NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
If you are interested in receiving these questions bi-weekly, join us as a member!
If you are a member who needs to receive the questions and newsletter via email, let us know!
October 6th, 2026
MKSAP Set D: Question 1, Question ID: INMCQ24065
A 28-year-old woman is evaluated for recurrent runny nose, nasal itching associated with sneezing, and occasional itching of the ears and throat. Symptoms are bothersome and interfere with concentration at work and sleep. They are worse in the springtime. She has no other medical problems and takes no medications.
On physical examination, vital signs are normal. She has clear rhinorrhea and mildly edematous nasal turbinates.
Which of the following is the most appropriate initial step in treatment?
A. Intranasal fluticasone
B. Intranasal ipratropium
C. Oral cetirizine
D. Oral montelukast
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Intranasal fluticasone
Educational Objective: Treat allergic rhinitis.
The most appropriate first step in treatment in this patient with seasonal allergic rhinitis is an intranasal glucocorticoid, such as fluticasone (Option A). Allergic rhinitis causes sneezing, congestion, and rhinorrhea, often secondary to a seasonal allergen or other exposure. It should be distinguished from nonallergic rhinitis, which occurs in response to nonallergic stimuli, such as spicy foods, cold air, and irritants. Watery or red eyes resulting from concomitant allergic conjunctivitis may accompany allergic rhinitis. First-line treatment of allergic rhinitis, as well as nonallergic rhinitis, consists of avoiding precipitating factors and monotherapy with intranasal glucocorticoids. Combination therapy with an intranasal glucocorticoid and an intranasal antihistamine may be used for more significant symptoms. Oral second-generation, nonsedating antihistamines are a reasonable treatment option in patients who do not tolerate glucocorticoids or prefer an oral medication to an intranasal medication. Nonsedating oral antihistamines can also be added to therapy with intranasal glucocorticoids if symptoms persist. This patient has recurrent rhinitis, nasal itching, and sneezing consistent with allergic rhinitis, and an intranasal glucocorticoid such as fluticasone is the most appropriate treatment.
Intranasal ipratropium (Option B) is a treatment option for vasomotor rhinitis but is not recommended as a first-line treatment for allergic rhinitis. It is less effective for allergic rhinitis than intranasal glucocorticoids.
Newer second-generation antihistamines, such as cetirizine (Option C), are effective for treating allergic rhinitis and are less sedating than and preferred to first-generation antihistamines. However, intranasal glucocorticoids are favored as first-line therapy because they are more effective than antihistamine therapy.
A leukotriene antagonist, such as montelukast (Option D), would not be the most appropriate treatment. Leukotriene antagonists are less effective than intranasal glucocorticoids and should not be used as first-line treatment in allergic rhinitis. Furthermore, neuropsychiatric adverse effects have been reported with montelukast, resulting in an FDA boxed warning.
Key Points
• First-line treatment of allergic and nonallergic rhinitis consists of avoiding precipitating factors and monotherapy with intranasal glucocorticoids.
• Patients with allergic rhinitis unresponsive to monotherapy with intranasal glucocorticoids may be treated with combination therapy consisting of an intranasal glucocorticoid and an intranasal antihistamine; oral nonsedating antihistamines are an additional treatment option.
Reference
Wise SK, Damask C, Roland LT, et al. International consensus statement on allergy and rhinology: allergic rhinitis – 2023. Int Forum Allergy Rhinol. 2023;13:293-859. PMID: 36878860 doi:10.1002/alr.23090
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2025 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
September 22nd, 2026
MKSAP 19 Rheumatology, Question 24
A 66-year-old woman is evaluated for a 10-year history of pain in the hands and knees. She has tried occupational therapy, with minimal benefit; she is enrolled in a weight loss program. She has hypertension and chronic kidney disease. Current medications are lisinopril and amlodipine.
On physical examination, Heberden and Bouchard nodes are present and there is carpometacarpal joint tenderness. The medial joint line of each knee is tender to palpation. There is bony enlargement of the medial knees, with crepitus on range of motion.
Laboratory evaluation shows a serum creatinine level of 2.2 mg/dL (194.5 μmol/L) and an estimated glomerular filtration rate of 45 mL/min/1.73 m2.
Which of the following is the most appropriate treatment?
A. Hydrocodone
B. Meloxicam
C. Topical capsaicin
D. Topical diclofenac
E. Topical lidocaine
Responses Received from Members (629 Responses):
The Correct Answer is: D. Topical diclofenac
Educational Objective: Treat osteoarthritis of the knees and hands with a topical NSAID.
The most appropriate treatment is topical diclofenac (Option D). Topical NSAIDs, such as diclofenac, are safe and effective for treatment of knee and hand osteoarthritis (OA). For OA in those locations, the 2019 American College of Rheumatology (ACR)/Arthritis Foundation (AF) guideline suggests that topical NSAIDs should be considered before oral NSAIDs because of fewer safety concerns. Topical NSAIDs are not effective for hip OA and have limited efficacy in OA of other sites.
There is minimal benefit of opioid therapy, including hydrocodone (Option A), for chronic pain control in patients with OA. Opioids pose a high risk for toxicity and dependence and should not be used to treat OA.
Oral NSAIDs, such as meloxicam (Option B), are an ACR/AF guideline–recommended first-line treatment for hand, knee, and hip OA. However, they should be used cautiously in patients older than age 50 years and avoided in those with comorbidities, such as a history of peptic ulcer disease or gastrointestinal bleeding, and in patients with hypertension, cardiovascular disease, or chronic kidney disease, as in this patient.
The ACR/AF guideline conditionally recommends topical capsaicin (Option C) for patients with knee OA and conditionally recommends against topical capsaicin in patients with hand OA. The guideline notes limited data supporting the efficacy of topical capsaicin for knee OA. No direct evidence supports topical capsaicin in the treatment of hand OA, and eye contamination is possible when it is used on the hands.Other topical agents are available, such as lidocaine (Option E) and methyl salicylate preparations, but they are not as well studied or as efficacious as topical NSAIDs. They may be used as adjunctive measures.
Key Points
- Topical NSAIDs are safe and effective for treatment of knee and hand osteoarthritis and should be considered before oral NSAIDs.
- Oral NSAIDs are recommended for the treatment of hand, knee, and hip osteoarthritis but should be avoided in patients with comorbidities, such as peptic ulcer disease, cardiovascular disease, and chronic kidney disease.
Bibliography
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72:220-233. PMID: 31908163 doi:10.1002/art.41142
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.