate 50 mg twice daily, aspirin 81 mg daily. Allergies: none. Medical history: coronary artery disease, stable angina. Labs: serum creatinine 1.0 mg/dL. New prescription: sildenafil 50 mg by mouth once daily as needed. Which action should the pharmacist take to ensure patient safety?
    Answer: Do not dispense and contact the prescriber because concomitant nitrates and sildenafil can cause severe hypotension This question assesses contraindication warnings for sildenafil with nitrates. The key patient-specific factor is the patient's nitroglycerin use for angina, risking severe hypotension. Choice B is the best because not dispensing and contacting the prescriber prevents life-threatening interactions, ensuring safety. Choice A is incorrect as no safe separation exists; choice C is wrong because doubling is unsafe; choice D is suboptimal as no REMS for dependence. Contraindicated combo: PDE5 inhibitors and nitrates. A framework involves screening for absolute contraindications in drug profiles.
  16. A 31-year-old female (58 kg) presents for depression management. Current medications: none. Allergies: none. Medical history: major depressive disorder. Labs: serum creatinine 0.7 mg/dL, alanine aminotransferase 18 U/L. A new prescription is written for paroxetine 20 mg by mouth daily. The patient is 10 weeks pregnant. What is the most critical safety consideration for this medication?
    Answer: Paroxetine is associated with fetal risk; the pharmacist should contact the prescriber to consider an alternative SSRI with a better pregnancy safety profile This question tests pregnancy-related safety warnings for SSRIs like paroxetine, which carries a risk of fetal cardiac malformations. The key patient-specific factor is the patient's 10-week pregnancy, heightening teratogenic concerns. Choice B is the best because paroxetine is associated with fetal risks, prompting prescriber contact for safer alternatives like sertraline to comply with safety guidelines. Choice A is incorrect as paroxetine increases cardiac malformation risk; choice C is wrong because paroxetine has no REMS for aplastic anemia; choice D is suboptimal as no federal law mandates child-resistant blister packs for it. Always prioritize fetal safety in pregnant patients on medications. A decision framework is to review pregnancy categories and recommend alternatives when risks outweigh benefits.
  17. A 56-year-old man (88 kg) presents with a prescription for zolpidem 10 mg by mouth nightly as needed for insomnia; quantity #90; refills: 1. Current medications: none. Allergies: none. Medical history: obstructive sleep apnea (uses CPAP inconsistently). Labs: not available. Which regulatory requirement applies to this prescription?
    Answer: It is a Schedule IV medication and may be refilled up to 5 times within 6 months from the date written under federal law This question tests knowledge of federal controlled substance scheduling and refill regulations for sleep medications. Zolpidem is classified as a Schedule IV controlled substance due to its potential for abuse and dependence. The correct answer (B) accurately states that Schedule IV medications may be refilled up to 5 times within 6 months from the date written under federal law. Option A is incorrect because zolpidem is Schedule IV, not Schedule II (Schedule II medications like opioids cannot have refills). Option C is wrong because no controlled substance can be refilled for 12 months - Schedule IV drugs are limited to 5 refills within 6 months. Option D is incorrect because there is no federal REMS requirement for special packaging of zolpidem, though it should be dispensed in child-resistant containers per standard requirements. The clinical pearl is that all "Z-drugs" for sleep (zolpidem, zaleplon, eszopiclone) are Schedule IV controlled substances with the same refill limitations, and pharmacists should monitor for signs of dependence or misuse, especially in patients with sleep apnea where these medications can worsen respiratory depression.
  18. A 35-year-old female (60 kg) presents with nausea and requests an oral antiemetic. Current medications: fluoxetine 40 mg daily. Allergies: none. Medical history: depression. Labs: serum creatinine 0.7 mg/dL. New prescription: ondansetron 8 mg by mouth every 8 hours as needed, quantity 30, refills 2. What is the most critical safety consideration for this medication?
    Answer: Counsel on potential QT prolongation risk, especially with other QT-prolonging agents, and advise seeking care for palpitations or syncope This question tests safety warnings for ondansetron's QT prolongation risk. The key patient-specific factor is the patient's fluoxetine use, which also prolongs QT, increasing arrhythmia potential. Choice A is the best because counseling on symptoms like palpitations ensures prompt care and safety. Choice B is incorrect as no iPLEDGE for ondansetron; choice C is wrong because it is not controlled; choice D is suboptimal as no refrigeration needed. Monitor QT with multiple prolongers. A framework involves counseling on rare but serious risks like QT changes.
  19. A 63-year-old male (77 kg) with heart failure presents for a new prescription. Current medications: carvedilol 25 mg twice daily, lisinopril 20 mg daily, furosemide 40 mg daily, spironolactone 25 mg daily. Allergies: none. Medical history: heart failure with reduced ejection fraction. Labs: potassium 5.6 mEq/L (high; normal 3.5–5.0), serum creatinine 1.6 mg/dL. New prescription: potassium chloride extended-release 20 mEq by mouth daily. Which action should the pharmacist take to ensure patient safety?
    Answer: Hold dispensing and contact the prescriber due to hyperkalemia risk with elevated potassium and concurrent spironolactone and lisinopril This question examines electrolyte safety warnings with potassium supplementation amid hyperkalemia risks. The key patient-specific factor is the patient's elevated potassium of 5.6 mEq/L and use of spironolactone plus lisinopril, which retain potassium. Choice B is the best because holding and contacting the prescriber prevents hyperkalemia complications like arrhythmias. Choice A is incorrect as supplementation is not required; choice C is wrong because increasing worsens hyperkalemia; choice D is suboptimal as salt substitutes add potassium. Monitor potassium with retaining agents. A framework is to review labs and interactions before dispensing electrolytes.
  20. A 62-year-old female (71 kg) presents for a new antibiotic. Current medications: dofetilide 500 mcg by mouth twice daily, levothyroxine 100 mcg daily. Allergies: none. Medical history: atrial fibrillation. Labs: serum creatinine 0.9 mg/dL, potassium 4.2 mEq/L. New prescription: ciprofloxacin 500 mg by mouth twice daily for 7 days. Which action should the pharmacist take to ensure patient safety?
    Answer: Contact the prescriber to avoid this combination due to increased risk of QT prolongation and serious arrhythmias This question examines interaction safety between ciprofloxacin and dofetilide, involving QT prolongation and level increases. The key patient-specific factor is the patient's dofetilide for atrial fibrillation, heightening arrhythmia risks. Choice B is the best because avoiding the combination prevents serious cardiac events, prioritizing safety. Choice A is incorrect as interactions exist; choice C is wrong because loperamide is unrelated; choice D is suboptimal as cipro dose reduction does not address QT risk. Assess QT-prolonging drug combos. A framework is to evaluate additive risks and recommend alternatives.

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