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Adverse Drug Reaction Reporting

The successful person has the habit of doing the things failures don't like to do. They don't like doing them either necessarily. But their disliking is subordinated to the strength of their purpose. E. M. Gray

1. Which one o f the following statements is FALSE I. ' adverse drug reactions(ADRs) are a cause o f significant morbidity and mortality in patients in all arenas o f health care it is estimated that 1/3 to as high as V2 o f ADRs are believed to be preventable adverse drug reactions (ADRs) are not a cause o f significant morbidity and mortality in patients in all arenas o f health care if 1 only is correct if 111 only is correct if I and II are correct if II and III are correct if I, II and III are correct

4. All the following are included in type A adverse drug reactions, except one A. they are extensions o f known pharmacology B. are responsible for the majority o f ADRs C. are usually dose dependent and predictable D. reactions include idiosyncratic reactions immunological or allergic reactions E. none 5. Which one o f the following is TRUE about type A ADRs A. to minimize type A reactions understanding the pharmacology o f the drug is important B. drugs with narrow therapeutic window should be monitored C. polypharmacy should be avoided if possible D. All o f the above E. None 6. Which one o f the following statements is TRUE A. recognition o f ADRs are often subjective B. Nomograms are useful in assessment o f causality in ADRS C. pharmacy departments should take the lead in the collection o f information D. ADR reporting information should be incorporated into institutional quality improvement programs E. All o f the above

II.

III.

A. B. C. D. E.

2. One which is unintended, and which occurs at doses normally used in man for the prophylaxis, diagnosis or therapy o f disease, or for the modification of physiological function is the definition given by the WHO for A. B. C. D. E. Adverse drug reaction side effect adverse drug event A&C all

3. Which one o f the following is included in an adverse drug event A. an event occurring from a drug overdose B. an event occurring from drug abuse C. an event occurring from drug withdrawal D. any significant failure o f expected pharmacological action E. All o f the above

7. Which one o f the following questions help in assessing the determination of causality

A. whether the onset o f symptoms occur after the drug was taken B. the time interval between taking the drug and the onset o f symptoms C. whether the symptoms resolve after the drug was discontinued D. whether the symptoms reoccur after the drug was reintroduced E. All of the above 8. What is NOT involved in surveillance program? A. monitoring patients using high-risk agents B. reviewing patients who have received antidote type drugs C. report appropriately identified ADRs to the FDA D. developing the use o f computer system to track ADRs E. reporting adverse events following the administration of vaccine. 9. The center for biological evaluation and research (CBER) ensures the safety and efficacy o f all the following, EXCEPT A. B. C. D. E. blood products allergenics somatic cell therapy dietary supplements none

B. C. D. E.

CBER CDC A&B A& C

12.The VAERS depends on voluntary reporting by health professionals to A. identify rare adverse reactions not detected in pre licensing studies B. monitor for increase in already known reactions C. identify risk factors or pre existing conditions that promote reactions D. identify particular vaccine lots with unusually high rates or unusual types o f events E. all the above 13. All the following should be reported to Med Watch, EXCEPT A. serious ADRs even if causality is not proven > B. malfunctioning devices C. problems with nutritional products D. mislabeling and poor packaging E. all o f the above 14. Which one o f the following statements is true? A. confidentiality o f both the reporter and the patient whose case is reported are protected by the FDA B. OTC products marketed with out New Drug Application( NDA) strongly require reporting C. reporting to manufacturers is described in the FDAs guidelines D. A & C E. all

10.The national vaccine adverse event reporting system(VAERS) is co administered by A. department o f health and human services (DHHS) B. the CBER o f the FDA C. the centers for disease control and prevention (CDC) D. all except B E. all

11 .Any adverse events after administration o f vaccines is reported to A. DHHS

ANSWERS

Adverse Drug Reaction Reporting

1. Answer: B. Ill is correct Explanation. Adverse drug reactions are a cause o f significant morbidity and mortality in patients in all arenas o f health care today. There is wide variation in the current health care literature, but it has been estimated that from 1/3 to as high as V2 o f ADRs are believed to be preventable.The suffering that patients experience because o f drug related events cannot be quantified.

2. Answer: A. Adverse drug reaction Explanation The terms adverse drug reaction, adverse drug event, untoward drug reaction, drug misadventure, side effects or drug related problems are many times used interchangeably but do not always describe the same situation.

3. Answer: E. All o f the above Explanation. The united states FDAs definition o f adverse drug event is any adverse event associated with the use o f drug in humans, whether or not considered drug related including the following: an adverse event occurring from a drug overdose, whether accidental or intentional; an adverse event occurring from drug abuse, an adverse event occurring from drug withdrawal and any significant failure o f expected pharmacological action. 4. Answer: D. reactions include idiosyncratic reactions immunological or allergic reactions. Explanation. Type A ADRs are extensions o f the drugs known pharmacology and are responsible for the majority o f ADRs. They are usually dose dependent and predictable but can be due to concomitant disease states, drug -d ru g interactions, or drug-food interactions. And type B ADRs include idiosyncratic reactions, immunological or allergic reactions and carcinogenic/teratogenic reactions. Type B reactions are usually not due to a known pharmacology o f the drug, but seem to be a function o f patient susceptibility. They are rarely predictable, are usually not dose dependent, and seem to concentrate in certain body systems such as liver, blood, skin, kidney, nervous system and other body systems.

5. Answer: D. All o f the above Explanation: Ways to minimize type A reactions include understanding the pharmacology o f the drug being prescribed, monitoring drugs with a narrow therapeutic window and avoiding polypharmacy

when possible. In type B ADRs, except for immediate hypersensitivity reactions, it usually takes 5 days before the patient demonstrates hypersensitivity to a drug. There is no maximum time for the occurrence o f a reaction, but most occur with in 12 weeks o f initiation o f therapy.

6. Answer: E. All o f the above Explanation. All the above statements are included in recognition and surveillance programs for ADRs.

7. Answer: E. All o f the above Explanation: Besides all the above other factors like, whether the patient actually ingested the drug, did drugdrug interactions contribute to the symptoms, were the drugs measured in toxic levels in the patients serum, has the reaction been previously seen with the use o f the drug and the personal experience o f the clinician is included. 8. Answer: E. reporting adverse events following the administration o f vaccine. Explanation. Developing the use o f computer system to track ADRs is part o f the national vaccine adverse event reporting system(VAERS). Other programs involved in surveillance programs include, encouraging all health care professionals to be involved in reporting and notifying prescribing o f suspected ADRs, and encourage thorough documentation o f the description o f the reaction as well as the outcome in patients medical records.

9. Answer: D. dietary supplements. Explanation. The center for biological evaluation and research (CBER) ensures the safety and efficacy o f blood products , vaccines, allergenics, biological therapeutics, somatic cell therapy, gene therapy, and banked human tissue. The center for food safety and applied Nutrition (CFSAN) established the CFSAN adverse events reporting systems ( CAERS) in 2002 to identify potentially serious problems secondary to the non-FDA approved herbs, minerals, vitamins, dietary supplements, and other substances.

10.Answer: E. All. Explanation. The VAERS is co-administered by the department o f health and human services( DHHS), the CBER o f the FDA, and the centers for disease control and prevention(CDC).

11 .Answer: A. DHHS Explanation.

The National Childhood Vaccine Injury Act(NCVIA) o f 1989 requires health professionals and manufacturers o f the vaccines to report to the DHHS adverse events following the administration o f vaccines specified in the act.

12.Answer: E. All the above. Explanation. VAERs is the national vaccine adverse event reporting system that depends on voluntary reporting by health professionals to monitor known reactions, identify rare adverse reactions, risk factors for pre-existing conditions and identifying vaccine lots with unusually high rates or unusual types o f events. 13. Answer: E. all of the above

Explanation. Serious ADRs( like death, life threatening events, prolonged hospitalization, disability and congenita] anomaly); malfunctioning devices ( such as heart valves, latex gloves, dialysis machines and ventilators); problems with nutritional products and product problem that can result in compromised safety or quality( product contamination, mislabeling, unclear labeling, poor packaging, potency problems and questionable stability).

14. Answer: A. confidentiality of both the reporter and the patient whose case is reported are protected by the FDA Explanation. Reporting o f problems with OTC medications are required when the product has been marketed with the new drug application. Reporting to manufacturers is not described in the FDAs guidelines although a section o f the Med Watch form can be checked off to inform the FDA that a copy o f the report has been forwarded into the manufacturer by the reporter.

Reviewing, Dispensing, and Compounding Prescription

A deadline is negative inspiration. Still, it's better than no inspiration at all.

Rita Mae Brown

3. A. B. C. D. E.

Which o f the following is NOT true about prescriptions? nondrug products could be ordered by prescriptions prescriptions should be presented in written form only pharmacists are allowed to order new medications pharmacist are allowed to change the dose o f existing medication none

2. A. B. C. D. E.

A prescription should necessarily include the following information, EXCEPT patient information, including full name and address date on which the prescription was issued the strength o f the product for a combination o f active ingredients name and dosage form o f the product none

3. The name of the product written on the prescription can be I . proprietary name II .generic name III .chemical name A. B. C. D. E. I only I or IJ only I, II or III II only II or III only

4. A. B. C. D. E.

As needed [pro re nata (pm)] refills are usually interpreted as allowing for refills for 1 month 4 months 6 months ] 0 months 3 year

5. A. B. C. D. E.

Direction for the pharmacist in the prescription should include the following preparation (e.g., compounding) labeling explicit instruction on the quantity, schedule and duration for proper use A and B All of the above

6.

The Drug Enforcement Administration (DEA) number is written in the prescription in cases

A. B. C. D. E.

where the prescription is written by midlevel practitioner where the drug is categorized with the controlled substances where the prescription is presented electronically where refills are required all but D

7. I. II. III.

Which o f the following is NOT true about medication orders? only the generic name o f the drug should be written they are intended for ambulatory patients they may be presented electronically

A. B. C. D. E.

if I only is correct if III only is correct if I and II are correct if II and III are correct if I, II and III are correct

8.

Which o f the following information given in prescriptions should be interpreted to know the intent o f the prescriber. the name and address o f the prescriber the patients disease or condition requiring treatment the reason the order is indicated relative to the medical need o f the patient unit o f measurement and Latin abbreviations all o f the above

A. B. C. D. E.

9.

One o f the following need NOT be considered when evaluating prescription appropriateness?

A. the patients disease or condition requiring treatment B. whether a licensed practitioner, acting in the course and scope o f practice, issued the prescription in good faith, for a legitimate medical purpose C. the prescribers hand writing D. possible drug-drug, drug-disease, or drug-food interaction E. the prescribed route o f administration

10. Pharmacists are required to review medication profiles to ensure the appropriateness of prescriptions or medication orders. This is called A. B. C. D. E. therapeutic intervention drug utilization review prescription review avoiding errors prescription control

11. When performing a therapeutic intervention, the following information should be provided EXCEPT A. B. C. D. E. A brief description o f the problem A reference sourcc that documents the problem A description o f the clinical significance o f the problem Informing other staff members that an error was made A suggestion o f a solution to the problem

12. Out o f the possible resolutions that can help solve a problem or concern, documentation o f the results o f the intervention are required if A. B. C. D. E. the prescription or medication order is dispensed as written the prescription or medication order is not dispensed the prescription or medication order is altered and dispensed A and B B and C

13. When processing prescriptions and medication orders, the pharmacist may come across product preparation which include all the following EXCEPT,

A. B. C. D. E.

calculating and providing the correct amount/number o f the medication generic substitution o f a drug product assembling the different parts o f drug delivery units compounding o f extemporaneous prescription reconstitution o f a powdered drug to make suspensions or solutions

14. The reason for proper selection o f a packaging material or container include A. legal requirements B. to make it easier for the patients to take the medication so that they will be encouraged to stick to the treatment regimen C. to prevent deterioration of the drug product D. all o f the above E. all but C

15. The labeling o f the prescribed drug product must include all the following EXCEPT A. B. C. D. name and address o f the pharmacy initials o f the prescriber expiration date products brand or generic name

E. the number o f the prescription

16. Auxiliary and cautionary labels are required for the following reasons EXCEPT A. B. C. D. E. to enhance compliance to make sure that the medication is properly stored to make sure that the medication is taken properly to make sure the patient follows the advice given to him by the pharmacist none

17. One o f following information is NOT included in the patient profile system in the prescription files and records kept by the pharmacist A. B. C. D. E. birth date o f the patient weight o f the patient the pharmacological action o f the prescribed medication disease state o f the patient OTC medication used

18. The patient profile should also contain information from each prescription or medication order, which include all the following EXCEPT A. B. C. D. E. dosage form direction for the pharmacist amount o f the medication to be dispensed prescribers name pharmacists initials

19. When advising a patient about potential adverse effects, which o f the following instructions should the patient be given I. II. III. A. B. C. D. E. how frequent the adverse effect occurs ways to alleviate the adverse effect how severe the adverse effect could be if I only is correct if III only is correct if I and II are correct if II and III are correct if I, II and III are correct

20. In order to administer a medication properly, a health professional should have all the following information EXCEPT

A. B. C. D. E.

dosage and dosage regimen drug-drug and drug-nutrition interaction mechanism o f action o f the drug possible incompatibilities potential adverse effects

21. Which o f the following is NOT a drug-related prblems? A. B. C. D. E. incorrect dose o f a drug wrong assessment inappropriate compliance adverse drug reactions unnecessary drug use

22. Which of the following statements about compounding is NOT true? A. it involves the preparation, mixing, assembling, packaging, or labeling o f a drug or device B. it is initiated based on the pharmacist/patient/prescriber relationship in the course o f professional practice C. it may be done for the purpose o f research, teaching, or chemical analysis D. it could not be carried out unless there is a definite prescription order from a practitioner E. none

23. Manufacturing involves: A. packaging and repackaging o f substances B. production, preparation, propagation, conversion or processing o f a drug or device C. extraction o f drugs from substances o f natural origin or the chemical or biological synthesis o f drugs D. labeling or relabeling o f containers E. All o f the above

24. Which o f the following is NOT true about manufacturing and compounding? A. compounded drugs are not meant for reselling while the main objective manufacturing is resale o f drugs B. like in compounding, manufacturers are required to and provide oversight o f individual patients C. compounded drugs are produced and administered by the patients health care professionals, which is not in manufacturing D. in manufacturing the drug produced are through normal channels o f interstate commerce to individuals known to the company, while in compounding there is direct relationship between the pharmacist/prescriber/patient E. none

25. Extemporaneous compounding by the pharmacist or a prescription order from a licensed practitioner is controlled by A. B. C. D. E. FDA USP/NF State board o f pharmacy Department o f health All

26. One o f the following is NOT a responsibility o f a pharmacist A. B. C. D. E. preparing a quality pharmaceutical product providing proper instructions regarding its storage advising the patient of any adverse effects ensuring the correct drug, dose and directions to decide the products, which should not be prepared extemporaneously

27. The beyond-use day according to the current USP criteria for non aqueous liquid and solid formulations (where a manufactured drug product is the source o f active ingredients) is not later than 50% o f the time remaining until the products expiration date or 1 year, which ever is earlier A. not later than 25% o f the time remaining until the products expiration date or 6 months, whichever is earlier B. not later than 50% o f the time remaining until the products expiration date or 6 months, whichever is earlier * C. not later than 25% o f the time remaining until the products expiration date or 3 months, whichever is earlier D. not later than 90% o f the time remaining until the product's expiration date or 1 year, whichever is earlier

28. The beyond-use day according to the current USP criteria for nonaqueous liquid and solid formulations where a USP or NF substance is the source o f active ingredients is A. B. C. D. E. not not not not not later than later than later than later than later than 3 months 1 year 6 months 1 month 2 weeks

29. For water-containing products, prepared from ingredients in solid form and stored in cold temperatures, the beyond-use date is not later than A. B. C. D. 1 month 3 weeks 10 days 14 days

E. 45 days

30. All the following quality control tests are required for ointments/creams /gels EXCEPT A. B. C. D. E. pH specific gravity rheological properties dissolution characteristics active drug assay

31. One o f the following tests is NOT required for suppositories, troches, lollipops, and sticks A. B. C. D. E. melting test weight disintegration test dissolution test physical stability

32. Which o f the following tests are common to both oral and topical liquids as well as parenteral preparations? I. II. III. IV. A. B. C. D. E. weight/volume osmolality pH pyrogenicity I and III II and III I and IV Ill only I only

33. Which o f the following does NOT need special consideration in the compounding o f solutions? A. B. C. D. E. pH stability uniformity o f the dosage solubility o f the drug or chemicals packaging .

34. Which o f the following solutions require special attention for their preparation? A. oral solutions B. topical solutions C. otic solutions

D. ophthalmic solutions E. all o f the above

35. One of he following statements is NOT true aboutthe preparation o f solutions? I. flavoring and sweetening agents should be prepared while preparing the solution II. a salt should be directly added to a syrup III. the free acid or base form o f the drug should be used IV. if an alcoholic solution o f a poorly water-soluble drug is used, no water should be added A. B. C. D. E. I only II only Ill only IV only I, II, III, and IV

36. Choose the CORRECT statement about the compounding procedure o f the following medication order. Phenobarbital Ig Belladonna Tr 5ml Preserved flavored syrup q.s. 120ml I. the free-base form o f phenobarbital should be used II. the phenobarbital should first be dissolved in the tincture III. the phenobarbital should first be dissolved in the preserved flavored syrup A. B. C. D. E. I only I and II only II only I and III only Ill only

37. Why should a pharmacist use caution when preparing the following medication order? Salicylic acid 2% Lactic acid 6ml Flexible collodion ad 30ml A. B. C. D. E. salicylic acid and lactic acid are incompatible flexible collodion is incompatible with acids flexible collodion is inflammable the amount o f lactic acid is too high C and D

38. Which is the correct order o f mixing the components o f the medication order in question No. 17/96? A. salicylic acid; lactic acid; flexible collodion B. salicylic acid; flexible collodion, lactic acid

C. lactic acid, flexible collodion, salicylic acid D. flexible collodion, lactic acid, salicylic acid E. A and B

39. In compounding the following medication order, a plastic or rubber spatula should be used. Why? Iodine 2% Sodium iodide 2.4% Alcohol q.s. 30ml A. B. C. D. E. because alcohol reacts with iron because alcohol catalyses the reaction between iodine and iron because iodine is corrosive because there iron and sodium iodide are incompatible C and D

40. Which o f the following is NOT true about suspensions? A. B. C. D. E. some suspensions should contain an antimicrobial agent as a preservative particle settling could be avoided by using suspending agents tight containers are necessary to ensure the stability of the final product the suspension should be viscous insoluble powders should be small and uniform in size to decrease settling

41. Which o f the following does NOT help minimize the physical instability of suspensions after their formation? A. B. C. D. E. reducing the particle size o f the powders using thickening agents using levigating agents using preservatives using flavoring agents

42. One o f the following is NOT a levigating agent? A. B. C. D. E. glycerin methylcellulose propylene glycol alcohol water

43. Which o f the following is a WRONG procedure in the preparation o f suspensions? A. the insoluble powders should be triturated into fine powders B. the final mixture should be transferred to a tight bottle for dispensing to the
patient

C. the water soluble ingredients should be added at the end o f the preparation process D. suspensions should be labeled shake well E. suspensions should never be filtered

44. One o f the following does NOT help prevent the two phases o f an emulsion from separating into two layers, A. B. C. D. E. proportion o f oil and water emulsifying agent freezing use o f hand homogenizer none

45. The percentages o f methylparaben and propylparaben that can be used together as preservatives in emulsions are, respectively A. B. C. D. E. 1% and 2 % 0.1% each 0.2% and 0.02% 0.2% and 0.1% 0.2% each

46. Which o f the following can be used for preparing only o/w emulsions? I. II. III. IV. A. B. C. D. E. gums methylcellulose soaps nonionic emulsifying agents I only I and II II and III II and IV Ill and IV

47. The correct ratio o f acacia to fixed oil and acacia to volatile oil used in the preparation of emulsions is A. B. C. D. E. lg lg lg lg lg to to to to to 4ml 2ml 2ml 4ml 3ml and and and and and 1g to 1g to 1g to lg to 1g to 8ml 4ml 3ml 2ml 6ml respectively respectively respectively respectively respectively

48. Which o f the following is CORRECT about the formation and preparation o f emulsions?

A. B. C. D.

most o f the time a mortar and pestle are the only equipments required a rapid motion should be avoided while triturating a mortar with rough surface should be avoided the size o f the mortar should be exactly equal to the volume o f the emulsion to be prepared E. to create an emulsion trituration o f at least 10 minutes is required

49. Which o f the following methods used for compounding emulsions is different from the others? A. B. C. D. E. dry gum method wet gum method bottle method beaker method C and D

50. Which o f the following is NOT true about the preservation of emulsions? I. II. III. A. B. C. D. E. refrigeration is usually sufficient to keep emulsions for extended period o f time the product could be frozen for better preservation if preservative is used, it must be soluble in the oilphase of the emulsion 1 ,11 and III II and III I and III I and II II only

51. Given the following medication order, Mineral oil 18ml Acacia q.s. Distilled water q.s. ad 90ml Sig: ltbspq.d. I f a dry gum method is used for preparing the primary emulsion, the amount o f the oil, gum and water required is respectively A. B. C. D. E. 36ml, 18g, and 9ml 9ml, 18g, and 36ml 18ml, 9g, and 4.5ml 9ml, 18g, and 4.5ml 18ml, 4.5g, and 9ml

52. Given the medication order, mineral oil 50ml water q.s. 100ml

sig: 2.5ml p.o. h.s. One o f the following precautions should NOT be mentioned on the label affixed to the container? A. B. C. D. E. shake well for external use only should be kept below 0C protect from light none

53. Which o f the following can NOT be a reason for using powdered dosage forms? A. B. C. D. E. powders can overcome stability and solubility problems they can be used to dispense unpleasant tasting medications they may be used when the powders are too bulky to make into capsules they may be used if the patient has problem with swallowing capsules they may be used for internal and external purposes

54. All o f the following statements are true about the blending o f powders EXCEPT A. when heavy powders are mixed with lighter ones, the heaviest powders should be placed on the top o f the lighter ones B. stirring using a spatula is one o f the methods o f blending powders C. light powders are mixed best by using mortar D. the mortar and pestle method is preferred when pulverization and a thorough mixing of ingredients are desired E. when mixing two or more powders, it is very important that each powder should be pulverized separately to about the same particle size before blending together

55. Bulk powders include which o f the following A. B. C. D. E. dusting powders douche powders laxatives insufflations all of the above

56. A container with a sifter top is intended for A. B. C. D. E. effervescent powders hygroscopic powders dusting powders eutectic mixtures insufflations

57. Eutectic mixtures may cause problems because

A. B. C. D. E.

they can absorb moisture they deteriorate very easily they are not water soluble they liquefy when mixed all of the above

58. Which o f the following statements about powder papers is NOT true? A. they are also called divided powders B. glassine lining is required in case o f hygroscopic, effervescent and deliquescent powders C. the amount o f the ingredients required for one dose are weighed separately and the blended D. plastic bags or envelopes with snap-and-seal closures can also be used for packaging powders E. none

59. All o f the following are correct about the compounding procedure o f the medication order given below EXCEPT camphor 1OOmg menthol 200mg zinc oxide 800mg talc 1900mg M foot powder Sig: apply to feet A. B. C. D. E. the camphor and menthol may be triturated in glass mortar geometric dilution may be used the product may be dispensed in a container with sifter top the final powder may be passed through a wire mesh sieve none

60. Which o f the following is the largest capsule in size? A. B. C. D. E. capsule No.l capsule No.2 capsule No. 00 capsule No. 0 capsule No. 5

61. The largest capsule size suitable for patient use is A. B. C. D. No. 0 No. 1 No. 2 No. 3

E. No. 4

62. What would be the best solution, if the amount o f the drug to be encapsulated under fills a larger capsule and over fills a smaller capsule? A. B. C. D. E. to use both capsule sizes to use the smaller one to use the larger one to avoid the use o f capsules all the above are possible

63. Which o f the following dosage forms does NOT match with its description? A. B. C. D. E. ointments; oleaginous creams; o/w or w/o emulsions jellies; suspensions gels; high content o f solids A and B

64. Ointments, creams, pastes and gels are intended A. B. C. D. E. to act on the surface o f the skin to carry drugs that penetrate into the skin to carry drugs that will be absorbed systemically A and B A,B&C

65. One o f the following statements about ointment bases is NOT true A. B. C. D. E. hydrophobic bases contain a mixture o f fats, oils, and waxes hydrophobic bases are emulsion bases the o/w emulsions can easily be washed o ff with water hydrophobic bases cannot be washed o ff using water C and D

66. The most suitable container for ointments is A. B. C. D. E. jars collapsible tubes chartulae narrow mouthed bottles A and B

67. Suppositories are inserted into the following human body orifices EXCEPT

A. B. C. D. E.

vagina rectum mouth Urethra None

68. The suppository base, which is fat-soluble mixture o f triglycerides that is most often used for rectal suppositories is A. B. C. D. E. Cocoa butter PEG Carbowax Glycerinated gelatin A and C

69. Suppository molds could be made from: A. B. C. D. E. stainless steel aluminum plastic rubber All o f the above

70. The fusion method o f preparing suppositories involves A. dissolving the all the ingredients in a volatile solvent, pouring these into a special mold and finally evaporating the solvent B. triturating the ingredients in a mortar to form a plastic like material and molding the suppositories using your fingers C. triturating the ingredients in a mortar to form a plastic like material and putting the this plastic like material in suppository compression device D. melting the suppository base, incorporating the medication and finally pouring the mixture into a mould E. A and D

71. Given the following medication order, calculate the amount o f suppository base required to make 10 suppositories o f 2g (hint: calculate for two extra suppositories, the density factor o f aspirin is 1.1) aspirin 300mg Cocoa butter q.s. Dispense 10 suppositories Sig: insert one supp once daily A. B. C. D. 30.5g 20.73g 25.43g 19.74g

E. 23.32g

72. Which of the following is a WRONG procedure in reconstitution of a dry powder from a vial? A. the surface o f the vial containing the sterile powder should be cleaned using alcohol pad B. after dissolving the powder, the vial should be in the inverted position to withdraw the desired volume C. the volume o f the syringe used for reconstitution should be exactly equal to the volume required for reconstitution D. a sterile cap or seal should be applied over the port o f the container E. none

73. A 5jam filter should be attached to the syringes when removing fluids from A. B. C. D. E. vials ampoules IV bags Prefilled cartridges All but A

74. Which of the following is NOT true about parenteral preparations? A. special knowledge and training is required to prepare parenterals B. they must be prepared using aseptic techniques C. all parenteral products must be administered directly from their container without further processing D. parenteral preparations could be prepared outside hospital pharmacies E. C and D

75. Which of the following is a WRONG procedure in the removal o f drug solutions from vials? A. B. C. the surface of the rubber closure should be swabbed with alcoholprep pad the needle must be inserted into the rubber closure at 90 [I a sterile air should be inserted into the vial to help remove the drug and to prevent the formation of negative vacuum pressure D. the rubber closure must be opened only for very brief period o f time to allow the removal of the drug solution E. B and D

Answers Reviewing and Dispensing Prescriptio


1. Answer: B. prescriptions should be presented in written form only. Explanation: Prescriptions are orders for medications, non drug products, and services that are written by a licensed practitioner or midlevel practitioner who is authorized by state law to prescribe. Pharmacists are increasingly being given prescribing privileges by enactment o f state collaborative drug therapy management (CDTM) legislation. This allows pharmacists to order new medication or change the dose existing medication under established protocols or guidelines agreed upon by the pharmacist and physician. Prescriptions may be written, presented orally (by telephone), or presented electronically (i.e., via fax or computer network) to the pharmacist. 2. Answer: C. the strength o f the product for a combination o f active ingredients. Explanation: The strength o f the product is not required if only one strength is commercially available or if the product contains a combination o f active ingredients. It is advisable to include the strength to reduce the chance o f misinterpretation the prescription. If the dose is to be calculated by the pharmacist, then the pharmacist can decide the strength o f the product dispensed after calculating the patients dose.

3. Answer: C. I, II or III.

Explanation: The name o f the product written on the prescription can be any o f the three mentioned above.

4. Answer: E. 1 year Explanation: I f refill is not supplied, it is generally assumed that no refills are authorized. As needed [pro re nata (pm)] refills are usually interpreted as allowing for refills for 1 year.

5. Answer: D. A and B Explanation: The explicit instructions on the quantity, schedule and duration for proper use are the directions intended for the patient. As directed should be avoided when giving instructions to the patient. If the directions vary, a minimum and maximum dose can be used. 6. Answer: B. where the drug is categorized with the controlled substances. Explanation:

Prescriber information written on the prescription should include the name, office address, signature o f the prescriber, and the Drug Enforcement Administration (DEA) number should be mentioned for controlled substances only.

7. Answer: C. 1 and II are correct Explanation: Medication orders are orders for medications by an individual authorized to prescribe and are intended for use by patients while in an institutional setting. They may be written, presented orally (by telephone), or presented electronically (i.e., via fax or computer network) to the pharmacist. The name o f the drug written on the prescription can be brand name, generic name, or chemical name. Medication orders do not have directions for patients. Instead, instructions are given to the administration, which includes quantity, route o f administration, schedule, and duration.

8. Answer: E. All o f the above. Explanation: A complete understanding o f all information contained in prescription or medication orders is required. Upon arrival o f the prescription or the medication order the pharmacist must read the entire prescription or medication order carefully to determine the prescribers intent by interpreting all the above mentioned information. Moreover, the name and address o f the patient, and the name o f the product, the quality prescribed, and instruction for use should also be studies carefully. 9. Answer: C. the prescribers hand writing. Explanation: Although the handwriting o f some prescribers can create certain difficulties, it is not considered when evaluating the appropriateness of the prescription. The pharmacist is more concerned about the appropriateness o f the prescription to the particular patient.

10. Answer: B. drug utilization review. Explanation: Pharmacists are required to review medication profiles to ensure the appropriateness o f prescriptions or medication orders. This is commonly called drug utilization review (DUR). Pharmacist should not fill prescriptions or medication orders that they have concerns with or that are considered inappropriate, but rather, should contact the prescriber. The process o f calling a prescriber to discuss concerns identified during a DUR is commonly called therapeutic intervention. 11 .Answer: D. Informing other staff members that an error was made. Explanation: Informing other staff members that an error was made by some prescriber may affect the pride o f the prescriber and may lead to loss o f confidence in the prescriber. This can lead to confrontation as well as lack o f cooperation and this will not help resolve the problem.

12 .Answer: C. the prescription or medication order is altered and dispensed. Explanation: Documentation o f the results o f a therapeutic intervention are required if the prescription or medication order is changed. The name o f the prescriber, date o f the communication, issues discussed, and resolution should be included in the documentation. This information should be kept for same time period as the prescription or medication order.

13.

Answer: B. generic substitution of a drug product.

Explanation: Generic substitution o f a drug product is not classified as product preparation. It is part o f product selection. 14. Answer: D. all o f the above. Explanation; The reasons for the proper selection o f a packaging material or container is that it is required by the law that each drug product should be packaged in a container that is appropriate for it; to make the patients more compliant since packaging material or container that is properly designed would make it easier for them to take the prescribed medication; and to ensure the drug product is protected from the external environment to prevent its deterioration and thus enhance its stability.

15. Answer: B. initials o f the prescriber. Explanation: The prescribers initials cannot be included in the prescription label, since s/he cannot be available when the medication is dispensed. Instead the initials of the pharmacist must be included. Other information that should be included are the name o f the patient, the date o f filling, instructions on how to use the medication, manufacturers name, the name o f the prescriber, the amount o f the medication dispensed, and product strength if more than one strengths are available.

16.Answer: E. none. Explanation: Auxiliary and/or cautionary labels are affixed to ensure the proper use o f medication, to encourage patient compliance, to inform the patient that the medication need to be stored in a proper place, and to reinforce the information given to the patient by the pharmacist during dispensing the medication. 17. Answer: C. the pharmacological action o f the prescribed medication.

Explanation: Birth date and weight o f the patient are important to make sure that the proper dose is given. The disease state o f the patient helps to assess if the proper medication was prescribed and to avoid

the possibilities o f drug-disease interaction. OTC medication use is important to avoid drug-drug, as well as drug-disease interactions, to assess the effectiveness o f the medication taken, and to identify the occurrence o f any adverse effect. Other information that need to be included are patients name; patients address; previous allergies, sensitivities, or idiosyncratic reactions; and occupation o f the patient that will help to identify the conditions associated with a particular occupation and to help determine if the patient may have any problem complying with the prescribed prescription.

18. Answer: B. direction for the pharmacist Explanation: The information obtained form each prescription or medication order that should be included in the patient profile include, name o f the product, dosage form and strength o f the product, prescription number, instruction for use, the amount o f the drug to dispensed, prescribers name, the initials o f the pharmacist, dispensing date, and the number o f the refills authorized and the number o f the refills left. 19.Answer: E. I, II and III. Explanation: It is the responsibility o f the pharmacist to make sure that the patient knows all the potential adverse effects o f the medication. Moreover, the pharmacist must ensure that the patient understands the frequency of occurrence o f the adverse effect (this will help the patient to identify the common adverse effects); the ways o f alleviating the adverse effects and their consequences (this will enable the patient to manage the adverse effects properly); and the severity o f the adverse effects (so that the patient could give proper attention to the most severe adverse effects).

20.

Answer: C. mechanism o f action o f the drug.

Explanation: It is not necessary that a health professional need to know the mechanism o f action o f a drug in order to administer the medication properly. Other information that the health professional need to know include the proper choice o f the drug product, the route o f administration, appropriate handing o f the drug product, potential interference o f the drug with laboratory results, the overall cost o f the drug product, nutritional requirements as well as the safe way o f disposing the medication.

21.Answer: B. Wrong assessment. Explanation: Although it is possible that wrong assessment o f a patient condition could lead to drug-related problems, it is not by itself a drug related problem.

22. Answer: D. it could not be carried out unless there is a definite prescription order from a practitioner. Explanation:

Compounding includes the preparation o f drugs and devices in anticipation o f prescription drugs based on routine, regularly observed patterns. 23. Answer: E. All o f the above Explanation: In addition to this, manufacturing involves the promotion and marketing o f drugs and devices. It also includes the preparation and promotion o f commercially available products from bulk compound for resale by pharmacies, practitioners, or other persons. 24. Answer: B. like in compounding, manufacturers are required to and provide oversight o f individual patients. Explanation: Manufacturers are not required to, and do not, provide oversight of individual patients. Compounded drugs on the other hand are personal and responsive to the patients immediate needs.

25. Answer: C. State board o f pharmacy. Explanation: As with the dispensing o f any other prescription, extemporaneous compounding by the pharmacist or a prescription order from a licensed practitioner is controlled by the state broads of pharmacy.

26. Answer: E. to decide the products, which should not be prepared extemporaneously Explanation: The FDA determines the list products that are not safe and/or effective to be prepared extemporaneously. It is important to note that certain dosage forms o f one drug are allowed to be prepared extemporaneously while other dosage forms of the same drug are not allowed.

27. Answer: B. not later than 25% of the time remaining until the products expiration date or 6 months, whichever is earlier. Explanation: The beyond-use day according to the current USP criteria for non aqueous liquid and solid formulations (where a manufactured drug product is the source o f active ingredients) is not later than 25% o f the time remaining until the products expiration date or 6 months, whichever is earlier.

28. Answer: C. not later than 6 months. Explanation: The beyond-use day according to the current USP criteria for non aqueous liquid and solid formulations where a USP or NF substance is the source o f active ingredients is not later than 6 months.

29. Answer: D. 14 days. Explanation: For water-containing products, prepared from ingredients prepared from ingredients in solid form and stored in cold temperatures, the beyond-use date is not later than 14 days.

30. Answer: D. dissolution characteristics. Explanation: Testing the dissolution characteristics is not required in case o f ointments/creams /gels. Other tests to be considered include physical observation (color, clarity, texture-surface, texture-spatula spread, appearance, feel) and theoretical weight compared to actual weight.

31. Answer: C. disintegration test. Explanation: The quality control tests required for suppositories, troches, lollipops, and sticks include weight, specific gravity, active drug assay, physical observation (color, clarity, texture of surface, appearance, feel), melting test, dissolution test, and physical stability.

32. Answer: A. 1 and III. Explanation: Osmolality and pyrogenicity tests are not required for oral and topical preparations, because these preparations are not sterile.

33. Answer: C. uniformity o f the dosage. Explanation: By definition, solutions are liquid preparations that contain one or more chemical substances dissolved (i.e., molecularly dispersed) in a suitable solvent or mixture o f mutually soluble solvents. Therefore, the uniformity o f the dosage form in a solution may be assumed. However, the stability, pH, solubility o f the drug or chemicals, tastes (for oral solutions), and packing need special attention.

34. Answer: D. ophthalmic solutions. Explanation: Parenteral and ophthalmic solutions should be sterile. Therefore, they need special attention when being prepared. The others are all non-sterile solutions.

35. Answer: E. I, II, III, and IV. Explanation:

If an alcoholic solution o f a poorly water-soluble drug is used. The aqueous solution is added to the alcoholic solution to maintain as high an alcohol concentration as possible. The salt form o f the drug, and not the free-acid or base form, which both have poor solubility, is used. Flavoring or sweetening agents should be prepared ahead o f time. When adding a salt to syrup, dissolve the salt in a few milliliters of water first; then add the syrup to volume. 36. Answer: E. Ill only. Explanation: The correct compounding procedure for the above medication order is the following. The sodium salt o f phenobarbital (equivalent to 1g o f the phenobarbital) should be used. This salt should be dissolved in the preserved, flavored syrup. The solution is then slowly added, in individual portions, to the tincture contained in a beaker and is stirred continuously.

37. Answer: C. flexible collodion is inflammable. Explanation: Pharmacists must use caution when preparing this prescription because flexible collodion is extremely flammable.
38. A nsw er: A . salicylic acid; lactic acid; flexib le collodion.

Explanation: The correct procedure o f compounding the above prescription is the following. A 1-oz applicator tip bottle is calibrated, using ethanol, which is poured out and allowed to evaporate, resulting in a dry bottle. Salicylic acid is directly added into the bottle, to which is added the 6ml o f lactic acid. The bottle is agitated or a glass stirring rod is used to dissolve the salicylic acid. Flexible collodion is added up to the calibrate 30ml mark on the applicator tip bottle.

39. Answer: C. because iodine is corrosive. Explanation: In compounding the above medication order, rubber or plastic spatula should be used, because iodine is corrosive.

40. Answer: B. particle settling could be avoided by using suspending agents. Explanation: Particles settle in suspensions even when a suspending agent is added; thus, suspensions must be well shaken before use to ensure the distribution o f particles for a uniform dose.

41. Answer: E. usine flavoring agents.

Review ing, Dispensing, and Compounding Prescription

Compounding includes the preparation o f drugs and devices in anticipation o f prescription drugs based on routine, regularly observed patterns. 23. Answer: E. All o f the above Explanation: In addition to this, manufacturing involves the promotion and marketing o f drugs and devices. It

42. Answer: B. methylcellulose Explanation: A levigating agent aids in the initial dispersion o f insoluble particles. Common levigating agents include glycerin, propylene glycol, alcohol, syrups and water. Methycellulose is used as thickening agent in the preparation o f suspensions.

43. Answer: C. the water soluble ingredients should be added at the end o f the preparation process. Explanation: The water-soluble ingredients, including flavoring agents, are mixed in the vehicle before mixing with insoluble ingredients.

44. Answer: C. freezing. Explanation: Emulsions are unstable, and the following steps must be taken to prevent the two phases o f an emulsion from separating into two layers after preparation. The correct proportions o f oil and water should be used during preparation. The internal phase should represent about 40%-60% o f the total volume. An emulsifying agent is needed for emulsion formation. A hand homogenizer, which reduces the size o f globules o f the internal phase, may be used. Preservative should be added if the preparation is intended to last longer than a few days. A shake well label should be placed on the final product. The product must be protected from light and extreme temperatures. Both freezing and heat may have effect on stability.

45. Answer: C. 0.2% and 0.02%. Explanation: Generally, a combination o f methylparaben (0.2%) and propylparaben (0.02%) may be used as preservatives for emulsions 46. Answer: B. I and II. Explanation: Gums, such as acacia or tragacanth, are used to form o/w emulsions. Methylcellulose and carboxymethylcellulose are used for o/w emulsions. Soaps and nonionic emulsifying agents can be used for both o/w and w/o emulsions depending on their emulsification properties. 47. Answer: D. lg to 4ml and lg to 2ml respectively. Explanation: In the preparation o f emulsions, one gram o f acacia powder is used for every 4ml o f fixed oil or lg to 2 ml for a volatile oil.

48. Answer: A. most o f the time a mortar and pestle are the only equipments required.

Explanation: A mortar and pestle are frequently the only equipments required for the preparation o f emulsions. A mortar with rough surface (e.g., Wedgwood) should be used. This rough surface allows maximal dispersion o f globules to produce a fine particle size. A rapid motion is essential when triturating an emulsion using a mortar and pestle. The mortar should be able to hold at least three times the quantity being made. Trituration seldom requires more than 5 minutes to create the emulsion.

49. Answer: D. beaker method. Explanation: : Beaker method is different from the other three methods in that all the other methods (i.e., wet gum method, dry gum method and bottle method) are for forming emulsions using natural emulsifying agents and require a specific mixing order. On the other hand, beaker method is used for forming emulsions using synthetic emulsifying agents and produces a satisfactory product regardless o f the order o f mixing.

50. Answer: B. II and III. Explanation: Emulsions should not be allowed to freeze at any time. If a preservative is used, it must be soluble in the water phase to be effective, since microorganisms can grow only in the water phase o f an emulsion. 51. Answer: E. 18ml, 4.5g, and 9ml. Explanation: With the dry gum method the amount o f oil, gum, and water required to form the primary emulsion is: 4 parts o f the oil, 2 parts o f water and 1 part o f gum. Therefore, to prepare the primary emulsion o f the above medication order, 18ml o f mineral oil, 4.5g o f powdered acacia, and 9ml o f distilled water is required.

52. Answer: C. should be kept below 0C. Explanation: Since it is not advisable to freeze emulsions, they should not be kept at a freezing temperature.

53. Answer: B. they can be used to dispense unpleasant tasting medications. Explanation: Powders are not suitable for medications that have unpleasant taste. In fact, this is one o f the disadvantages o f using powders. 54. Answer: C. light powders are mixed best by using mortar. Explanation:

Light powders are mixed best by using the sifting method. The sifting is repeated three to four times to ensure thorough mixing o f the powders.

55. Answer: E. All o f the abvoe Explanation: Bulk powders, which may be used internally or topically, include dusting powders, douche powders, laxatives, insufflations, and antacids.

56. Answer: C. dusting powders. Explanation: After a bulk powder has been pulverized and blended, it should be dispensed in an appropriate container. Hygroscopic and effervescent powders should always be placed in a tight, wide mouthed jar. Dusting powders should be placed in a container with a sifter top.

57. Answer: D. they liquefy when mixed. Explanation: Eutectic mixtures are problematic in that, their melting point is decreased when they are mixed as a result o f which they liquefy upon mixing. One remedy is to add an inert powder, such as magnesium oxide, to separate the eutectic materials.

58. Answer: C. the amount o f the ingredients required for one dose are weighed separately and the blended. Explanation: Incase o f powder, the entire powder is initially blended. Each dose is then individually weighed.

59. Answer: E. none Explanation: The compounding procedure o f the above medication order o f as fol!ows:the camphor and menthol are triturated in a glass mortar, where a liquid eutectic is formed. The zinc oxide and talc are blended and mixed with the eutectic, using geometric dilution. This mixing results in a dry powder, which is passed through a wire mesh sieve. The final product is dispensed in a container with a sifter top.

60. Answer: C. capsule No. 00. Explanation: The capsule size in increasing order o f powder capacity is: No. 5, 4, 3, 2, 1,0, 00, and 000. Therefore, o f the above given capsules, capsule No.00 is the largest. These capsules are for human use. Capsules for veterinarians are available in Nos. 10, 11. and 12, containing approximately 30, 15 and 7.5g , respectively.

61. Answer: A. No. 0. Explanation: Capsule No. 0 is usually the largest oral size suitable for patients.

62. Answer: C. to use the larger one. Explanation: In such cases, it is advisable to use the larger capsule. The remaining space can be filled with sufficient amount o f diluents such as lactose.

63. Answer: D. gels; high content o f solids. Explanation: Ointments, creams, and pastes are semisolid dosage forms intended for topical application to the skin or mucous membranes. Ointments are characterized as being oleaginous in nature; creams are generally o/w or w/o emulsions, and pastes are characterized by their high content o f solids (about 25%). Gels (sometimes called jellies) are semisolid systems consisting o f suspensions made up o f either small inorganic particles or large organic molecules interpenetrated by a liquid.

64. Answer: E. A,B &C Explanation: Ointments, creams, pastes, and gels are semisolid preparations generally applied externally. They are applied for the following purposes: act solely on the surface o f the skin to produce local effect (e.g., antifungal agent); to release the medication, which in turn, penetrates into the skin (e.g., cortisol cream); and to release medication for systemic absorption through the skin (e.g., nitroglycerin).

65. Answer: B. hydrophobic bases are emulsion bases. Explanation: Hydrophilic bases are usually emulsion bases. The o/w type emulsions can easily washed off with water, but the w/o type is slightly more difficult to remove.

66. Answer: E. A and B. Explanation: For easy removal o f the preparation, ointments should be packaged in wide opened jars or in collapsible tubes.

67. Answer: C. mouth Explanation:

Suppositories are solid bodies o f various shapes and weights, adapted for introduction into the rectal, vaginal, or urethral orifices o f the human body. They usually melt or, soften, or dissolve at body temperature. They may act as protectants to the local tissue at the point o f introduction or as carrier agents for systemic or local action.

68. Answer: A. Cocoa butter. Explanation: : Cocoa butter (theobroma oil), which melts at body temperature, is fat-soluble mixture o f triglycerides that is most often used for rectal suppositories. Polyethylene glycol (PEG, Carbowax) derivatives are water-soluble bases suitable for vaginal and rectal suppositories. Glycerinated gelatin is water-miscible base often used in vaginal and rectal suppositories.

69. Answer: E. All o f the above Explanation: All the above materials could be used in the manufacture o f suppository molds.

70. Answer: D. melting the suppository base, incorporating the medication and finally pouring the mixture into a mould. Explanation: In the fusion method o f preparing suppositories, small amount o f the base is melted. The finely powdered drug is added to this with continuous stirring. The remainder o f the suppository is added with stirring. The mixture is finally poured into the lubricated molds.

71.Answer:B. 20.73g. Explanation: Calculating for two extra suppositories, the total weight o f 12 suppositories would be 24g; and 3.6g (12 x 300mg) o f aspirin will be required. 3.6g o f aspirin divided by 1.1, the density factor of aspirin, gives 3.27. Therefore, 3.6g o f aspirin displaces 3.27g o f cocoa butter. The amount of cocoa butter required will be 24-3.27, or 20.73g.

72. Answer: C. the volume of the syringe used for reconstitution should be exactly equal to the volume required for reconstitution. Explanation: The syringe chosen for reconstitution should have a volume which is slightly greater than the volume required for reconstitution.

73. Answer: B. ampoules. Explanation:

Because glass particles may become dislodged during ampoule opening, the product must be filtered before administration. For this purpose, a filter should be attached to the syringe when removing fluids from ampoules.

74. Answer: C. all parenteral products must be administered directly from their container without further processing. Explanation: Not all parenteral preparations need to be administered directly without further processing. Some drugs, which are unstable in solution form, are packaged as dry powders. Such drugs are to be reconstituted into solution with the proper solvent just before they are administered. Moreover, some drug solutions may be packaged in their concentrated form. These drugs are to be diluted before they are administered. 75. Answer: E. B and D. Explanation: The rubber closure is never to be opened at any time. Drug solutions are removed by injecting a need through the rubber closure at angle o f 90.

Asthma and Chronic Obstructive Pulmonary Disease

Failure is the opportunity to begin again, more intelligently

Henry Ford

1. Which o f the following statements is FALSE about Asthma? A. It is a chronic inflammatory disorder o f the airways. B. It is a syndrome which develops as a result o f bacterial infection only. C. It involves a complex interaction between many cells and inflammatory mediators. D. It is characterized by obstruction which may be partially or completely reversible after treatment E. None

4. Asthmatic reactions to drugs may occur due to: A. Hypersensitivity B. As an extension o f the pharmacological effect. C. Administration o f a drug to induce asthmatic syndromes. D. All o f the above E. A and B only

5. All o f the following drugs are implicated in induction o f asthmatic syndrome EXCEPT: A. B. C. D. E. Aspirin Ibuprofen Bethanechol Ephedrine None

2. Classification o f asthma based on severity plays an important role in determining the most appropriate pharmacotherapeutic approach and is determined by: A. Symptoms B. Treatment requirements C. Objective measurement o f lung function D. All o f the above E. A and B only

6. All o f the following characteristics have been identified on postmortem examination o f patients with asthma EXCEPT: A. Hypertrophy o f smooth muscle B. Vasoconstriction o f the vasculature C. Collagen deposition in basement membranes D. Airway containing plugs consisting o f inflammatory cells and their debris . proteins, and mucus. E. Denuded airway epithelium

3. One o f the following symptoms classifies asthma as Mild intermittent A. The symptoms occur more than two times a week but not every day; exacerbations may affect activity. B. Daily symptoms; daily use o f inhaled short-acting (3-agonist; exacerbations affect activity; exacerbations more than 2 times a week and may last days. C. Symptoms occur less than 2 times a week; asymptomatic between exacerbations; exacerbations brief from a few hours to a few days. D. Continual symptoms, limited physical activity and frequent exacerbations.

7. Which o f the following cells are involved in secretion o f inflammatory mediators and influences the airways in asthmatic conditions? A. B. C. D. E. F. Mast cells Eosinophils Erythrocytes Reticulocytes A and B C and D

8. Which o f the following are causes o f airway obstruction in asthmatic patients? A. Bronchoconstriction B. Air wall edema C. Mucus plug formation D. AH o f the above E. B and C only

12. Which of the following statements is NOT TRUE? A. The early asthmatic response can be blocked by the administration o f pagonist. B. The early asthmatic response begins within 30 minutes o f trigger exposure. C. The late asthmatic response is characterized by persistent airflow obstruction, airway inflammation, and bronchial hyperresponsivness. D. The late asthmatic response does not respond to administration of corticosteroids. E. None

9. In asthma, Airway inflammation contributes to the development of: A. B. C. D. E. Airway widening Air way hyper-responsiveness Respiratory symptoms All o f the above B and C only

10. Air way remodeling is a condition which may lead to airway obstruction in asthma. Which o f the following statements best describes airway remodeling? A. It is a condition which occurs due to inflammation and is characterized by subbasement collagen deposition and fibrosis B. It is bronchoconstriction which occurs due to increase o f parasympathetic receptors in the airways. C. It is congenital narrowing o f the airways. D. It is hypersensitivity which occurs in patients taking antiasthmatic drugs. E. None

13. Which one o f the following anti inflammatory drugs is used in blocking asthmatic response? A. Aspirin B. Ibuprofen C. Naproxen D. Cromolyn sodium E. None

14.The main event(s) in asthma include A. Triggering B. Signaling C. Migration D. Cel] activation E. All o f the above

11. In the triggering stage o f asthma, after exposure to an allergic trigger the antigen binds to: A. B. C. D. E. IgM IgG IgE IgA IgD

15. All of the following are signaling chemicals released by signaling cells which attract additional inflammatory cells to the airways EXCEPT: A. Cytokines B. Eicosanoids C. Corticosteroids D. Leukotrienes E. Chemokines

16. In the migration phase o f an asthmatic attack, in addition to the migration o f inflammatory cells, cells in the circulation are attracted to the airways by: A. Erythrocytes B. Adhesion molecules C. Antibodies D. Enzymes E. None

B. Marked respiratory distress, loud wheezing, coughing, difficulty speaking, accessory chest muscle use, and chest hyperinflation C. Severe respiratory distress, confusion, lethargy, cyanosis and disappearance o f breath sounds. D. Mild dyspnea and wheezing E. None o f the above

21 .In which o f the following stages o f an acute asthmatic attack, arterial pH may be increased? A. Mild B. Moderate C. Severe D. Respiratory failure E. A and B

17. Which o f the following chemical signals appears to be the most important in the cell activation phase o f asthma? A. B. C. D. E. Chemokines Eicosanoids Cytokines Leukotrienes None

22. Which o f the following pulmonary function test parameters are increased during an acute exacerbation o f asthmatic? A. Forced expiratory volume in 1 second B. Forced vital capacity C. Residual volume D. Total lung capacity E. C and D

18. In asthmatic conditions leukotrienes appear to be important in the development of: A. Bronchoconstriction B. Decreased mucus production C. Increased vascular permeability D. All o f the above E. A and C only

19. All o f the following are common findings in acute exacerbations o f asthma EXCEPT: A. Shortness o f breath B. Wheezing C. Bradycardia D. Cough E. Chest tightness

23. Which o f the following statements is FALSE about peak expiratory flow rate? A. It correlates well with forced expiratory volume in 1 second (FEV1). B. It is used in assessment o f therapy, trigger identification and assessment o f the need for referral to emergency care. C. It is used in making the diagnosis of asthma. D. Its monitoring is recommended for patients who have had severe exacerbations. E. FEFR is best measured in early morning, before medication administration

20. The symptoms o f severe asthma include A. Respiratory distress at rest and marked wheezing

24.Airway hyper responsiveness and less than adequate asthma control is inferred if the diurnal variation in PEFR measurement is greater than. A. B. C. D. E. 15% 10% 100% 20% None

A. Minimal or no chronic symptoms day or night B. No limitations o f activities C. Minimal or no exacerbations D. Minimal or no adverse effects from medications. E. All o f the above

29. Which o f the following statements is NOT TRUE about the stepped approach in the management o f asthma? A. In the step-down approach the therapy starts one step above the patients assessed asthma severity to give rapid disease control. B. In the step-down approach the therapy starts one step below the patients assessed asthma severity to give rapid disease control. C. In the step-up approach the therapy begins with a treatment regimen at the same step as the patient's asthma severity to give rapid disease control. D. The more aggressive step-down approach is advocated by experts. E. A&C

25. Which o f the following instruments is used in assessing the degree o f hypoxemia during an acute exacerbation o f asthma? A. Sphygmanometer B. Viscometer C. Osmometer D. Oximeter E. None

26.Electrocardiogram may be used as a diagnostic test in asthma. In asthma an electrocardiogram may show: A. Sinus tachycardia B. A trio-ventricular block C. Sinus Bradycardia D. Tachyarrthymias E. None

30. Which o f the following statements is FALSE about prevention and treatment of exercise induced bronchospasm in , asthmatic patients? A. Patients should be advised that a warm-up period might be helpful in preventing exercise induced bronchospasm. B. Exercise induced bronchospasm can be prevented by administration o f a short acting P-agonist 15 minutes before exercise. C. Cromolyn sodium has been shown to be ineffective in the management o f exercise induced bronchospasm. D. Regardless o f the prophylactic approach, all patients who experience exercise induced bronchospasm should have a short-

27. All o f the following are signs of respiratory distress (in asthma) EXCEPT: A. Declining mental status B. Inability to speak C. Cyanosis D. Peak expiratory flow rate more than 90%. E. Absence o f respiratory sounds

28. The goals in the treatment o f asthma include:

acting p-agonist available for treatment o f breakthrough symptoms. E. None

31. Some diseases frequently co-exist with asthma .Which o f the following diseases may lead to improved control o f asthma if they are adequately controlled?

A .Allergic rhinitis B. Sinusitis C. Gastro-esophageal reflux disease D. All o f the above E. A and B only

A. Systemic administration o f these agents should be reserved for patients who cannot use inhalation therapy. B. When prescribed with other inhaled agents, they are usually administered first. C. Regimens with long-acting agents should also include a concurrent inhaled corticosteroid D. All regimens containing long-acting agents should also include a shortacting agent for treatment o f acute symptoms. E. They should only be used in combination with a corticosteroid in the prevention o f exercise induced bronchospasm.

32.Condition(s) for which Long acting P~ agonists are indicated is(are): A. In the prophylaxis o f exercise induced bronchospasm. B. In patients with chronic obstructive pulmonary disease. C. Maintenance treatment o f moderate persistent asthma in combination with corticosteroids. D. Maintenance treatment o f severe persistent asthma in combination with corticosteroids. E. All o f the above

35. Which o f the following p-agonists is associated with induction o f myocardial ischemia, myocardial necrosis, and arrhythmias because o f excessive cardiac stimulation? A. Albuterol B. Isoproterenol C. Bitolterol D. Pirbuterol E. None

33. All o f the following are effects o f stimulation o f p2receptors EXCEPT: A. Insulin secretion B. Tremor C. Glycolysis D. Activation o f Na+ , K+ -adenosine triphosphate (ATPase) E. Gluconeogenesis

36.Tachyphylaxis can occur with regular use o f inhaled or oral p-agonists. The possible mechanisms o f this are: A. A decrease in the number o f P receptors due to movement o f receptors from the cell surface into the cell. B. A decreased sensitivity in the p receptors to stimuli, making them unable to activate adenyl cyclase. C. An increase in the number o f p receptors. D. An increased sensitivity in the P receptors to stimuli. E. A and B

34. Which o f the following statements is NOT TRUE about long acting p-agonists?

37. Levoalbuterol HC1 is comprised of: A. The R-isomer B. The S-isomer C. Racemic mixture C. A and B D. None

II. Inhibition o f release o f inflammatory genes. III. Increased transcription o f anti inflammatory genes. A. B. C. D. E. if I only is correct if III only is correct i f l & II are correct if II&III are correct if 1,11, and III are correct

38. Which o f the following statements is FALSE? A. If the dose o f Levoalbuterol is increased to 1.25 mg, the incidence of adverse reactions is similar to the corresponding dose o f albuterol. B. Concomitant use o f systemic 13agonists with monoamine oxidase inhibitors, tricyclic antidepressants, or methyldopa may lead to severe hypotension. C. P-agonists should not be combined with other sympathomimetic agents because of the additive cardiovascular effects. D. Systemic adverse reactions when the recommended starting dose o f Levoalbuterol is used appear to be similar to or slightly less frequent than the effects o f albuterol. E. None

41 . Which o f the following are desirable characteristics o f systemic corticosteroids for the treatment o f asthma? I. Good glucorticoid activity II. Minimal mineralocorticoid activity III. Minimal glucorticoid activity A. B. C. D. E. i f l only is correct if III only is correct if I & II are correct if II&III are correct if I,II, and III are correct

42. Which o f the following statements is NOT TRUE? A. Intravenous corticosteroids are administered to patients who are unable to take oral medications. B. Intravenous corticosteroids are the first line treatments in all asthmatic conditions. C. Oral corticosteroids are acceptable as emergency treatment if the patient can tolerate the oral route and is not believed to be in imminent danger o f respiratory arrest. D. There is no significant difference in the clinical efficacy o f the corticosteroid agents currently available. E. None

39. All o f the following are clinical effects o f corticosteroids EXCEPT: A. Reduced production o f inflammatory mediators. B. Enhanced p-adrenergic receptor expression. C. Increased mucus production D. Prevention of endothelial and vascular leakage. E. Decreased mucus production

40. The mechanism(s) by which Corticosteroids reduce inflammation include: I. Inhibition o f transcription genes of inflammatory genes.

43. Which o f the following are the most frequently used oral corticosteroids in the treatment o f asthma?

expectorate after administration. These are helpful for: A. minimizing orpharyngeal drug deposition B. minimize local adverse reactions C. minimize gastrointestinal absorption D. All o f the above E. A and B only 48. AH o f the following result in a decreased plasma concentration o f corticosteroids if they are concurrently taken EXCEPT: I. Rifampicin II. Hydantoins III.Cyclosporine A. if I only is correct B. if III only is correct C. if I & II are correct D. if II&III are correct E. if I,II, and III are correct

A. B. C. D. E.

Beclomethasone Budesonide Prednisone Prednisolone C and D

44. Inhaled corticosteroids should be used for chronic treatment o f asthma whenever possible because: A. They are less likely to produce adverse reactions. B. They are more effective than oral corticosteroids in all conditions. C. They are less effective than other oral corticosteroids. D. Their action is systemic. E. None

45. Careful monitoring is required when systemic corticosteroids are given to patients with: A. B. C. D. E. Heart failure Peptic ulcer disease Immunosuppressi on Osteoporosis All o f the above

49. Which o f the following antibiotics decrease the clearance o f corticosteroids? A. B. C. D. E. F. Erythromycin Clarithromycin Ampicillin Amoxicillin A and B C and D

46.The inhaled corticosteroid associated with short-term growth suppression o f approximately 1 cm in the first year o f its use is: A. B. C. D. E. Beclomethasone Fluticasone Flunisolide Budesonide None

50.Concurrent Administration o f corticosteroids with the following drugs results in an enhanced Hypokalemia: I. Thiazides II. Furosemide III. Amphotericin A. B. C. D. E. i f l only is correct if III only is correct if I & II are correct if II&III are correct if 1,11, and III are correct

47. Patients taking inhaled corticosteroids should gargle, rinse their mouth, and

51 .All o f the following are Leukotriene receptor antagonists EXCEPT: L Montelukast II. Zafirlukast III. Zileuton A. B. C. D. E. if l only is correct if III only is correct i f l & II are correct if II&III are correct if I,II, and III are correct

55.Zileuton is inhibitor o f the enzyme lipoxygenase, thereby inhibiting the synthesis of: A. B. C. D. E. Prostaglandins Histamines Thyroxine Leukotrienes None

56.Zileuton increases plasma concentrations of: A.Propranolol B.Terfenadine C.Theophylline D. All o f the above E. None o f the above

52. Which o f the following statements is FALSE about Leukotriene antagonists? I. they have anti-inflammatory activity II. they have bronchodilator activity III. they are more effective than inhaled corticosteroids A. B. C. D. E. i f l only is correct if 111 only is correct if I & II are correct if II&III are correct if 1,11, and III are correct

57. Which o f the following statements is(are) TR U Eabout cromolyn sodium and nedocromil sodium? A. They are nonsteroidal anti inflammatory drugs. B. They are less effective in their anti inflammatory effects than inhaled corticosteroids. C. They are frequently used in children because they have excellent safety profile. D. They prevent asthma induced by exercise, cold air and sulfur dioxide when used prophylactically. E. All o f the above

53.A serious adverse effect o f Leukotriene antagonists which occurred in patients whose chronic steroid regimens is tampered and discontinued is: A. B. C. D. E. Headache Dizziness Eosinophilic vasculitis Dyspepsia None

58.The mechanism o f action o f anti inflammatory effects o f Cromolyn sodium and nedocromil sodium is: A. They stimulate in vivo synthesis o f anti- inflammatory steroids. B. They stabilize mast cells and thereby inhibit mast cell degranulation. C. They inhibit Leukotriene synthesis D. They antagonize the action o f Leukotrienes at the receptor level.

54 .All o f the following drugs decrease zafirlukast blood concentrations EXCEPT: A. B. C. D. E. Erythromycin Aspirin Theophylline Terfenadine None

E. None

E. Inhibition o f production of contractile prostaglandins

59. In which o f the following conditions are cromolyn sodium and nedocromil sodium not effective? A. B. C. Treatment o f Acute asthma exacerbation Maintenance therapy for asthma Prophylactically for the prevention o f asthma induced by cold air or exercise. Prevention o f exercise induced bronchospasm. None

62. Which o f the following Theophylline containing products has the highest theophylline content? A. B. C. D. E. Oxtriphylline Aminophylline anhydrous Aminophylline hydrous Theophylline anhydrous None

D. E.

63.All the following drugs increase the clearance o f theophylline EXCEPT: A. B. C. D. E. Carbamazepine Phenobarbital Cimetidine Rifampin Phenytoin

60. Which one o f the following statements is FALSE about theophylline and its compounds?

A. Theophylline compounds may be considered if P-agonists and corticosteroids fail to control an acute asthma exacerbation. B. Theophylline is an alternative to long-acting P-agonists in the treatment o f persistent asthma. C. p-agonists produce bronchodilation to a lesser extent than theophylline compounds. D. Theophylline is most beneficial as an adjuvant to inhaled corticosteroids in patients with nocturnal or early morning symptoms. E. None

64. Which o f the following factors increase the clearance o f theophylline? A. B. C. D. E. Smoking High protein diet High carbohydrate diet Old age A and B

65. Which o f the following statements is NOT TRUE about ipratropium bromide? A. it is particularly useful in older asthmatic patients and patients with coexisting chronic obstructive pulmonary disease. B. It is recommended for use in combination with p-agonists for the treatment o f severe acute asthma exacerbation. C. It is highly recommended in the chronic management o f asthma. D. It is an alternative bronchodilator in some patients who can not tolerate paeonists.

61 .All o f the following are true about the suggested mechanisms o f action o f theophylline EXCEPT: A. Alteration o f intracellular calcium B. Increased binding of cAMP to its binding protein. C. Adenosine antagonism D. Decreased circulating

Asthm a and Chronic Obstructive Pulmonary D isease

C. Reduced PaC 02 D. Peak expiratory flow rate less than

C. It is chronic inflammation o f the air ways especially, the bronchiole.

E. None

C. Triamcinolone D. Budesonide E. None

66. Chemically ipratropium bromide is a: A. B. C. D. E. Quaternary ammonium compound. Tertiary amine Cyclic amine Primary amine None 70.All o f the following are disadvantages o f nebulizers in the management o f asthma EXCEPT: A. B. C. D. they are expensive Longer administration time Size o f the device Drug delivery inconsistency between devices E. They are cheaper

67. Which o f the following therapies may precipitate bronchospasm when used in the treatment o f asthma? A. B. C. D. E. Anti-histamine therapy Antibiotic therapy Immunotherapy Mucolytic therapy None

71 .Which o f the following statements is FALSE about dry powder inhalers? A. They are used more frequently because many patients find them easier to use than an MDI. B. Spacers are used with dry powder inhalers. C. The patients taking dry powder inhalers are advised to inhale the powder rapidly as opposed to slow inhalation required for MDI administration. D. Patients should be advised to keep dry powder inhalers away from moisture E. Avoid exhaling into the mouth piece before inhalation

68. Which o f the following statements is FALSE about metered dose inhalers in the management o f asthma? A. Their efficacy is similar to that of nebulizers when administered with good technique and a spacer. B. They can be administered to patients on mechanical ventilation with the use o f a spacer designed for mechanical ventilator circuit. C. The dose of a drug administered with a metered dose inhaler and a spacer is larger than that administered by nebulizers. D. For small children to be able to use metered dose inhaler properly, a spacer with a face mask should be used. E. None

72. Heliox is a mixture o f oxygen and: A. B. C. D. E. Hydrogen Helium Nitrogen Holmium None

69.An inhaled corticosteroid available in metered dose inhaler that comes with a spacer is: A. Flunisolide B. Fluticasone

73. All o f the following may occur in status asthmaticus EXCEPT: A. Altered consciousness
B. Cyanosis

C. Reduced PaC 02 D. Peak expiratory flow rate less than 1OOL/min E. FEV1 less than 1 liter

74. Accumulation o f air in the pleural spice, as some times occurs during an acute asthmatic attack is a condition common referred to as A. B. C. D. E. Pneumonia Pneumothorax Status asthmaticus Pneumonitis None

C. It is chronic inflammation of the air ways especially, the bronchioles. The airflow to the lungs is not affected. D. It is a transient blockade o f the airways which occurs due to bacterial infection. E. None

77.The two major forms o f chronic obstructive pulmonary disease (COPD) are: A. B. C. D. E. Chronic bronchitis Emphysema Asthma Allergic rhinitis A and B

75. Which o f the following statements! FALSE about atelectasis? A. It is also known as collapsed liir g B. Gas exchange is inhibited durii); respiration C. It may occur as a result o f airwa obstruction. D. In asthmatics it only involves th(e left middle lobe o f the lungs. E. In asthmatics it usually involve^ the right middle lobe o f the lungs

78. Smoking may lead to chronic obstructive pulmonary disease because it prevents a r antitrypsin from binding with and inactivating the enzyme: A. B. C. D. E. Elastase Lactase Dipeptidase Aminotransferase None

76. Which o f the following is a correct definition o f chronic obstructive pulmc nary disease by American thoracic society? A. It is a disease state characterized by airflow limitation that is not ful y reversible. The air flow limitation is usually both progressive and associated with an abnormal inflammatory response o f the lifngs to noxious particles or gases. B. It is a disease state characterized by airflow limitation due to chroni bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompan ed by airway hyperactivity and m: ,y be partially reversible.

79. In chronic bronchitis respiratory tissue inflammation results in vasodilatation, congestion, mucosal edema, and goblet cell hypertrophy. These events trigger goblet cells to produce excessive amounts of: A. B. C. D. E. antibodies mucus elastase oxygen None

80. Which o f the following organisms normally colonize sterile airways A. B. C. D. Streptococcus pneumoniae Hemophilus influenzae Staphylococcus aureus Pseudomonas aeruginosa

E. All o f the above

D. A destruction o f the nasopharyngeal wall. E. None

81 .All o f the following statements are TRUE about the events that occur in chronic bronchitis EXCEPT: A. Cartilage atrophy, infiltration of neutrophils and other cells, and impairment o f cilia. B. Decrease in P aC 0 2 C. The air ways degenerate and overall gas exchange is impaired. D. The cilia are impaired. E. Airways are blocked by thick mucus

85. In chronic bronchitis productive cough occurs due to: A. Blockade o f the airways by thick mucus secretions. B. Infiltration o f neutrophils and other cells to inflamed areas. C. Relaxation o f smooth muscles in the airways. D. Hypoxemia E. None

82. Which o f the following characteristics are common to both chronic bronchitis and emphysema? A. B. C. D. E. Inflammation Excessive mucus secretion Hypercapnia Respiratory acidosis A and B

86.The term blue bloater is frequently used to describe patients with chronic bronchitis because: A. Their sputum is blue colored. B. They tend to develop cyanosis C. The radiographic examination o f their chest shows blue spots D. The exhaled air is blue. E. None 87. Which o f the following pulmonary function test parameters are decreased in chronic bronchitis? A. Vital capacity B. Residua! volume C. Forced expiratory volume in 1 second D. Total lung capacity E. A and C

83. Which o f the following types of emphysema is associated with a r antitrypsin (AAT) deficiency? A. B. C. D. E. Panlobular emphysema Centrilobular emphysema Paraseptal emphysema Mixed emphysema None

84. Which o f the following damages are likely to be present in emphysema which occurs due to smoking? A. A destruction which involves all lung segments B. A central destruction selectively involving respiratory bronchioles. C. The lung periphery adjacent to fibrotic regions is the site o f alveok r distention and alveolar wall destruction.

88.In chronic bronchitis the number o f some blood cells may increase. Which of the following blood cells may increase in response to hypoxemia? A. B. C. D. E. Neutrophils Erythrocytes WBC Platelets None

89.Which o f the following pulmonary function parameters is reduced in both chronic bronchitis and emphysema? A. B. C. D. Residual volume Total lung capacity Vital capacity Forced expiratory volume in 1 second E. None

93. Which o f the following statements is NOT TRUE about the dosage and administration o f anticholinergics in the treatment o f COPD? A. The dose o f glycopyrrolate is 1-2 mg every 8 hours.(it can be nebulized in combination with pagonists) B. An MDI dose o f 40pg o f Ipratropium bromide four times daily results in severe systemic adverse effects. C. Tiotropium bromide capsules contain 22.5 pg Tiotropium bromide monohydrate equivalent to 18 pg Tiotropium. D. Ipratropium should be administered regularly because o f a slower onset and longer duration o f action. E. None

90.Treatment objectives endorsed by GOLD (global initiative for chronic obstructive lung disease) for the treatment ofC O PD include: A. Prevent disease progression. B. Relieve symptoms and improve exercise tolerance. C. Prevent and treat exacerbations. D. All o f the above E. A and B only

94. Which o f the following statements is FALSE about the use o f p-agonists in the 91. The most commonly used agents in the management o f COPD? treatment o f COPD are: A. They are administered via inhalation A. Methyl-xanthines B. p-agonists o f the same duration B . Corticosteroids should not be used in combination C. Anticholinergics because an adequate dose o f a single D. p-agonists agent provides peak E. C and D bronchodilation. C. Long acting P-agonists are 92. Which o f the following statements is recommended for rescue therapy. WRONG? D. Long acting P-agonists may be used as first-line bronchodilators in the A. Anticholinergics may be used as maintenance therapy o f COPD. first-line bronchodilators or in E. None o f the above conjunction with p-agonists in the treatment o f COPD. B. Atropine is more potent and has 95. Which one o f the following p-agonists fewer side effects than ipratropium. has the shortest duration o f action? C. Ipratropium bromide and tiotropium bromide reduce sputum volume. D. Anticholinergics produce A. Formoterol bronchodilation by competitively B. Salmeterol inhibiting cholinergic responses. C. Pirbuterol E. None o f the above D. Terbutaline

E. None 96. Theophylline compounds are used in the management o f COPD because: I. they increase mucociliary clearance II. they enhance diaphragmatic contractility III. they have potent bronchodilator activity A. B. C. D. E. i f l only is correct if III only is correct if I & II are correct if II&III are correct if I,II, and III are correct 99. Antibiotics are used to treat exacerbations with suspected infection as evidenced by : A. B. C. D. E. Increase in volume o f sputum Change in color o f sputum Viscosity o f the sputum All o f the above A and B

100. Which o f the following statements is WRONG about the use o f antibiotics in the management o f COPD? A. Prevention o f infection with chronic antibiotic therapy is controversial and should be considered only in patients with multiple exacerbations annually. B. Ambulatory antibiotic treatment o f exacerbations in patients with COPD is recommended when there is evidence o f worsening dyspnea and cough with purulent sputum and increased sputum volume. C. Antibiotic treatment o f pneumonia in hospitalized patients with COPD includes either a second or third generation cephalosporin. D. Antibiotics may be used in the management o f COPD even if the only symptom is fever.

97.Serum theophylline levels should be closely monitored in patients with congestive heart failure because: A. There is decreased metabolism of theophylline in such patients. B. Theophylline misguides the diagnosis o f congestive heart failure. C. Theophylline worsens preexisting congestive heart failure. D. Theophylline leads to increased levels o f drugs used in the treatment o f congestive heart failure E. None

98. Inhaled Corticosteroids which may be used in the prolonged rrj^nagement o f COPD should be symptomatic and they should have a documented spirometric response. The spirometric responses are:

101. In patients with COPD if infection with C.pneumoniae is suspected the drug o f choice is: A. B. C. D. E. Doxycycline Procaine penicillin Streptomycin Amikacin None

A. Increase in FEVi o f at least 15 % and 200mL after 6 weeks to 3 months o f use B. Decease in FEVi o f at least 20 % after 5 months o f use C. A decrease in peak expiratory volume o f at least 30 % D. An increase in peak expiratory volume o f at least 30 % E. None

102. The drugs o f choice for pneumonia caused by M.pneumoniae or Legionella

pneumophilia in hospitalized patients with COPD are: A.Aminoglycoside antibiotics B.Macrolide antibiotics C.Tetracyclines D. Aminopenicillins E.None

C. Potassium iodide D. N-acetylcysteine E. None

106. Which one o f the following vaccines is recommended in COPD because o f its ability to reduce death and serious illness by almost 50%? A. B. C. D. E. Polyvalent pneumococcal vaccine Tetanus immunoglobulin Varicella zoster immunoglobulin Influenzae virus vaccine None

103. Infections (in patients with COPD) caused by each o f the following organisms require treatments for approximately 7-10 days EXCEPT: A. B. C. D. E. S.pneumoniae H.influenzae M.pneumoniae M.catarrhal is None

107. Smoking cessation is one o f the important nonpharmacological treatments which improve COPD. All o f the following are useful in smoking cessation EXCEPT: A. B. C. D. E. Nicotine gum Patches Buproprion Inhaled corticosteroids Clonidine

104. Which one o f the following drugs allows shorter duration o f therapy for the treatment o f infections in patients with COPD? A. Erythromycin B. Ampicillin C. Azithromycin D. Clarithromycin E. None

108. Chest physiotherapy has all o f the following effects in patients with COPD EXCEPT: A. B. C. D. E. Loosens mucus secretions. Helps re-expand the lungs. Increases the efficacy o f respiratory, Has anti-bacterial effect. None

105. Which one o f the following drugs may improve sputum clearance and disrupt mucus plugs? A. Iodinated glycerol B. Guaifenesin

Answers Asthma and Chronic Obstructive Pulmonary Disease


1. Answer: B. It is a syndrome which develops as a result o f bacterial infection only Explanation: Asthma is a chronic inflammatory disorder o f the airways. It involves complex interactions between many cells and inflammatory mediators that result in inflammation, obstruction (partially or completely reversible after treatment or resolves spontaneously, and increased airway responsiveness (i.e, hyperresponsivness).

2. Answer: D. All o f the above Explanation: An asthmatic patients severity classification plays an important role in determining the most appropriate pharmacotherapeutic approach and is determined by: -Treatment requirements -Objective measurements o f lung function, including diurnal variations - Symptoms, and -Frequency o f nocturnal symptoms

3. Answers: C. Symptoms occur less than 2 times a week; asymptomatic between exacerbations; exacerbations brief from a few hours to a few days Explanation: Choice A is classified as Mild persistent, choice B as Moderate persistent,choice C as Mild interm ittent, and choice D as severe persistent.

4. Answer:

E. A and B only

Explanation: Asthmatic reactions to drugs may occur due to hypersensitivity or as an extension o f the pharmacological effect.

5. Answer: D. Ephedrine Explanation: Drugs implicated in asthma include: Aspirin and other nonsteroidal anti-inflammatory drugs. Anti-adrenergic and cholinergic drugs (e.g. p-adrenergic blockers , Bethanechol) Medications (or foods) that contain tartrazine, sulfates, and other preservatives. Ephedrine, a sympathomimetic is a drug used in the treatment o f nasal congestion. It will not induce asthma.

6. Answer: B. Vasoconstriction o f the vasculature Explanation: In postmortem examination o f asthmatic patients, all o f the above characteristics are identified except choice B. Vasodilatation (rather than vasoconstriction) o f the vasculature is evident.

7. Answer: E. A and B Explanation: The involvement o f inflammatory cells is one o f the important contributory factors in the pathophysiology o f asthma. The inflammatory cells include mast cells, Eosinophils, activated T cells, macrophages, and epithelial cells.These inflammatory cells secrete mediators and influence the airways directly or via neural mechanisms. Erythrocytcs and Reticulocytes are not inflammatory' cells.

8. Answer: D. All o f the above Explanation: The airway obstruction in asthmatic patients is believed to be a result o f bronchoconstriction, airway edema, mucus plug formation, smooth muscle hypertrophy, airway remodeling and hyperplasia.

9. Answer: E. B and C only Explanation: In asthma airway inflammation is crucial to the development o f asthma and contributes to airway hyperresponsivness, respiratory symptoms, airflow obstruction and disease chronicity.

10. Answer: A. It is a condition which occurs due to inflammation and is characterized by subbasement collagen deposition and fibrosis Explanation: Air way remodeling is a structural change to the lung. It can result from persistent inflammation when asthma is poorly controlled. The resulting damage can yield permanent airway abnormalities because o f subbasement collagen deposition and fibrosis.

11 .Answer: C. IgE Explanation: After exposure to an allergic trigger, antigen binds to immunoglobulin E(IgE) which is attached to activated mast cells.

12. Answer; D. The late asthmatic response does not respond to administration o f corticosteroids Explanation: The late asthmatic response can be blocked by administration of corticosteroids or anti inflammatory agents such as cromolyn sodium or nedocromil.

13.Answer: D. Cromolyn sodium Explanation: Cromolyn sodium or nedocromil are used in blocking early and late asthmatic response.

14.

Answer: E. All o f the above

Explanation: The five main events that occur in asthma are triggering, signaling, migration, cell activation, tissue stimulation and damage.

15. Answer:

C. Corticosteroids

Explanation: Corticosteroids are not signaling molecules. They have anti-inflammatory activity. Cytokines, Eicosanoids, Leukotrienes and chemokines are chemical signals released by activated mast cells and other signaling cells.

16.Answer: B. Adhesion molecules Explanation: In migration phase, an influx o f inflammatory cells (e.g. Eosinophils, lymphocytes, monocytes* granulocytes. In addition to the migration o f these cells to the airway, up regulation o f adhesion molecules begin. These adhesion molecules affix themselves to cells in the circulation and attract these cells to the air ways.

17.Answer: D. Leukotrienes Explanation: Cell activation is required before cells can release inflammatory mediators. Once present in the airways, Eosinophils are activated. Leukotrienes appear to be important in this cell activation.

18.

Answer: E. A and C only

Explanation: Leukotrienes appear to be important in the development o f bronchoconstriction, increased mucus production, increased vascular permeability, and hyperresponsivness.

19.Answer: C. Bradycardia Explanation: The cardiac effects o f acute asthmatic exacerbations include tachycardia and tachypnea. (Not bradycardia) 20.Answers: B. Marked respiratory distress, loud wheezing, coughing, difficulty speaking, accessory chest muscle use, and chest hyperinflation Explanation: Choice A are symptoms o f Moderate asthma,Choice B are symptoms o f severe asthma, Choice C are symptoms o f respiratory failure,and choice D are symptoms o f mild asthma. 21 .Answer: E. A and B

Explanation; Arterial pH may increase in mild and moderate stages o f an acute asthmatic attack

22.Answer: E. C a n d D Explanation: Forced expiratory volume in 1 second (FEVi) is maximum volume o f air forcibly exhaled in 1 second (normal value o f 3.8 liters). Forced vital capacity is the maximum volume o f air that can be forcefully exhaled after inhalation to total lung capacity. The volume o f air entering or leaving the lungs during a single breath is called tidal volume. Residual volume is the volume o f air remaining in lungs at the end o f tidal volume (Normal value o f 2.4 liters). Total lung capacity is the volume o f air within both lungs at the end o f a maximal inhalation (6.0 liters). Forced expiratory volume in 1 second (FEV}) and Forced vital capacity decrease while Residual volume and total lung capacity may increase during acute asthmatic exacerbations.

23.

Answer:

C. It is used in making the diagnosis o f asthma

Explanation: Peak expiratory flow rate is not used in the diagnosis o f asthma. All other choices are correct.

24.Answer: D. 20% Explanation: Diurnal variation o f greater than 20% in peak expiratory flow rate measured during the day suggests airway hyperresponsivness.

25.Answer: D. Oximeter

Explanation: Pulse Oximetry is a noninvasive means o f assessing the degree o f hypoxemia during an acute exacerbation. The Oximeter measures oxygen saturation in arterial blood and pulse.

26.Answer: A. Sinus tachycardia Explanation: In asthmatic attacks, an Electrocardiogram may show sinus tachycardia. An ECG may be particularly useful in an older patient.

27.

Answer: D. Peak expiratory flow rate more than 90%

Explanation: The signs o f respiratory distress in asthma include use o f accessory muscles, Declining mental status .Peak expiratory flow rate o f less than 50% ,Cyanosis, and absence o f respiratory sounds

28. Answer: E. All o f the above Explanation: The goal o f therapy in asthma is to provide symptomatic control with normalization o f lifestyle and to return pulmonary function as close to normal as possible.

29. Answer: B. In the step-down approach the therapy starts one step below the patients assessed asthma severity to give rapid disease control Explanation: A stepped approach based on severity o f disease is used to manage persistent asthma. Gaining control o f asthma may be achieved with either a step-up or step-down approach (determined by severity o f disease); however, the more aggressive step-down approach is advocated by experts. The step-down approach starts with treatment one step above the patients assessed asthma severity to give rapid disease control. The step-up approach begins with treatment regimen at the same step as the patients severity.

30.Answer: C. Cromolyn sodium has been shown to be ineffective in the management of exercise induced bronchospasm Explanation: Cromolyn sodium and nedocromil may be used to prevent exercise-induced bronchospasm and exacerbations related to exposure to other asthma triggers. Cromolyn and nedocromil should be administered no more than 1 hour before exercise or exposure.

31 .Answer: D. All o f the above Explanation:

Allergic rhinitis, sinusitis, and Gastro-esophageal reflux disease frequently coexist with asthma. Asthma control has been shown to improve if these conditions are adequately controlled.

32. Answer: E. All o f the above Explanation: Indications for long-acting p-agonists are: -Maintenance treatment o f moderate and severe persistent asthma in combination with inhaled corticosteroids, particularly for patients with frequent nocturnal symptoms. -Prophylaxis o f exercise induced bronchospasm -Patients with chronic obstructive pulmonary disease (COPD)

33.Answer: C. Glycolysis Explanation Stimulation o f p2receptors in skeletal muscle accounts for tremor, gluconeogenesis (synthesis of glucose), insulin secretion, activation o fN a+, K+-adenosine triphosphate (ATPase). Glycolysis is break down o f glucose. Glycolysis is not found in stimulation o f p2 receptors.

34. Answer: E. They should only be used in combination with a corticosteroid in the prevention o f exercise induced bronchospasm Explanation: Long acting p-agonists can be used alone in the prevention o f exercise induced bronchospasm.

35.Answer: B. Isoproterenol Explanation: Nonselective p-agonists (e.g. Isoproterenol) may induce myocardial ischemia, myocardial necrosis, and arrhythmias because o f excessive cardiac stimulation. Use o f p2-agonists (e.g., albuterol, Bitolterol, pirbuterol) is preferred.

36.Answer: E. A and B Explanation: Tachyphylaxis can occur with regular use o f inhaled or oral p-agonists. The possible mechanisms include: A decrease in the number o f active p-receptors due to movement o f receptors from the cell surface into the cell. A decreased sensitivity in the p-receptors, making them unable to activate adenyl cyclase.

37.

Answer: A. the R-isomer

Explanation:

Albuterol is a racemic mixture o f albuterols R- and S- isomers, but Levoalbuterol HC1 is comprised o f R-isomer.

38. Answer: B. Concomitant use o f systemic (3-agonists with monoamine oxidase inhibitors, tricyclic antidepressants, or methyldopa may lead to severe hypotension Explanation: Concomitant use o f systemic p-agonists with monoamine oxidase inhibitors, tricyclic antidepressants, or methyldopa may lead to severe hypertension.

39. Answer: C. Increased mucus production Explanation: Corticosteroids decrease the production of mucus.

40. Answer: E. if I,II, and III are correct Explanation: Increased proliferation o f inflammatory cells leads to worsen inflammation and corticosteroids do not increase proliferation o f inflammatory cells. Corticosteroids bind to glucocorticoid receptors on the cytoplasm. The activated receptor regulates transcription o f target genes. Corticosteroids reduce inflammation via: -inhibition o f transcription and release o f inflammatory genes. -increased transcription of anti-inflammatory genes that produce proteins that participate in or suppress the inflammatory process.

41 .Answer: C. I & II are correct Explanation: Systemic corticosteroids for the treatment of asthma should have the following characteristics: Good glucorticoid activity (good glucorticoid activity means better anti-inflammatory activity) Minimal mineralocorticoid activity (mineralocorticoid activity results in an increase o f Na^ reabsorption and increased excretion o f K+and H+). Excessive mineralocorticoid activity causes marked Na+ and water retention with resultant increase in the volume o f extra-cellular fluid, Hypokalemia, alkalosis, and hypertension. Short to moderate duration o f action.( short duration o f action is preferable in order to get faster response action o f the drug)

42.Answer: B. Intravenous corticosteroids are the first line treatments in all asthmatic conditions Explanation: There is no significant difference in the clinical efficacy of the corticosteroid agents currently available. The route o f administration is determined by the condition o f the patient.

Intravenous corticosteroids are administered to patients who are unable to take oral medications. They are also for patients believed to be impending respiratory arrest and for initial treatment o f exacerbations that require ICU admission. Oral corticosteroids are acceptable as emergency treatment if the patient can tolerate the oral route and is not believed to be in imminent danger o f respiratory arrest.

43.Answer:

E. C and D

Explanation: The most frequently used oral corticosteroids in the treatment o f asthma are prednisone and Prednisolone. Becolmethasone and Budesonide are available as inhalations.

44. Answer: A. they are less likely to produce adverse reactions Explanation: Inhaled corticosteroids are least likely to produce adverse reactions, therefore the inhaled route should be used whenever possible for chronic treatment. However, these inhaled corticosteroids should not be used to treat acute exacerbations.

45.Answer:

E. All o f the above

Explanation: Careful monitoring is necessary in patients with diabetes, hypertension, congestive heart failure( they may result in sodium retention thus they may worsen the condition ) , peptic ulcer disease, lmmunosuppression( because they have Immunosuppressive property),osteoporosis, chronic infections, cataracts, glaucoma, myasthenia gravis , and psychiatric diseases (e.g. depression , psychosis ).

46.

Answer: D. Budesonide

Explanation: Two major publications demonstrated short-term growth suppression o f approximately 1 cm in the first year of Budesonide treatment, but without long-term effects on the final adult height. To avoid this child should be treated with the lowest effective dose.

47. Answer: D. All of the above Explanation: Spacers should be prescribed for patients who receive moderate to high doses of inhaled corticosteroids via metered-dose inhalers. Patients should also gargle, rinse their mouth and throat, and expectorate after administration. Both o f these interventions minimize orpharyngeal drug deposition, local adverse reactions, and gastrointestinal absorption.

48.Answer: B. Ill only is correct

Explanation: Rifampicin, Hydantoins, and barbiturates induce hepatic microsomal enzymes resulting in enhanced corticosteroid metabolism if they are given concurrently. (The overall result is decreased plasma concentration) Cyclosporine may increase the plasma concentration o f corticosteroids.

49.Answer: E. A and B Explanation: Concurrent use estrogens, oral contraceptives, ketoconazole, or macrolide antibiotics (e.g. erythromycins, Clarithromycin,) may decrease corticosteroid clearance. Ampicillin and amoxicillin have not been shown to decrease corticosteroid clearance.

50.Answer: E. 1,11, and III are correct Explanation: Administration o f potassium-depleting diuretics (e.g. thiazides, Furosemide) or other potassiumdepleting drugs (e.g. amphotericin) with corticosteroids causes enhanced Hypokalemia. Serum potassium should be closely monitored, especially in patients on digitalis glycosides.

51 .Answer: C. I & II are correct Explanation: - Montelukast, zafirlukast and Pranlukast are Leukotriene receptor antagonists. Zileuton is a lipoxygenase inhibitor.

52.Answer: C. I & II are correct Explanation: Leukotriene antagonists have anti-inflammatory and bronchodilator activity. They may allow reduction in corticosteroid doses in some patients. Because they are less effective agents than inhaled corticosteroids, they are considered second-line agents. They may be useful in patients with concurrent allergic rhinitis.

53.Answer:

C. Eosinophilic vasculitis

Explanation: Churg-strass syndrome is a form o f Eosinophilic vasculitis, which has been associated with zafirlukast, Montelukast and Pranlukast. It has usually, but not always, occurred in patients whose chronic steroid regimens were tampered and discontinued.

54.Answer: Explanation:

B. Aspirin

Aspirin increases zafirlukast blood concentrations. Others decrease the zafirlukast concentrations.

55.Answer:

D. Leukotrienes

Explanation: Zileuton is inhibitor o f the enzyme lipoxygenase, thereby inhibiting the synthesis o f leukotrienes.

56.Answer: D. All o f the above Explanation: Zileuton has not been shown to increase the plasma concentration o f propranolol, terfenadine and theophylline.

57. Answer:

E. All o f the above

Explanation: Cromolyn sodium and nedocromil sodium are nonsteroidal anti-inflammatory drugs. These medications are less effective in their anti-inflammatory properties than the inhaled corticosteroids; however, because o f their excellent safety profile, they are frequently used in children. They prevent asthma induced by exercise, cold air and sulfur dioxide when used prophylactically.

58.Answer: B. They stabilize mast cells and thereby inhibit mast cell degranulation Explanation: Cromolyn sodium and nedocromil sodium are believed to act locally by stabilizing mast cells and thereby inhibiting mast cell degranulation. There is also evidence for inhibitory effects on inflammatory cells such as macrophages, Eosinophils, neutrophils, monocytes, and platelets.

59.

Answer:A.

treatment o f acute asthma exacerbation

Explanation: Cromolyn sodium and nedocromil sodium are not effective during an acute asthma exacerbation. They should only for the prevention o f persistent asthma or prevention o f exercise induced bronchospasm.

60.Answer: compounds

C. P-agonists produce bronchodilation to a lesser extent than theophylline

Explanation: Theophylline compounds produce bronchodilation to a lesser extent than p-agonists.

61 .Answer:

D. Decreased circulating catecholamines

Explanation: The suggested mechanism o f action o f theophylline is that it results in increased circulating catecholamines.

62.Answer:

D. Theophylline anhydrous

Explanation: The theophylline content o f Theophylline containing products is given below Oxtriphylline (64%) Aminophylline anhydrous (86%) Aminophylline hydrous (79%) Theophylline anhydrous (100%)

63.Answer:

C. Cimetidine

Explanation: The drugs which increase the clearance o f theophylline (resulting in a decrease o f blood levels) include: Carbamazepine, Phenobarbital, phenytoin and Rifampin. The drugs which decrease the clearance o f theophylline (increase the blood level) include Allopurinol, p-blockers, calcium-channel blockers, cimetidine, clindamycin, fluoroquinolones, macrolides, oral contraceptives, ticlopidine and zafirlukast?influenza virus vaccine.

64. Answer:

E. A and B

Explanation: Smoking and high-protein diet are likely to increase theophylline clearance. It is expected that old age and high-carbohydrate diet decrease the clearance o f theophylline. Other factors that decrease theophylline clearance are Cor pulmonale, congestive heart failure, fever/viral illness, liver dysfunction.

65. Answer:

C. It is highly recommended in the chronic management o f asthma

Explanation: The benefits o f ipratropium bromide in the chronic management o f asthma have not been established. The other statements are true.

66.Answer:

A. Quaternary ammonium compound

Explanation: Chemically ipratropium bromide is a quaternary ammonium compound.

hoch

HO

C H C H 2 N H C {H 3)3 OH

#H2s a

More info: Quaternary ammonium compounds are salts o f quaternary ammonium cations with an anion. They are used as disinfectants, surfactants, and fabric softeners.

67. Answer:

D. Mucolytic therapy

Explanation: Mucus may contribute to airway obstruction in asthma. However, because mucolytics may precipitate bronchospasm, they should not be used for the treatment o f patients with asthma. Anti-histamines are useful for asthmatic patients with co-existing allergic rhinitis; however, their role in the treatment o f asthma remains unclear. Antihistamines compete with histamine for histamine-receptor sites on effector cells; thus, help prevent the histamine-mediated responses that influence asthma. Antibiotics are not used for the treatment o f asthma; however, research is under way to determine the role o f infection in asthma pathogenesis. Immunotherapy improves asthma control in some patients and is ineffective in others. A recent meta-analysis demonstrated that immunotherapy may improve lung function, reduce symptoms, and decrease medication requirements in a significant number o f patients.

68. Answer: C. The dose o f a drug administered with a metered dose inhaler and a spacer is larger than that administered by nebulizers.

Spacer

Inhaler
Explanation: When administered with a good technique and a spacer, the efficacy o f metered dose inhalers is similar to that o f nebulizers, despite the lower doses administered with an MDI and a spacer. N e b u lizer

tu b in g

69.Answer: C. Triamcinolone Explanation: The only metered dose inhaler that comes with a built-in spacer is the azmacort (triamcinolone) inhaler.

70.Answer:

E. They are cheaper

Explanation: Disadvantages o f nebulizers include cost, preparation, and administration time, drug delivery inconsistencies between devices, and size o f the device.

71 .Answer: B. Spacers are used with dry powder inhalers. Explanation: Spacers are not used with dry powder inhalers. The dose is loaded into the delivery chamber and inhaled by close mouth technique. Except the choice (B), all other choices in this question are true.

72.Answer:

B. Helium

Explanation: Heliox is a mixture o f oxygen and helium.

73.Answer: C. Reduced P aC 0 2 Explanation: The findings in status asthmaticus include altered consciousness, cyanosis (even with oxygen therapy), elevated PaC 02 PEFR less than 1OOL/min in adults, and FEV i less than 1 L.

74.Answer:

B. Pneumothorax

Explanation: During an acute asthmatic attack some times accumulation o f air in the pleural space occurs. This condition is referred to as Pneumothorax . The symptoms o f Pneumothorax may include sudden pleuritic chest pain, dyspnea, hacking cough and anxiety.

75.

Answer:

D. In asthmatics it only involves the left middle lobe of the lungs

Explanation: Atelectasis or collapsed lung inhibits the gas exchange during respiration and may occur as a result o f airway obstruction. In asthmatics, Atelectasis usually involves the collapse o f right middle lobe, but some times affects the entire lung. The symptoms o f Atelectasis include dyspnea and anxiety.

76. Answer: B. It is a disease state characterized by airflow limitation due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive may be accompanied by airway hyperactivity and may be partially reversible Explanation: The national heart, lung and blood institute/world health organization global initiative for chronic lung disease definition o f chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. The air flow limitation is usually both progressive and associated with an abnormal inflammatory response o f the lungs to noxious particles or gases. The American thoracic society definition is a disease state characterized by airflow limitation due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperactivity and may be partially reversible.

77.Answer:

E. A and B

Explanation: The two major forms o f chronic obstructive pulmonary disease (COPD) are chronic bronchitis and Emphysema. These two coexist very frequently.

78.Answer: A. Elastase Explanation: Cigarette smoking is the primary etiologic factor for the development o f chronic obstructive pulmonary disease. There is also increased risk o f COPD in people who have di-antitrypsin (AAT) deficiency. One in three people with genetic AAT deficiency develop emphysema, usually as young adults. AAT is a serine protease inhibitor, and it is also an acute-phase reactive protein. The major physiological function of AAT is inhibition of neutrophil elastase.

79.Answer:

B. mucus

Explanation: Respiratory tissue inflammation in chronic bronchitis results in vasodilatation, congestion, mucosal edema, and goblet cell hypertrophy. These events trigger goblet cells to produce excessive amounts o f mucus.

80.

Answer:E.Allo f

the above

Explanation: Normally sterile airways become colonized with Streptococcus pneumoniae, Hemophilus influenzae, Staphylococcus aureus, Pseudomonas aeruginosa species and Moraxella catarrhal is.

81 .Answer:

B. Decrease in PaC 02

Explanation: In chronic obstructive pulmonary disease the hypoxemia results in increased carbon dioxide tension (i.e. increasing P aC 02).0 th er choices are true.

82.Answer:

E.A and B

Explanation: In both chronic bronchitis and emphysema there is inflammation and excessive mucus secretion. In chronic bronchitis hypercapnia (i.e. increasing P aC 0 2) is common but in emphysema hypercapnia and respiratory acidosis are uncommon because the imbalance in ventilation to perfusion ratio is compensated for by an increased respiratory rate. In chronic bronchitis sustained hypercapnia desensitizes the brains respiratory control center chemoreceptors. As a result, compensatory action to correct hypoxemia and hypercapnia (i.e. a respiratory rate or depth increase) does not occur. Instead hypoxemia serves as the stimulus for breathing.

83.Answer:

A. Panlobular emphysema

Explanation: There are specific lung regions in which characteristic anatomical changes of emphysema occur.

In Panlobular emphysema, all lung segments are involved. The alveoli enlarge and atrophy, and the pulmonary vascular bed is destroyed. This form o f emphysema is associated with ctr antitrypsin (AAT) deficiency. In centrilobular emphysema destruction is central, selectively involving respiratory bronchioles. Typically, bronchioles and alveolar ducts become dilated and merge. In Paraseptal emphysema, the lung periphery adjacent to fibrotic regions is the site o f alveolar distention and alveolar wall destruction.

84.Answer:

B. A central destruction selectively involving respiratory bronchioles

Explanation: Cigarette smoking causes centrilobular emphysema in which the destruction is central, selectively involving respiratory bronchioles. Typically, bronchioles and alveolar ducts become dilated and merge. Destruction of the nasopharyngeal wall does not occur in any type of emphysema.

85. Answer:

A. Blockade o f the airways by thick mucus secretions.

Explanation: In chronic bronchitis, respiratory tissue inflammation results in vasodilatation, congestion, mucosal edema, and goblet cell hypertrophy. These events trigger goblet cells to produce excessive amounts o f mucus. Airways become blocked by thick, tenacious mucus secretions, which trigger a productive cough.

86.Answer:

B. they tend to develop cyanosis

Explanation: The term blue bloater is frequently used to describe patients with chronic bronchitis because they tend to develop cyanosis.( a condition characterized by blue coloring o f skin which occurs due to inadequate oxygenation o f blood).

87.Answer:

E. A and C

Explanation: Pulmonary function may be normal in the early disease stages. Later, they show an increased residual volume, a decreased vital capacity, and a decreased F E V ,. Unlike emphysema, chronic bronchitis patients have normal diffusing capacity, normal static lung compliance, and normal TLC (total lung capacity).

88.Answer:

B. Erythrocytes

Explanation: In response to hypoxemia (shortage o f oxygen), erythropoiesis (production of erythrocytes) results an increase in the number of erythrocytes. WBC count may be increased if there is bacterial infection. (But not in response to hypoxemia).

89. Answer:

D. Forced expiratory volume in 1 second

Explanation: In emphysema pulmonary tests show normal or increased lung compliance, reduced FEV, and diffusing capacity and increased Total lung capacity (TLC) and residual volume (RV).

90. Answer:

D. All o f the above

Explanation: The treatment objectives endorsed by GOLD for treatment o f COPD include: -Relieve symptoms and improve exercise tolerance (enable the patient to perform normal daily activities) -Prevent disease progression (smoking cessation) -Improve health status -Prevent and treat exacerbations -Reduce mortality - Prevent and treat complications 91 .Answer: E. C and D Explanation: Anticholinergics and [3-agonists are the most commonly used agents. Methyl-xanthines are usually added when the response to other agents is inadequate. Corticosteroids are beneficial when an allergic component has been demonstrated.

92.Answer:

B. Atropine is more potent and has fewer side effects than ipratropium

Explanation: Ipratropium bromide is three to five times more potent and has significantly fewer side effects than atropine.

93. Answer: B. An MDI dose o f 40pg o f Ipratropium bromide four times daily results in severe systemic adverse effects Explanation: Initial MDI dosing o f Ipratropium bromide is two inhalations (40 pg) four times daily, but dosing can be increased to six inhalations four times daily without significant risk.

94. Answer:

C. Long acting p-agonists are recommended for rescue therapy

Explanation: The P-agonists used for rescue therapy in COPD should be short acting. Other choices are true.

95.Answer: D .Terbutaline Explanation: The duration o f action o f some P-agonists is as given in the following table.

S.No 1 2 3 4

Duration o f action (hr) 10-12 hr 10-12 hr 5 hr 3-6 hrs ( I), 1.5-4 hr (P), 4-8 hr (O) Note-I= Inhalational route P= Parenteral 0= oral route

Name of a (3-agonist Formoterol Salmeterol Pirbuterol Terbutaline

Salmeterol and formoterol (long acting p-agonists) are administered twice daily. They may also be used in combination with ipratropium bromide or tiotropium. Neither agent is used on an as-needed basis for rescue therapy, although Formoterol does have a rapid onset of action.

96.Answer:

C I& II are correct

Explanation: In general the methyl-xanthines (Theophylline and related compounds) do not have good bronchodilator activity. In COPD, theophylline compounds are used because they increase mucociliary clearance, stimulate the respiratory drive, and enhance diaphragmatic contractility, improve the ventricular ejection fraction, and stimulate renal diuresis.

97. Answer:

A. There is decreased metabolism o f theophylline in such patients

Explanation: Serum theophylline levels should be closely monitored in patients with Congestive heart failure or Cor pulmonale due to decreased metabolism of theophylline.

98.Answer:

A. Increase in FEVI o f at least 15 % and 200mL after 6 weeks to 3 months o f use

Explanation: Inhaled Corticosteroids play a less prominent role in COPD than in asthma. Candidates for prolonged use o f inhaled Corticosteroids therapy should: Be symptomatic and have a documented spirometric response (i.e. increase in FEVi o f at least 15% and 200 mL after 6 weeks to 3 months o f use. Have an FEV] < 50% predicted with a history o f repeated exacerbations requiring systemic Corticosteroids or antibiotics.

99.Answer:

D. All o f the above

Explanation: Antibiotics are used to treat exacerbations with suspected infection as evidenced by an increase in volume or change in color or viscosity of the sputum.

100. Answer: D. Antibiotics may be used in the management o f COPD even if the only symptom is fever Explanation: Fever does not always indicate infection; it may also due to noninfectious causes (e.g. drug interactions, phlebitis, neoplasms, metabolic disorders, arthritis). Antibiotics are used to treat acute exacerbations with suspected infections as evidenced by an increase in volume or change in color or viscosity.

101.

Answer:

A. Doxycyclinc

Explanation: If infection with C.pneumoniae is suspected, oral Doxycycline is the drug o f choice.

102.

Answer:

B. Macrolide antibiotics

Explanation: Antibiotic treatment of pneumonia in hospitalized patients with COPD includes either a second or third generation cephalosporin (e.g. Cefuroxime, ceftriaxone, Cefotaxime)or a p~lactamase inhibitor(e.g. ampicillin/sulbactam piperacillin/Tazobactam) If infection with M.pneumoniae or Legionella pneumophilia is a concern, a macrolide (e.g. erythromycin, Clarithromycin, Azithromycin) may be added.

103.

Answer:

C . M .pneumon iae

Explanation: S.pneumoniae, H.influenzae and, M.catarrhalis infections should be treated for approximately 7 10 days. Cases o f M.pneumoniae may require longer therapy ranging from 10-14 days.

104.

Answer:

C. Azithromycin

Explanation: Azithromycin has a uniquely long half-life (68 hours), thereforefTt allows a therapy o f 5 days.

105.

Answer:

A. lodinated glycerol

Explanation: Mucolytics (e.g. iodinated glycerol) may improve sputum clearance and disrupt mucus plugs, but their benefits are small, and they are not recommended. Antioxidants such as N-acetylcysteine may reduce exacerbation frequency. However, routine use cannot be recommended based on currently available data. Expectorants such as Guaifenesin may be used, but the evidence o f effectiveness is anecdotal.

106.

Answer:

D. Influenzae virus vaccine

Explanation: Influenzae virus vaccination is recommended because o f its ability to reduce death and serious illnesses by almost 50%. Polyvalent pneumococcal vaccine is not currently recommended due to lack o f evidence for efficacy.

107.

Answer:

D. Inhaled corticosteroids

Explanation: Inhaled corticosteroids have not been shown to be effective in smoking cessation and they are not used in the management o f smoking cessation. Smoking cessation and avoidance o f other irritants has been shown to slow the rate o f decline in F E V ]. Nicotine gum, patches, inhalers, buproprion, or clonidine may be useful in smoking cessation. Behavior intervention significantly enhances the effectiveness o f pharmacological therapy in smoking cessation.

108.

Answer:

D. Has anti-bacterial effect

Explanation: Chest physiotherapy loosens secretions, helps re-expand the lungs, and increases the efficacy o f respiratory muscle use. It does not have any effect against infective organisms.

Basic Pharmacokinetics

Losers visualize the penalties o f failure. Winners visualize the rewards of success.

Dr. Rob Gilbert

1. The order o f a reaction is A. The velocity with which the reaction occurs. B. The way in which temperature affects the rate of the reaction C. The way in which the concentration o f the reactants affects the rate of reaction D. The way in which the concentration o f the products affects the rate o f reaction E. C and D

constant, C0 is the drug concentration at time 0 and t is the time? A. dC/dt = -kC B. C = C0e kt C.In C = -kt/2.30 + In C0 D.log C - -kt/2.30 + log C0 E. B and D 5. The half-life (t y2) o f a reaction is A. the time required for the concentration o f a drug to decrease by one-half B. the time required for the concentration of a drug to be half that o f the product. C. the time that indicates the reaction is not half complete D. dependent on concentration o f the reactant given by 693/2k E. C and D 6. A compartment is A. not a real physiologic or anatomic region B. is a mathematic description o f a biologic system and is used to express quantitative relationship C. is a group o f tissues with similar blood flow and drug affinity D. A and C E. A and B

2. Which o f the following is true about zero-order reactions? A. The reactants concentration decreases with respect to time at a constant rate B. The reactants concentration increases with respect to time at a constant rate C. The reactants concentration decreases with respect to time at a variable rate D. The reactants concentration increases with respect to time at a variable rate

3. Which o f the following equations represents zero-order reactions, where C is the drug concentration, K0 is the zero-order rate constant, C0 is the drug concentration at time 0 and t is the time? A. B. C. D. E. dC/dt - - K0 or C = - K0t + C0 dC/dt = K0 or C = - K0t + C0 dC/dt ~ K0 or C = K0t + C0 dC/dt = - K0 or C = K0t + C0 A and C

7. Which o f the following tissues/organs will have the slowest distribution o f drugs? A. B. C. D. E. Liver Kidney Heart Adrenals Fat

4. Which o f the following equations doesnt represent the first-order reaction in which drug concentration changes with respect to time, where C is the drug concentration, K0 is the zero-order rate

8. drugs rapidly cross capillary' membranes into tissues due to A. active diffusion B. passive diffusion

c. hydrostatic pressure D. osmotic pressure E. B and C only

12. Which o f the following is NOT true about apparent volume o f distribution? A. it helps in determining the amount o f drug in the body relative to the amount o f the drug in the plasma B. it does not represent any actual physical volume inside the body C. the volume o f distribution decreases as the drug distributes more extravascularly into the tissues D. it can be much larger than body volume E. A and C 13. which o f the following is not true in the one-compartment pharmacokinetic model o f a drug administered as an oral dosage form, A. drug absorption is a first order process B. elimination is a first order process C. the time for maximum drug absorption depends only on the constant rate o f elimination and absorption D. lag-time happens only with delayedrelease dosage forms E. none

9. the distribution o f drugs to body tissues

is affected by A. the physiology o f the tissue B. the physicochemical characteristics o f the drug C. plasma protein binding o f drugs D. special affinity o f the tissue for the drug E. All o f the above

10. Which o f the following is true about one-compartment open model assumes A. the entire drug dose enters the body rapidly B. the rate o f absorption is not put into account in doing the calculations C. the body acts like a single, uniform compartment D. the drug distributes instantaneously and homogenously throughout the body/compartment E. all o f the above

11 .Which o f the following is NOT true about the pharmacokinetic parameters in one compartment model after IV bolus injection? A. drug elimination is a first-order kinetic process B. the biological half-life can be calculated form the elimination rate constant using the equation Un = 0.693/K, where K is the elimination rate constant C. AUCo-,, = clearance /dose D. The first order elimination rate constant is the sum o f all rate constant involved in elimination E. All but A

14. Which o f the following is NOT true about the plasma profile o f an intravenous infusion? A. Like in the IV bolus injection, the plasma level is at its peak immediately after administration B. The absorption is a zero-order process C. Elimination is first order process D. Upon termination o f infusion, the plasma drug concentration declines by first order process E. It is possible to calculate the elimination rate constant and elimination half life from the declining plasma drug concentration versus time curve

15.The plasma drug concentration at any time after the start o f an infusion is calculated by the formula A. B. C. D. E. Cp = [R7k][ 1-e'kt] Cp = [R/VD k] [l-e"kt] C p = [R /V D ] [ l- e kt] C p = [2R/k][l - e kt] C p = tRVD /k ][l-e k']

19.All the following are correct about multiple drug dosing EXCEPT A. it is used in the treatment o f chronic diseases B. in multiple dosing, the plasma drug concentration fluctuates between a maximum and minimum values at the steady-state C. all drugs that are given as multiple doses follow the superimposition principle D. the principle o f superimposition assumes that early doses o f drug do not affect the pharmacokinetics of subsequent doses E. according to the superimposition principle, the total plasma drug concentration is obtained by adding the residual drug concentrations found after each previous dose 20. Which o f the following parameters can be adjusted in developing a dosage regimen? A. B. C. D. E. elimination half life the size o f the dose the apparent volume o f distribution the frequency o f doing B and D

16. Which o f the following is the correct formula for calculating the infusion rate required to reach the steady state concentration? A. B. C. D. E. R R R R B = [Css|[ VD k]/ [l-e 'k 1 ] = Css VD k = CssCl = Css/ V D k and C

17.The formula for calculating the loading dose to obtain the steady state concentration as soon as possible is I. II. III. Dl = CssVD D l = R/k DL = Rk

A. I only is correct B. Ill only is correct C. I and II are correct D. II&III are correct E. I,II&III are correct

21 .Which o f the following is NOT true? I .as long as the dosing interval is unchanged, the expected average drug concentration at steady-state is the same II .changing the dosing rate will change the values o f C"m ax and C'r'm m III. for a larger dose given over a longer interval there will be smaller fluctuation between C'm ax and Cm ;n

18. Which o f the following is NOT true about the intermittent IV infusion? A. The drug is infused for relatively long period of time B. it is used for a few drugs C. steady-state drug concentrations are not achieved D. A and B E. None

A. I only is correct B. Ill only is correct C. I and II are correct D. II&III are correct E. I,II&III are correct

22. What is the correct formula for calculating C"m 3 X at steady state concentration after multiple rapid IV bolus injection? I.C max=[D o/V D] / ( l - e kT) II . r m ax = C V (l-e -kT ) III -C"m ax = [VD /D o]/(l- ekT)

B. after IV bolus injection, the drug distributes rapidly throughout the body C. in this model the drug distributes between the central compartment and tissue compartment D. the drug distributes rapidly and uniformly in the tissue compartment E. all the above

A. I only is correct B. Ill only is correct C. I and II arc correct D. II&III are correct E. I,II&III are correct

26.For a drug administered orally, twocompartment characteristics are seen if I. the drug is rapidly absorbed II . the drug is distributed slowly III . the drug is absorbed slowly A. B. C. D. E. I only I and II I and III II and III 1,11 and III

23.The loading dose for multiple oral doses, D l is calculated by the formula A. B. C. D. D l D m/ e Dl = D m | l / ( l - e kT)] DL = DM [e-kT] D L = DM- [ e 'kT]

27. Which o f the following is NOT true about the kinetics o f multicompartments? 24. Which o f the following is true about drugs that exhibit multi compartment models? A. they distribute into different tissue at different rates B. highly perfused tissue groups equilibrate more rapidly than poorly perfused tissue groups drugs that bind to proteins are expected to accumulate in skeletal muscles D. the physicochemical properties of the drug and the characteristics of the tissue determine the distribution o f the drug into the different tissues E. none A. drug elimination is presumed to take place from the peripheral compartments B. if additional one compartment is added, one more first-order plot is required C. pharmacokinetic analysis gets simpler as the number o f . compartments is increased D. dosage regimens are calculated from the rate constant o f the elimination phase E. A and C

28. Which o f the following is NOT true about nonlinear pharmacokinetics? A. it is also called capacity limited or dose dependent or saturation pharmacokinetics B. it may result from saturation of an enzyme or carrier-mediated system

25. Which o f the following about twocompartment model (IV bolus injection) is correct? A. the plasma drug concentration declines monoexponentially

C. it does not follow first-order kinetics as the dose increases D. It is relatively easier to calculate the dose for drugs that follow nonlinear pharmacokinetics E. A and B

E. All the above 32. Which of the following is the correct unit for clearance? A. B. C. D. E. volume /time mass/time mass2/time mass/volume mass2/volume

29.Non-linear pharmacokinetics is characterized by all the following EXCEPT A. the elimination half-life remains constant even if the dose is increased B. the AUC is not proportional to the dose C. presence o f other drugs may affect pharmacokinetics o f the drug in question D. the composition and/or ratio o f the metabolites o f a drug may be affected by a change in the dose E. none

33. Which o f the following equations correctly expresses the measurement of total body clearance? A. B. C. D. E. CIt = F Dcok/AUC ClT = VD k C1t = FD m/AUC [dDe/dt]/Cp All but A

30. Which o f the following is NOT true about the Michael-Menten kinetics? A. it describes the velocity o f enzyme reactions B. it describes the elimination o f drug by a saturable process C. the Michael-Menten equation describes the rate o f change o f plasma drug concentration after IV bolus injection D. the Michaelis constant (KM ) equals the elimination constant E .A and D 31 .Drugs that follow nonlinear pharmacokinetics may show A. zero-order elimination rates at low drug concentrations B. a mix o f zero- and first-order elimination rates at intermediate drug concentrations C. first-order elimination rates at high drug concentrations D r A and C only

34.Renal excretion is the major route o f drug elimination for all the following EXCEPT A. B. C. D. polar drugs water-soluble drugs gaseous drugs drugs with molecular weight less than 500 E. drugs that are biotransformed slowly

35. Which o f the following substances can be used to estimate GFR? A. B. C. D. E. mannitol sodium thiosulfate inulin creatinine all the above

36. Which o f the following transport mechanisms is active process? A. GF B. Tubular reabsorption C . Tubular secreti on

D. A and B E. B and C

37. Which ofthe following conditions will decrease the tubular reabsorption o f a weakly acidic drug? A. B. C. D. E. the use o f a diuretic if it exists in the nonionized form if the urine is made more alkaline A and C none

A. clearance ratio >1; filtration plus active tubular secretion B. clearance ratio = 1; tubular secretion plus reabsorption C. clearance ratio < 1; filtration plus reabsorption D. A and B E. None 41 .Which o f the following is NOT true about the hepatic clearance? A. It is the volume of drug containing plasma that is cleared by the liver per unit time B. hepatic clearance is equivalent to nonrenal clearance C. hepatic clearance is the ratio of blood flow and the extraction ratio D. it can calculated as the product of blood flow and the extraction ratio E. none 42.Extraction ratio is A. the fraction o f drug that enters a particular tissue B. the fraction o f drug that leaves a particular tissue C. the amount o f drug that enters a particular tissue minus the amount that leaves that particular tissue D. the fraction o f the drug that is removed irreversibly by a particular tissue as the plasma containing drug perfuses the tissue

38. Which of the following is NOT true about the active tubular secretion? A. It is the process in which a drug is passed from blood into glomerular filtrate B. it involves the transport o f drugs in accordance with the concentration gradient C. there are two active secretion systems in the kidneys; one for weak acids and one for weak bases D. it shows a competitive effect which can be employed to provide longer biological half-life o f some drugs E. none 39. Which o f the following is NOT true about the renal clearance? A. it is defined as the volume o f drugcontaining plasma that is cleared of drug by the kidney per unit time. B. It is expressed in units o f volume per time C. It puts in consideration the physiological mechanism o f excretion D. A and B E. None 40. Which o f the following is a WRONG match between the value a clearance ratio and the most probable mechanism o f drug clearance?

43. What will be the fraction o f drug removed by the liver if the arterial plasma concentration o f a drug entering the liver is 2.35 mg/ml and the venous plasma concentration o f the drug is 2.1 lmg/ml? A. B. C. D. E. 0.10 0.12 0.34 0.29 0.43

44.Blood enters the liver through A. B. C. D. E. hepatic vein hepatic portal vein hepatic artery mesenteric vessels B and C

in the GI tract may hydrolyze the glucuronide moiety allowing the released drug to be reabsorbed D. from the bile drugs may empty back (through the bile duct) into the GI tract for absorption once again E. all o f the above

45. Which o f the following is most affected by sudden changes in protein binding? A. hepatic clearance o f drugs that have high extraction ratios and high intrinsic clearance values B. hepatic clearance o f drugs that have low extraction ratios and high intrinsic clearance values C. drugs that are highly plasma protein-bound and have low intrinsic clearance D. drugs that are not highly plasma protein-bound and have low intrinsic clearance E. A and C 46. Which o f the following is NOT true about biliary drug excretion? A. it is an active process B. it is a type o f hepatic clearance C. it involves drugs with molecular weight greater than 500, polar drugs and glucuronide conjugates o f various drugs D. there is competition between weakly acidic drugs and weakly basic drugs for the secretion systems E. none

48.First pass effect usually occurs with those drugs that are administered A. B. C. D. E. Orally IV IM Rectally Topically

49. The most common mechanism o f first pass effect is A. metabolism o f drugs by GIT mucosal cells B. metabolism o f drugs by the intestinal flora C. biliary secretion o f drugs D. rapid biotransformation o f drugs by the liver enzymes

50.In order to have a better bioavailability for a drug that is affected by first pass effect, one should. A. use other routes o f administration that avoid the first pass effect B. increase the dose o f the drug C. use a delayed release dosage form o f the drug D. A and B only E. All the above

47. Which o f the following is/are correct about the enterohepatic circulation? A. it is the reabsorption o f drug after the hepatic pass B. it is responsible for the drug being recycled C. for those drugs emptied into GIT as glucuronide metabolite, the enzymes 51 .Which o f the following is NOT true about mean residence time? A. it is also called mean transit time or mean sojourn time B. it is the average time for the drug molecule to reside in the body

C. it is independent o f the route o f administration D. it is calculated by dividing the total residence time for all drug molecules in the body by the total number o f drug molecules. E. The mean residence time for a drug given by a noninstantaneous input is longer than the MRTiv

52.How is the MRTiv related to the elimination half-life? A. B. C. D. E. MRTiv MRTiv MRTiv MRTiv MRTiv = = = = = k2 1/k 2k Vk 1/2k

53. Which o f the following is NOT true about clinical pharmacokinetics? A. it is the application of pharmacokinetic principles to drug therapy B. it deals in individualizing dosage regimen based on the patients disease state and patient specific considerations C. it studies the pharmacokinetic differences o f drugs in various populations groups D. the main objective is to increase the efficiency and decrease the toxicity E. none

ANSWERS Basic Pharmacokinetics


1. Answer: C. The way in which the concentration o f the reactants affects the rate o f reaction.

Explanation: The order o f a reaction refers to the way in which the concentration o f the reactants influences the rate o f a chemical reaction. The velocity with which the reaction occurs refers to the rate o f the chemical reaction.

2. Answer: A. The reactants concentration decreases with respect to time at a constant rate. Explanation: For every reaction there is no way the concentration o f the reactants increase as the reaction progress. And in case o f the zero-order reaction the rate o f the reaction is independent of concentration.

3. Answer: A. dC/dt = - K0 or C = - K0t + C0. Explanation: If the amount of a drug decreases at a constant time interval (ie. Zero-order reaction), then the rate o f disappearance o f the drug is expressed as dC/dt = - K0. Integration o f this equation gives C = - K0t + Co. The negative sign indicates that the amount o f the drug is decreasing.

4. Answer: C. In C = -kt/2.30 + In CO Explanation: In first-order reaction, the drug concentration changes with respect to time equals the product o f the rate constant and the concentration o f drug remaining according to the relation dC/dt = -kC; integrating this equation between the limits concentration at time 0 (Co) and any time t (C ) gives, InCo InC = -k(O-t); InC = -kt + InCo. Natural logarithm can be converted into common logarithm by multiplying the above equation by 2.303 to give the equivalent equation log C = kt/2.3 + log Co.

5. Answer: A. Is the time required for the concentration o f a drug to decrease by one-half. Explanation: H alf life is the time necessary for the amount of drug in the body to be reduced to 50 percent. The relation between half life and k can be determined by the formula - 0.693/k.

6. Answer: D. A and C

Explanation: A compartment is a group o f tissue with similar blood flow and drug affinity. A compartment is not a real physiologic or anatomic region. A mathematic description o f a biologic system is known as the model and is used to express quantitative relationships.

7. Answer: E. fat. Explanation: Drugs distribute rapidly to tissues with high blood flow and more slowly to tissues with low blood flow. From the tissues/organs listed above, the adrenals have the highest blood flow followed by the kidneys, liver and the heart. Fat tissues have the least blood flow, therefore they will have the slowest distribution o f drugs.

8. Answer: E. B and C only. Explanation: Passive diffusion and hydrostatic pressure are the two processes by which drugs transverse capillary membranes.

9. Answer: E. all o f the above Explanation: The distribution o f drug into body fluids and tissues is an important determinant o f therapeutic effect o f the drug. Although there are exceptions, most drugs are not distributed in the plasma alone but appear to be also distributed in other body fluids and/or tissues. Among the many factors that affect distribution o f drugs; the physiology o f the tissue, the physicochemical characteristics o f the drug, plasma protein binding o f drugs, and special affinity o f the tissue for the drug are some examples.

10. Answer: E. all o f the above Explanation: The one-compartment open model is the simplest way o f describing the process of drug distribution and elimination in the body. This model assumes that the drug can enter or leave the body, and the body acts like a single, uniform compartment. The simplest route of drug administration that gives such a model is IV bolus. The drug is injected all at once into a box (therefore, no absorption rate considered) or compartment, and that the drug distributes instantaneously and homogenously throughput the compartment.

11 .Answer: C. AUC0-O T= clearance /dose. Explanation: In one-compartment model, after IV bolus injection, the total area under curve is determined using one o f the following equations: AUC0. = dose/clearance, or AUC0., = Co/ K, where Co is the extrapolated drug concentration at zero time on the y-axis o f the semi-logarithmic plot of concentration versus time, and k is the first order elimination rate constant.

12. Answer: C. the volume o f distribution decreases as the drug distributes more extravascularly into the tissues. Explanation: The apparent volume o f distribution is the term used to describe the volume o f fluids that would be required to account for all drug in the body. Its value will be decreased if more of the drug is contained in the plasma, and its value will increase if the drug distributes more to the extravascular tissues.

13.Answer: D. lag-time happens only with delayed-release dosage forms. Explanation: The lag-time is the time that elapses between administration o f the dosage form and appearance o f drug in systemic circulation. Delayed-release dosage forms are intended to release their content at a time later than the time o f administration of the dosage form. Although the conventional dosage forms are intended to release their contents immediately after administration, they exhibit certain degree o f delayed release due to some factors that may be related to the dosage form, the patient or the drug.

14.Answer: A. Like in the IV bolus injection, the plasma level is at its peak immediately after administration. Explanation: In IV bolus injection, since the entire dose is placed in plasma at once, the concentration o f drug in plasma is at its peak level immediately after administration. In IV infusion however, the entire dosage is not administered all at once. So the concentration of the drug in the plasma is not at its peak when the infusion is started.

15.Answer: B. Cp = [R/VDk] [1-e-kt], Explanation: The change in the amount o f drug in the body at any time (dDB/dt) during the infusion is the rate o f input minus the rate o f output. dDB /dt = R - kDB Where DB is the amount of drug in the body, R is the infusion rate (zero order), and k is the elimination rate constant (first order). Integration o f the above equation and substitution o f DB CpVDgives Cp = [R/VD k] [l-e 'kt].

16.Answer: E. B and C. Explanation:

As the drug is infused, the plasma drug concentration increases to plateau or steady state concentration (Css). This occurs at infinite time (t = co) and the expression ekt approaches zero and the equation Cp = [R/VD k] [l-e"kl] is reduced to Css = R/ VD k. Therefore, R = Css VD k and since VDk = Cl, R = CssC).

17.Answer: C. 1 and II are correct Explanation: The loading dose is the amount o f drug that, when dissolved in the apparent VD , produces the desired Css. Therefore, it is given by the equation DL = Css VD. However, Css = R/[VD k], Therefore, Dl = R/k.

18.

Answer: A. The drug is infused for relatively long period o f time

Explanation: Intermittent IV infusion involves infusing the drug for a short period o f time so that drug accumulation and toxicity are avoided.

19. Answer: C. all drugs that are given as multiple doses follow the superimposition principle. Explanation: There are situations in which the superimposition principles do not apply, even with those drugs that are given in multiple doses. In these cases, the pharmacokinetics o f the drug change after multiple dosing due to various factors, including changing pathophysiology in the patient, saturation o f drug carrier system, enzyme induction, and enzyme inhibition. Drugs that follow nonlinear pharmacokinetics generally do not have predictable plasma drug concentrations after multiple doses using superimposition principle.

20. Answer: E. B and D. Explanation: When designing a multiple-dosage regimen, only the dosing rate can be adjusted easily. The dosing rate involves the size o f the dose and the time interval between doses.

21 .Answer: B. Ill only is correct Explanation: For a larger dose given over a longer interval the value o f C"m ax is lower and the value o f Cm j is higher as compared to a small dose given more frequently. Therefore, the fluctuation between Cm ax and C 'lm will be larger.

22.Answer: C. I and II are correct Explanation:

To determine the concentration o f a drug in the body after multiple doses, the amount o f drug in the body is divided by the volume in which it is distributed. Therefore, C"m ax = D " o/V d But D o = Do/( 1- e kT). Therefore, Cm ax = [D o/V d]/( 1- e'kT) Moreover, Cp = D o/'V d. Therefore, Cm ax = Cp/(1- e'kT)

23.Answer: B. DL = DM [1/(1 -e kT)] Explanation: Loading doses are given to achieve desired plasma concentrations as soon as possible. For multiple oral dose loading dose is calculated by the formula DL = DM [l/(l-e 'kT)], where DM is the maintenance dose and 1/(1-ekT) is the accumulation rate.

24.

Answer: C. drugs that bind to proteins are expected to accumulate in skeletal muscles.

Explanation: Drugs that bind to proteins are expected to be concentrated in the plasma since there are proteins in the blood and since drugs bound to proteins do not diffuse into tissues.

25.Answer: C. in this model the drug distributes between the central compartment and tissue compartment. Explanation: The plasma level-time curve for a drug that follows a two-compartment model shows that the plasma drug concentration declines biexponentially as the sum of twro first-order processesdistribution and elimination. A drug that follows the pharmacokinetics o f a two-compartment model does not equilibrate rapidly throughout the body, as is assumed for a one-compartment model. In this model, the drug distributes into two compartments, the central compartment and the tissue or peripheral compartment. The central compartment represents the blood, extracellular fluid, and highly perfused tissues. The drug distributes rapidly and uniformly in the central compartment. The tissue compartment contains tissues in which the drug equilibrates more slowly.

26.

Answer: B. I and II

Explanation: A drug with a rapid distribution phase may not show two compartment characteristics after oral administration. Two-compartment models are seen if the drug is absorbed rapidly but distributes slowly.

27.Answer: E. A and C. Explanation: In a multi compartment systems, elimination is presumed to take place form the centra] compartment unless other information about the drug is known. This is because major sites of drug elimination (renal excretion and hepatic drug metabolism) occur in organs, such as the

kidney and liver, which are highly perfused organs. Adequate pharmacokinetic description of multicompartment models is often difficult and depends on proper plasma sampling and determination o f drug concentrations.

28. Answer: D. drugs that follow nonlinear pharmacokinetics are relatively easier to calculate the dose. Explanation: Although most drugs follow linear pharmacokinetics, in some drugs steady-state concentrations do not change proportionally with change in size o f the dose. In such cases, a plot o f steady-state concentration o f a drug in plasma as a function o f dose is not linear and the drug is said to follow non-linear pharmacokinetics, dose dependent, capacity limited, or saturation pharmacokinetics. Drugs that exhibit nonlinear pharmacokinetics are often very difficult to dose correctly.

29. Answer: A. the elimination half-life remains constant even if the dose is increased. Explanation: In non-linear pharmacokinetics, the biological half-life changes with increasing dose. Usually, half-life increases with increasing dose, but in some cases, half-life may decrease with increasing dose (e.g., carbamazepine).

30.Answer: D. Michaelis constant (KM) equals the elimination constant. Explanation: The Michae-Menten equation is given by the formula, -dCp/dt = Vm ax Cp/(KM+ Cp), Where Vm axis the maximum elimination rate and KMis the Michaelis constant that reflects the capacity o f the enzyme system. It is important to note that KMis not an elimination constant, but actually a hybrid rate constant in enzyme kinetics, representing both the forward and backward reaction rates and equal to the drug concentration or amount o f drug in the body at 0.5 Vm ax.

31 .Answer: B. a mix o f zero- and first-order elimination rates at intermediate drug concentrations. Explanation: At low drug concentrations (Cp), where KM Cp, Michael-Menten equation is reduced to a first-order rate equation because both KMand Vm ax are constants. -dCp/dt = Vm ax Cp/ K m = k Cp At high drug concentrations, where Cp K m, the Michael-Menten equation is reduced to a zeroorder rate equation. -dCp/dt = Vmax

32. Answer: A. volume /time Explanation:

Clearance is the measure o f drug elimination from the body. Instead o f describing the rate o f elimination in terms o f a certain quantity or amount o f drug eliminated per unit time, clearance describes the rate o f elimination in terms o f volume o f fluid that is cleared o f drug per unit time. Therefore, the units for clearance are volume/time.

33.Answer: E. All but A Explanation: Clearance can be calculated using elimination rate constant (k) and apparent volume of distribution (V d) (both obtained from the plasma profile o f the drug) from the relation, C1t = K V d. It can also be calculated based on the concept that the amount o f drug excreted in urine per unit time (rate o f excretion o f the drug in the urine, dDe/dt) is proportional to the concentration o f the drug in plasma, Cp. The relation is as follows, [dDe/dt]/Cp. In case o f noncompartmental (model independent) clearance model, clearance is calculated by the equation C1T = FDoo/AUC.

34.

Answer: C. gaseous drugs.

Explanation: Anesthetic gases, vapors, and volatile drugs are excreted through the lungs (i.e., pulmonary excretion).

35.Answer: E. all the above Explanation: GFR can be determined by measuring the extent o f excretion and plasma level o f a test substance. The substance used to measure filtration rate should have the following properties; it should be removed from plasma by filtration only and not be (actively) secreted or reabsorbed by the tubules. It should not be metabolized, stored, or protein-bound, and not affect filtration rate. Substances commonly used to measure GFR include mannitol, sodium thiosulfate, inulin, and creatinine.

36.Answer: C. tubular secretion. Explanation: GF is a passive process by which small molecules and drugs are filtered through the glomerulus o f the nephron. Tubular reabsorption is a passive process that follows Ficks law o f diffusion. Tubular secretion on the other hand is a carrier-mediated active transport system that requires energy.

37.

Answer: D. A and C

Explanation: The use o f diuretic increases the flow o f urine as a result o f which more o f the drug will be excreted. If a drug exists primarily in the nonionized form (i.e., lipid soluble form), then it is reabsorbed more easily from the lumen o f the nephron. Depending on the pKa o f the drug.

alteration o f the urine pH alters the ratio o f ionized to nonionized drug and affects the rate o f drug excretion. For example alkalization o f urine increases the excretion (decreases tubular reabsorption) o f a weakly acidic drug.

38.Answer: B. it involves the transport o f drugs in accordance with the concentration gradient. Explanation: Tubular secretion is an active transport process whereby the drug is transported against a concentration gradient from blood capillaries across the tubular membrane into renal tubule. This active process accounts for the fact that certain drugs, although extensively bound to plasma proteins, are rapidly eliminated from the body essentially by renal excretion 39. Answer: C. It puts in consideration the physiological mechanism o f excretion.

Explanation: Renal clearance describes drug elimination from the body without identifying specific mechanism o f the process. The probable mechanism o f renal clearance is obtained with a clearance ratio (which relates the drug clearance to inulin clearance (a measure o f GFR)) or from a plot of excretion rate vs plasma concentration o f drug.

40. Answer: B. clearance ratio = 1; tubular secretion plus reabsorption Explanation; Clearance ratio is the ratio o f drug clearance to inulin clearance (i.e.GFR). Therefore, if the clearance ratio is 1, then it indicates that the most probabale mechanism o f drug clearance is filtration only. -

41. Answer: C. Hepatic clearance is the ratio o f blood flow and the extraction ratio Explanation: Hepatic clearance is a product o f blood flow into the liver and the extraction ratio 45/124. Extraction ratio is

42. Answer: D. the fraction o f the drug that is removed irreversibly by a particular tissue as the drug containing plasma pass through it. Explanation: Extraction ratio is the fraction o f drug removed from the plasma by a particular tissue. It is a measure o f the efficiency with which an organ eliminates a given drug. It is obtained by measuring the plasma drug concentration entering the liver and the plasma drug concentration exiting the liver.

43.Answer: A. 0.10 Explanation: Extraction ratio is given by the formula.

Extraction ratio = [arterial plasma drug concentration - venous plasma drug concentration]/arterial plasma drug concentration. Therefore, for the above case, the fraction o f drug removed by the liver (i.e., the extraction ratio) will be [2.35-2.11]/2.35 = 0.1.

44.Answer: E. B and C Explanation: Blood enters liver by hepatic portal vein and hepatic artery, and leaves the liver by hepatic vein. After oral drug administration, the drug is absorbed from the GI tract into the mesenteric vessels and proceeds to hepatic portal vein, to liver, and then to systemic circulation.

45.Answer: C. drugs that are highly plasma protein-bound and have low intrinsic clearance. Explanation: For a drug that has a low extraction ratio and is less than 75-80% bound, small changes in protein binding will not produce significant changes in hepatic clearance. Drugs that are highly bound to plasma protein but with low extraction ratios are considered capacity limited and biding sensitive, because a small displacement in the protein binding o f these drugs will cause a very large increase in the free drug concentration.

46. Answer: D. there is competition between weakly acidic drugs and weakly basic drugs for the secretion systems. Explanation: Because there are separate active secretion systems for weak acids and weak bases, there cannot be competition between weakly acid drugs and weakly basic drugs.

47. Answer: E . All o f the above Explanation: Some drugs are absorbed from the GI tract by the mesenteric and hepatic portal vein into the liver. The liver may secret some o f the drug (unchanged or as a glucuronide metabolite) into the bile. Glucuronide metabolite o f the drug may empty from the bile into GI tract where bacteria may hydrolyze the glucuronide conjugate allowing the released drug to be reabsorbed.

48.Answer: A. orally. Explanation: First pass effect is a phenomenon, which usually occurs with orally administered drugs. In this phenomenon, a portion o f the orally administered drug undergoes elimination before it has a chance to be systemically absorbed. It is for this reason that this phenomenon is also called presystemic elimination.

49. Answer: D. rapid biotransformation o f drugs by the liver enzymes. Explanation: Although the other factors also contribute, first pass effect generally occurs due to rapid drug biotransformation by the liver enzymes.

50.Answer: E. all the above. Explanation: Using other routes o f administration (other than oral) that avoid first pass effect is successfully employed for such drugs as sublingual nitroglycerin, insulin subcutaneous, and estradiol transdermal. Increasing the dose makes over for the amount o f drug lost due to the first pass effect (e.g., penicillin and propranolol). Using delayed release dosage form o f the drug allows the drug to be absorbed more distally in the GI tract (e.g., enteric-coated aspirin, mesalamine).

51 .Answer: C. it is independent o f the route o f administration. Explanation: Actually, MRT is independent o f the route o f administration because the route o f the administration does not influence the mean time that molecules reside in the body. However, the interpretation o f the ratio o f AUMC and AUC does change as a function o f administration because this ratio only yields the MRT when the input is instantaneous (i.e., IV administration). In other routes o f administration, it does not give MRT. Fro example. In oral administration, AUMC/AUC = MRT + MAT. Hence, we say MRT is dependent on the route of administration.

52. Answer: B. MRTiv = 1/k. Explanation; The MRT can be related to elimination half-life by considering the situation in which a drug displays monoexponential decline. The MRT can be written as MRT = AUMC/AUC, but AUMC =( initial concentration)/k2 and AUC = (initial concetration)/k. Therefore, MRT = (initial concentrationYk2 ^ 1/k (Initial concentration)/k

53. Answer: C. it studies the pharmacokinetic differences o f drugs in various populations groups. Explanation: The study o f pharmacokinetic differences in various population groups is known as population pharmacokinetics.

Bioavailabilty and Bioequivalence

RH

Nothing great was ever achieved without enthusiasm

Ralph Waldo Emerson

1. For drugs that are not intended to be absorbed into the bloodstream bioavailability may be assessed by: A. Measuring the rate and extent of absorption o f therapeutically active drug that is systemically absorbed. B. Measurements intended to reflect the rate and extent to which the active ingredient becomes available at the site o f action. C. Measuring the rate o f drug elimination D. Measuring the rate o f drug distribution E. Measuring the extent o f elimination

4. All o f the following are TRUE about therapeutic equivalent drug products EXCEPT: A. They are pharmaceutical equivalents B. They are expected to have the same clinical effect and safety profile when administered to patients under the same conditions. C. They need not necessarily be bioequivalent. D. They should meet an acceptable in vitro standard.

5. All o f the following are pharmaceutical alternatives EXCEPT: A. Tetracycline hydrochloride versus tetracycline phosphate B. Sustained release nifedipine versus immediate release nifedipine C. Doxycycline hydrochloride capsules versus Doxycycline tablets D. Doxycycline hydrochloride versus Tetracycline hydrochloride E. Amoxycillin capsules versus syrup

2. If two drug products are considered pharmaceutical equivalents they may differ: A. In the chemical form o f the active ingredient. B. In the dosage form. C. Packaging D. Excipients E. C and D

3. Which one o f the following is NOT TRUE? A. Reference drug product is usually the currently marketed, brand name product with a full New drug application approved by the FDA B. The generic drug product requires an Abbreviated New Drug Application for approval by the FDA C. Generic drug product is marketed after patent expiration of the reference drug product D. eneric drug products require Full New drug application for approval by the FDA E. Generic drug product can be manufactured by any pharmaceutical company

6. Bioavailability and bioequivalence may be determined using: A. Pharmacokinetic studies B. Measurement o f an acute pharmacodynamic effect C. Comparative clinical studies. D. In vitro studies E. All o f the above

7. In the determination o f bioequivalence and Bioavailability the choice o f study method is based up on: A. The site o f action o f the drug B. The ability of the study design to compare drug delivered to that site by the two products.

C. On the preference o f the person doing the study. D. The dose o f drug to be studied E. A and B

8. Acute pharmacodynamic effects o f a drag can be used to measure Bioavailability when: A. No assay for plasma drug concentration is available. B. The plasma drug concentration does not relate to the pharmacological response. C. the plasma drug concentration is related well to the pharmacological response. D. the drug is hydrophobic. E. A and B

D. The intensity o f pharmacological effect is proportional to the number o f receptors occupied by the drug up to a maximum pharmacological response. E. If two oral products contain the same amount o f active drug but different excipients, the dosage form that yields the faster rate o f drug absorption has the longer T MAX (Time for peak plasma drug concentration)

11 .Area under the concentration versus time curve (AUC) relates to: A. Amount or extent o f absorption B. Duration o f action C. The maximum plasma concentration o f the drug. D. The amount o f drug excreted E. None

9. The time taken by a drug to achieve minimum effective concentration after administration o f drug is: A. B. C. D. E. Onset time -Duration o f action Time for peak plasma concentration Half-life None

12. Which o f the following is/are true? A. the plasma drug concentration at Tmax relates to the intensity o f the pharmacological response B. ideally, Cmax should be within the therapeutic window C. the amount o f systemic drug absorption is directly related to the AUC D. the AUC is calculated by the trapezoidal rule and is expressed in units o f concentration multiplied by time E. All o f the above

10. Which one o f the following is WRONG? As long as the drug concentration remains above the minimum effective concentration, pharmacological activity is observed. B. Minimum toxic concentration is the plasma concentration o f the drug above which a toxic or adverse response is observed. C. Quantification o f the pharmacological effect versus time profile can be used as a measure o f A.

13.Determination o f bioavailability by measurement o f urinary drug excretion is most accurate if A. the active therapeutic moiety is excreted unchanged in significant

Bioavailability and Bioequivalence

A. all products B. products in which the bioavailability o f the active ingredient is affected by food

_i i i

23. Which o f the following statements is wrong?

B. the active therapeutic moiety has many metabolites excreted in the urine C. the drug is potent D. the metabolites o f the drug have pharmacological activity E. the active therapeutic moiety is excreted unchanged in small quantity in the urine

14. All o f the following are TRUE Except: A. the cumulative amount o f active drug excreted in the urine is directly related to the extent o f systemic drug absorption B. the rate o f drug excretion in the urine is directly related to the rate o systemic drug absorption C. The time for the drug to be completely excreted corresponds to the gap between drug absorption and determination o f the amount o f drug absorbed systemically. D. As a drug is absorbed, the drug concentration at the receptor rises lti> a minimum effective concentration and a pharmacological response is initiated E. The time for the drug to be completely excreted corresponds to the total time for drug to be | systemically absorbed and completely excreted after administration.

C. if its value is less than 1, the reference and the product under examination have the same bioavailability D. it is very important in generic drug studies E. if its value is 1? the drug bioavailability form both test and standard dosage forms is the same but does not indicate the completeness o f systemic drug absorption

16.The absolute bioavailability is calculated as A. the ratio o f the AUC for the dosage form given orally to the AUC obtained after IV drug administration B. the ratio o f the AUC for the dosage form given IV to the AUC obtained after oral administration C. the ratio o f the AUC for the dosage form given orally to the AUC obtained after administration given by other route D. The ratio o f the AUC for the dosage form given 3V to the AUC obtained after subcutaneous administration. E. None

17.An F value (absolute bioavailability) o f 0.8 (80%) indicates th a t: A. 20% o f the drug was systemically available from the oral dosage form B. 80% o f the drug was systemically available from the oral dosage form C. 180% of the drug was systemically available from the oral dosage form D. 120% o f the drug was systemically available from the oral dosage form E. None

15. Which o f the following is NOT TRUE about relative bioavailability? j A. it is the systemic availability o f thb drug from a dosage form as compared to a reference standard given by the same route o f administration B. it is calculated as the ratio o f the AUC for the dosage form to the AUC for the reference dosage forjn given in the same dose

18.In the bioequivalence studies food intervention study is recommended for:

A. all products B. products in which the bioavailability o f the active ingredient is affected by food C. potent drugs D. A and C E. "None

23. Which o f the following statements is wrong? A. the first o f the two sided tests determine whether a generic product (test), when substituted for a brand product (reference) is significantly less bioavailable B. the second o f the two sided tests determine whether a brand name product when substituted for a generic product is significantly less bioavailable C. The second o f the two sided tests determine whether a brand name product when substituted for a generic product is significantly more bioavailable D. The plasma drug concentration versus time curve is most often used to measure the systemic bioavailability o f a drug from a drug product E. None

19.The type o f food used in food intervention study is A. B. C. D. E. Fat rich food Protein rich Carbohydrate rich food Any type o f food None

20.Cross over study may not be practical in drugs with A. B. C. D. E. long half-life short half-life all drugs A and C None

21 .Pharmacokinetic analysis of bioavailability data includes calculation o f the following parameters for each subject EXCEPT: A. AUC to the last quantifiable concentration (AUC 0-j) and t infinity (AUCo-oo) B. Tmax C. Cmax D. Elimination rate constant (K) F C

24.In two one sided test procedure the difference for each o f statistical test methods was said to be significant if it is greater than: A. B. C. D. E. 80% 40% 20% 60% none

25.In bioequivalence studies, an analysis o f variance (ANOVA) should be performed on A. AUC and Cmax values obtained directly from each subject B. Log transformed AUC and Cmax values obtained from each subject C. The relative bioavailability D. A and C E. None

22.The statistical methodology for analyzing bioequivalence studies is called A. B. C. D. E. two one sided test procedure analysis o f variance cross over studies parallel studies none

may be encountered while determining their bioequivalence 26.The bioavailability studies recommended for drug products where plasma concentrations are not useful to determine delivery o f the substance to the site o f activity are: A. in vitro studies B. equivalence studies with pharmacodynamic end points C. equivalence studies with clinical end points D. in vivo bioequivalence studies E. All except D A. B. C. D. E. propranolol, verapamil phenytoin cholestyramine resin, sulcralfate selegilene probucol

30.Drugs with non linear pharmacokinetics 31.Drugs with long elimination half-life 32.Drugs with active metabolites 33.Drugs with highly variable bioavailability 34.Orally administered drugs that are not systemically absorbed

27.Bioequivalence study is not required for all o f the following products except A. B. C. D. E. Parenteral solutions oral solutions tablets ophthalmic solution none

35. Which one o f the following is wrong about bioequivalence study using pharmacodynamic measurements? A. they aTe difficult to obtain and the data tend to be variable requiring large number o f subjects compared to the bioequivalence studies for systemically absorbed drugs B. a bioequivalence study using pharmacodynamic measurements tries to obtain a pharmacodynamic effect versus time profile for the drug in each subject C. the area undeT the effect versus time profile, peak effect and time to peak effect are obtained for the test and reference products and are then statistically analyzed D. they can be used for drugs in which plasma concentrations are useful to determine delivery o f the drug substance to the site o f activity E. None

28.For which o f the following products the plasma concentrations are not useful to determine delivery o f the drug substance to the site o f activity? A. B. C. D. E. inhalers nasal sprays topical products applied to the skin capsules all except D

29.The confidence interval in ANOVA for both pharmacokinetic parameters, AUC and Cmax must be entirely within: A. B. C. D. 80% 70% 60% 75% to to to to 125% 130% 135% 140%

DIRECTION [30-34]: Match the following drugs with the problem, which

36.A method that has been suggested for measuring the bioequivalence o f topical products intended for local activity is A. B. C. D. E. dermatology dermatopharmacokinetics pharmacodynamic measurement toxicokinetics none

C. it is the current basis for FDA approval o f therapeutic equivalent generic drug products D. A and C E. None

40. Which one o f the following statements is NOT TRUE about switchability? A. it refers to the measurement of individual bioequivalence B. it requires knowledge o f individual variability (intra-subject variability) and subject-by-formulator effect C. it assures that the substituted generic drug product produces the same response in the individual patient D. It is the method o f determining the concentration o f a drug in a blood sample. E. None

37. Generic drug substitution is the process o f dispensing A. a generic product in place o f a brand name product B. a generic product in place o f another generic product C. a drug from one class to replace a drug from another class having the same indication. D. A and B E. None

38.Generic drug products that are classified as therapeutic equivalents by the FDA are expected A. to produce the same clinical effects as the prescribed drug B. to produce the same safety profile as the prescribed drug C. to be products o f the same company D. A and B E. None

41 .Which o f the following represent a pair o f therapeutic alternative? A. B. C. D. E. Amoxicillin - ampicillin Nifedipine - propranolol Amoxicillin -Rifampicin Aspirin - celecoxib None

42. A formulary is A. B. C. D. E. a list of drugs a list o f industrial chemicals a list o f poisonous substances a list o f all laboratory chemicals None

39. Which o f the following statements are TRUE about prescribability? A. it refers to the measurement of average bioequivalence in which the comparison o f population means of the test and reference products falls within the acceptable criteria B. it refers to the measurements pharmacokinetics parameters useful in bioequivalence studies

43.A formulary which lists all the drugs that may be substituted is A. B. C. D. E. positive formulary negative formulary neutral formulary restrictive formulary none

44. The FDA annually publishes approved drug products with therapeutic equivalence evaluation, the book is known as A. B. C. D. E. Orange book USP BP National formulary None

45. Which o f the following may have a formulary that provides guidance for drug product substitution? A. B. C. D. E. various hospitals insurance plans health maintenance organizations All o f the above None

Bioavailability and Bioequivalence

B. the active therapeutic moiety has

C. if its value is less than 1. the

Answers Bioavailabilty and Bioequivalece


]. Answer: B. Measurements intended to reflect the rate and extent to which the active ingredient becomes available at the site o f action Explanation: Bioavailability is the measurement o f the rate and extent to which the active ingredient becomcs available at the site o f action. Bioavailability is also considered as a measure o f the rate and extent o f therapeutically active drug that is systemically absorbed .For drug products that are not intended to be absorbed into the blood stream, bioavailability may be assessed by measurements intended to reflect the rate and extent to which the active ingredient becomes available at the site o f action.

2. Answer: E. C and D Explanation: Pharmaceutical equivalents are drug products that contain the same therapeutically active drug ingredients(s); same salt, ester or chemical from; are o f the same dosage form; and are identical in strength, concentration and route o f administration. Pharmaceutical equivalents may differ in characteristics such as shape , scoring configuration ,release mechanisms, packaging ,and excipients (including colors ,flavoring, and preservatives).

3. Answer: B. Generic drug products require Full New drug application for approval by the FDA. Explanation: The generic drug product requires an Abbreviated New Drug Application for approval by the FDA. Reference drug product is usually the currently marketed, brand name product with a full New drug application approved by the FDA. Generic drug product is marketed after patent expiration o f the reference drug product

4. Answer: C. They need not necessarily be bioequivalent. Explanation: Therapeutic equivalent drug products are pharmaceutical equivalents that can be expected to have the same clinical effect and safety profile when administered to patients under the same conditions and they are shown to have same bioequivalence.

5. Answer: D. Doxycycline hydrochloride versus Tetracycline hydrochloride. Explanation: Pharmaceutical alternatives are drug products that contain the same therapeutic moiety but are different salts, esters, or complexes (e.g tetracycline hydrochloride versus tetracycline phosphate) or are different dosage forms (e.g tablet versus capsule; immediaterelease dosage forms versus controlled release dosage form) or strengths. Doxycycline

hydrochloride and Tetracycline hydrochloride do not contain the same therapeutic moiety thus they are not Pharmaceutical alternatives.

6. Answer: E. All o f the above Explanation: Bioavailability and bioequivalence may be determined using Pharmacokinetic studies, Measurement o f an acute pharmacodynamic effect, Comparative clinical studies or in vitro studies.

7. Answer: E. A and B Explanation: In the determination o f bioequivalence and bioavailability the choice o f study method is based up on the ability o f the study design to compare drug delivered to that site by the two products. The choice should not be based on the preference o f the person doing the study or dose o f the drug.

8. Answer: E. A and B Explanation: Acute pharmacodynamic effects, such as changes in heart rate, blood pressure, electrocardiogram (ECG), clotting time, or forced expiratory volume can be used to measure bioavailability when no assay for plasma drug concentration is available or when the plasma drug concentration does not relate to the pharmacological response(e.g a bronchodilator such as albuterol given by inhalation).

9. Answer: A. Onset time Explanation: The time taken by a drug to achieve minimum effective concentration after administration o f drug is Onset time. Duration o f action is the time for which the drug concentration remains above the minimum effective concentration. Time for peak plasma concentration is the time taken by a drug to reach Peak plasma concentration^ m ax). Half-life o f a drug is the time taken for h alf o f the drug to be eliminated.

10. Answer: E. If two oral products contain the same amount o f active drug but different excipients, the dosage form that yields the faster rate o f drug absorption has the longer T (Time for peak plasma drug concentration)

m ax

Explanation: If two oral products contain the same amount o f active drug but different excipients, the dosage form that yields the faster rate o f drug absorption has the shorter T m a* (Time for peak plasma drug concentration).

11 .Answer: A. Amount or extent o f absorption

Explanation: Area under the concentration versus time curve (AUC) relates to the amount or extent o f drug absorption.The amount o f systemic drug absorption is directly related to the AUC. The AUC is usually calculated by the trapezoidal rule and is expressed in units o f concentration multiplied by time ( eg. mg x hr/ml)

12. Answer: E. All of the above Explanation: All o f the above statements are true.

13. Answer: A. the active therapeutic moiety is excreted unchanged in significant quantity in the urine Explanation: Measurement o f urinary excretion can determine bioavailability from a drug product. This method is most accurate if the active therapeutic moiety excreted unchanged in significant quantity in the urine, so the assay will be only to determine the unchanged drug and this provides more accuracy in determining the amount o f drug excreted.

14. Answer: C. The time for the drug to be completely excreted corresponds to the gap between drug absorption and determination o f the amount o f drug absorbed systemically. Explanation: In the measurement o f urinary drug excretion (in the determination of bioavailability) the time for the drug to be completely excreted corresponds to the total time for the drug to be systemically absorbed and completely excreted after administration.

15. Answer: C. if its value is less than 1, the reference and the products under examination have the same bioavailability Explanation: Relative bioavailability is the systemic bioavailability o f the drug from a dosage form as compared to a reference standard given by the same route o f administration. Relative bioavailability is calculated as the ratio o f the AUC for the dosage form to the AUC for the reference dosage form.

16. Answer: A. the ratio o f the AUC for the dosage form given orally to the AUC obtained after IV drug administration Explanation absolute bioavailability is the fraction o f drug systemically absorbed from the dosage form. It is calculated as the ratio o f the AUC for the dosage form given orally to the AUC obtained after IV drug administration.

17.Answer: B. 80% of the drug was systemically available from the oral dosage form Explanation An F value (absolute bioavailability) of 0.8 (80%) indicates that only 80% o f the drug was systemically available from the oral dosage form.

18. Answer: B. products in which the bioavailability o f the active ingredient is affected by food Explanation: If the bioavailability o f the active ingredient is known to be affected by food, the generic drug manufacturer must include a single-dose, randomized, cross over, food effects study comparing equal doses o f the test and reference products.

19.Answer: A. Fat rich food Explanation: In food intervention studies the reference and test products are given immediately after a standard high-fat content breakfast.

20.

Answer: A. long half-life

Explanation: In Cross over studies the drugs are given to the subjects alternatively, thus they can not be used in drugs with long half-lives (there may be carry over effect i.e the results o f the two products will interfere with each other). For drugs having long half-lives parallel study design is recommended.

21 .Answer: E.Cmin Explanation: Pharmacokinetic analysis o f bioavailability data includes calculation for each subject o f the AUC to the last quantifiable concentration AUC to the last quantifiable concentration (AUC 0-t ) and to infinity (AUCo-oo), Tmax, Cmax . Additionally, the elimination rate constant (K), the elimination half-life, and other parameters may be estimated.

22.Answer: A. two one sided test procedure Explanation: Cross over and parallel studies are study designs. The statistical methodology for analyzing bioequivalence studies is called two one sided test procedures.

23. Answer : C. The second o f the two sided tests determine whether a brand name product when substituted for a generic product is significantly more bioavailable. Explanation: In the analysis o f bioequivalence studies two situations are tested by the two one sided test procedure. - the first o f the two sided tests determine whether a generic product (test), when substituted for a brand product (reference) is significantly less bioavailable. - the second o f the two sided tests determine whether a brand name product when substituted for a generic product is significantly less bioavailable.

24.Answer: C. 20%

Explanation: Based on the opinions o f FDA medical experts, a difference o f greater than 20% for each o f statistical test methods was determined to be significant and therefore, undesirable for all drug products

25. Answer : B. Log transformed AUC and Cmax values obtained from each subject Explanation: Jn bioequivalence studies, an analysis o f variance (ANOVA) should be performed on the Log transformed AUC and Cmax obtained from each subject.

26.Answer: E. All except D Explanation: Alternate methods such as in vitro studies or equivalence studies with clinical or pharmacodynamic end points are used for drug products where plasma concentrations are not useful to determine delivery of the substance to the site o f activity.

27.Answer: C. tablets Explanation: No bioequivalence study is required for certain drug products given as a solution such as o ra l,parenteral, ophthalmic , or other solutions because bioequivalence is self-evident. For solid dosage forms such as tablets, capsules bioequivalence study is a must.

28.Answer: E. all except D Explanation: Inhalers, nasal sprays and topical products applied to the skin are intended to act locally, thus plasma concentrations are not useful to determine delivery o f the drug substance to the site o f activity. For dosage forms such as capsules the plasma concentration is a good measure o f the extent o f absorption and the amount o f drug which reaches the site o f activity.

29.Answer: A. 80% to 125% Explanation: The confidence interval for both pharmacokinetic parameters, AUC and Cm ax must be entirely within 80% to 125% boundaries. Because the mean o f the study data lies in the center o f the 90% confidence interval, the mean o f the data is usually close to 100% (a reference ratio o f 1).

30.Answer: -[B] 31.Answer: -[E] 32.Answer: -[D] 33.Answer: -[A] 34.Answer: ~[C]

Explanation: Drugs with non linear pharmacokinetics result in problems o f bioavailability. Nonlinear pharmacokinetics is also known as capacity-limited, dose-dependent, or saturation pharmacokinetics. Nonlinear pharmacokinetics does not follow first-order kinetics as the dose increases. Nonlinear pharmacokinetics may result from the saturation o f an enzyme-or carriermediated system. , Characteristics o f non linear pharmacokinetics include: - The AUC is not proportional to the dose] - The amount o f drug excreted in the urin^ is not proportional to the dose. - The elimination half-life may increase at high doses. The ratio o f metabolites formed changes witli increased dose. Another problem while determining bioavailability is long eliminaticjn half-life for some drugs. If the elimination half-life is long, there may be carry over effects for the products compared and this may result in wrong figures which in turn leads to wrong conclusion. Determining the bioavailability o f drugs with active metabolites may be difficult because tne assay methods available can not determine all metabolites.

35. Answer; D. they can be used for drugs iiji which plasma concentrations are useful to determine delivery o f the drug substance tojthe site o f activity

Explanation: Pharmacodynamic measurements are more difficult to obtain and the data tend to be variable requiring large number o f subjects Compared to the bioequivalence studies for systemically absorbed drugs. A bioequivalence study using pharmacodynamic measurements tries to obtain a pharmacodynamic effect versus time profile for the drug in each subject. The area under the effect versus time profile, peak effect and tijme to peak effect are obtained for the test and reference products and are then statistically analyzed. For drugs in which plasma concentrations are useful to determine delivery o f the drug substancc to the site o f activity direct determination o f the plasma concentration is recommended instead o f pharmacodynamic measurements.

36.Answer: B. dermatopharmacokinetics e development o f a reliable marker that may be Explanation: In vitro studies may require th< ty data. For example, the penetration o f drug into correlated with human in vivo bioavailabil pharmacokinetics) has been suggested as a method for layers o f skin with respect to time (dermato; measuring the bioequivalence o f topical drtig products intended for local activity.

37.Answer: D. A and B Explanation: Generic drug substitution is the process o f dispensing a generic drug product in place o f the prescribed drug product (e.g., generic product for brand name product, generic product in place o f another generic product, a brand name product for a generic product).

3 8.Answer: D. A and B

Explanation: Generic drug products that are classified as therapeutic equivalents by the FDA are expected to produce the same clinical effect and safety profile as the prescribed drug.

39.Answer: D. A and C Explanation: Prescribability refers to the measurement o f average bioequivalence in which the comparison of population means o f the test and reference products falls within the acceptable criteria. Prescribability is the current basis for FDA approval of therapeutic equivalent generic drug products.

40.

Answer: D. It is the method o f determining the concentration o f a drug in a blood sample.

Explanation: switchability refers to the measurement of individual bioequivalence, which requires knowledge o f individual variability (intra-subject variability) and subject-by-formulator effect. It assures that the substituted generic drug product produces the same response in the individual patient. It is not a method o f determining the concentration o f a drug in a blood sample.

41 .Answer: A. Amoxicillin - ampicillin Explanation: Therapeutic substitution is the process o f dispensing a therapeutic alternative in place o f the prescribed drug product. The substituted drug product is usually in the same therapeutic class (e.g. calcium channel blocker) and is expected to have the similar clinical profile. For example amoxicillin is dispensed for ampicillin. Nifedipine (calcium channel blocker) and propranolol (p-blocker) are antihypertensive drugs, but they are not o f the same class, thus they are not therapeutic equivalents. Amoxicillin and Rifampicin have different clinical indications and they do not belong to the same class, thus they are not therapeutic equivalents. Aspirin (salicylates) and celecoxib (a selective cyclooxygenase inhibitor) are nonsteriodal anti inflammatory drugs but they belong to different classes and their clinical profiles are the same, thus they are not therapeutic equivalents.

42. Answer : A. a list o f drugs Explanation: A formulary is a list o f drugs. It is not a list o f all molecules that have pharmacological activity, industrial chemicals or poisonous substances.

43.Answer: A. positive formulary Explanation: A positive formulary lists all the drugs that may be substituted (after prescription), where as a negative formulary lists drugs for which the pharmacist may not substitute.

44.Answer: A. Orange book

Explanation: The FDA annually publishes approved drug products with therapeutic equivalence evaluation, the book is known as the Orange book.

45. Answer: D. All o f the above Explanation: Various hospitals, institutions, insurance plans, health maintenance organizations, and other third-party plans may have a formulary that provides guidance for drug product substitution.

Bioavailability and Bioequivalence

Explanation
T r phannacokineiirs 7 WemS Nonlinear dose-dependem, or d u ratio n

Biochemistrty

Organic chemistry is the chemistry of carbon compounds. Biochemistry is the study of carbon compounds that crawl
M ike Adam

1. Which of the monosaccharide? A. B. C. D. E. Sucrose Maltose Dextrose Lactose Cellulose

following

is

C. D. E. F. 6.

Lyases Transferases Isomerases Oxidoreductases

Pyrimidine base that is found only in RNAis A. B. C. D. E. Thymine Cytosine Adenine Guanine Uracil

2. Pyranose is the systematic name for A. Straight chain mono-saccharides B. Five membered acyclic mono saccharides C. Cyclic five membered mono saccharides D. Cyclic six membered mono saccharides E. Acyclic di-saccharides 3. Mutarotation refers to change in optical rotation due to conversion of A. Either the pure - or pure Danomer of a monosaccharide into an equilibrium B. mixture of both forms C. -anomer to -anomer D. -anomer to -anomer E. anomer to epimer F. None 4. Human intestinal tract is able to secrete enzymes that can hydrolyze the below mentioned carbohydrates EXCEPT A. B. C. D. E. Lactose Cellulose Maltose Starch Sucrose

7. Which of the following are building blocks of Proteins A. B. C. D. E. Amino acids Pyrimidines Nucleotides Monosaccharides Purines

8. The structure of protein that gives information regarding sequence of amino acids and location of disulfide bonds is A. B. C. D. E. Primary structure Secondary structure Tertiary structure Quaternary structure None

9. Which of the following is Hetero polysaccharide A. B. C. D. E. Starch Heparin Glycogen Cellulose None

10. Bonds present in Carbohydrates are A. B. C. D. E. Peptide bonds Glycosidic bonds Phosphodiester bonds Disulfide bonds Amide bonds

5. Decarboxylases and Deaminases are the enzymes, which catalyze the removal of functional groups by the process other than hydrolysis, will fall into the category A. Ligases B. Hydrolases

11. Which o f the following serves as a template for required protein synthesis

A. B. C. D. E.

rRNA mRNA tRNA DNA None

12. N-acetyl-D-glucosamine and N-acetylmuramic acid moieties are alternatively present in the heteropolysaccharide A. B. C. D. E. Glycogen Cellulose Heparin Hyaluronic acid Starch

A. In DNA, three ot-helical strands are present B. The strands in DNA are anti parallel - the 51. 31 - inter nucleotide phophodiester bonds are in opposite directions. C. Adenine & Thymine are linked by triple bond whereas Guanine & Cytosine are linked by double bonds. D. AUG & GUG are terminating codons E. UAG & UAA are starting codons 17. The phenomenon o f reactions, which involve consumption of energy to form new biochemical compounds is termed as A. B. C. D. E. Anabolism Catabolism Amphibolic pathway Anaplerotic reactions None

13. Which o f the following are Nucleic acids? A. B. C. D. E. DNA&RNA Purines & Pyrimidines Thymine & Cytosine Adenine & Guanine Glycine & Alanine

18. Formation of glucose from non carbohydrate source is known as A. B. C. D. E. Glycolysis Glycogenesis Glycogenolysis Gluconeogenesis None

14. Backbone o f Nucleic acids is A. Pyrimidines B. Purines C. Alternating sugar & phosphate units, each one further attached with a base D. Proteins E. Lipids 15. Which of the following statement is FALSE A. DNA doesnt contains hydroxyl group at the pentose C2 position B. DNA contains Thymine instead of Uracil C. DNA contains Uracil instead o f Thymine D. The successive nucleotides are joined by phosphodiester bonds. E. Nucleotides are the backbones of Nucleic acids 16. Which of the following statement is TRUE

19. Which o f the following reaction is coupled with electron transport system, from which the released energy is used to form ATP in mitochondria A. B. C. D. E. Substrate level phosphoiylation Oxidative phosphorylation Anabolism Catabolism None

20. Upon metabolism, Triglycerides are converted to A. B. C. D. E. Fatty acids & glycerol Amino acids Monosaccharides Uric acid None

21. Metabolism of steroids produce the metabolite A. B. C. D. E. Bile acids Insulin Vitamin D Cortisone Estrogen are

may

not 27. Aspartate, Glutamate, Glycine, Formyl tetra hydrofolate and carbon dioxide involves in synthesize of A. B. C. D. E. Purines Pyrimidines Steroids Proteins Carbohydrates pathway involves

22. Human beings synthesize A. B. C. D. E. Bile acids Pyruvic acid Succinic acid Linoleic acid Glycogen

unable

to

28. Krebs-Henseleit synthesis of A. B. C. D. E.

23. Which of the following does not come under Terpenes A. B. C. D. E. Cholesterol Vitamin A Vitamin K Bile acid Vitamin C

Vitamin-B]2 Estrogen Phosphatidyl choline Sphingolipids Urea

29. An enzyme that is complete and catalytically active is called as A. B. C. D. E. Co-enzyme Prosthetic group Holoenzyme Apoenzyme Co-factor

24. Nitrogen metabolism involves metabolism of A. B. C. D. E. Steroids Carbohydrates Nucleic acids & amino acids Lipids Fatty acids

30. Drugs like Nitroglycerine and Aspirin undergo degradation mostly by A. B. C. D. E. Oxidation Hydrolysis Reduction Glucuronization Sulfation

25. Which of the following is essential amino acid A. B. C. D. E. Glycine Leucine Alanine Tyrosine Proline

26. In amino acid metabolism, after removal of amino group, the carbon skeleton will be metabolized into any of the below EXCEPT A. B. C. D. E. Ketogenic amino acids Glycogenic amino acids Carbon dioxide Water Cyanocobalamine

ANSWERS

Biochemistry
1. Answer: C. Dextrose Explanation: Monosaccharide is the simple carbohydrate, which cannot be further hydrolyzed. Dextrose is D-glucose monohydrate, a monosaccharide usually obtained by the hydrolysis o f starch. Sucrose, Maltose and Lactose are Di-saccharides, which contains two monosaccharides joined covalently by glycosidic bonds. Sucrose is composed of glucose and fructose; Maltose is composed o f two glucose molecules; Lactose also called as milk sugar consists o f glucose and galactose. Whereas Cellulose comes under Polysaccharides (which are long chain polymers o f monosaccharides may be either linear or branched) which is linear and unbranched.

H "1 H HO HU H UH H H UH Ul i . UM HO H = 0 HU "H HU H H

OH

H OH OH

OH

dh

D-galactose (aldehyde)

D-glucose (aldehyde)

D-fructose (ketone)

D-itunitose (aldehyde)

2. Answer: D. Cyclic six membered mono-saccharides


Explanation: The systematic names o f straight chain monosaccharides are based on a stem name indicating the number o f carbon atoms, a prefix indicating the configuration o f the hydroxy group and either the suffix -ose (aldoses) or -ulose (ketoses). In addition the name is also prefixed by the D- (dextro rotatory) or L- (Levo) as appropriate according to the configuration o f their pentultimate CHOH group. In the D form this hydroxy group projects on the right o f the carbon chain towards the observer whilst in the L form it projects on the left o f the carbon chain towards the observer when the molecule is viewed with the unsaturated group at the top. Five membered ring monosaccharides have the stem name 'furanose whilst six membered ring compounds have the stem name pyranose together with the appropriate configurational prefixes indicating the stereochemistry o f the anomers. Monosaccharides in which one o f the hydroxy groups has been replaced by a hydrogen atom have the prefix deoxy- with the appropriate locant, except if it is at position 2, when no locant is given.

Some monosaccharides may also be classified as epimers. Epimers are compounds that have identical configurations except for one carbon atom. For example, D-D-glucose and -D-fructose are epimers. Another e.g., L-D-glucose and D-D-mannose are also epimers. 4. Answer: B. Cellulose.

Explanation: Cellulose, linear unbranched polymer o f D-glucose, is a water insoluble structural homo polysaccharide present in plant cell walls. Human beings are unable to digest cellulose because the human intestinal tract doesnt secrete any enzyme that can hydrolyze cellulose. Lactose also called as milk su g ar will get hydrolyzed by the enzyme Lactase into its components glucose and galactose; Maltose by maltase enzyme into two molecules o f glucose,; Sucrose by sucrase enzyme into glucose and fructose. Starch a homo polysaccharide can also be hydrolyzed by salivary or pancreatic enzyme amylase into monosaccharides (glucose, dextrose) and/or Oligosaccharides (maltose). 5. Answer: C. Lyases Explanation: Lyases are the enzymes that catalyze the removal o f functional groups. E.g., Decarboxylation reaction by decarboxylase enzyme and Deamination reaction by deaminase enzyme. I f the reaction involves hydrolysis catalyzed by enzymes like proteolytic enzymes, amylases, esterases they are classified as Hydrolases. Ligases are enzymes that catalyze coupling o f molecules. E.g., DNA ligase (Participates in DNA synthesis by coupling nucleotides). Transferases catalyze the transfer o f groups E.g., Phosphate and amine groups. Isomerases catalyze various isomerization reactions. E.g., Conversions like D-form to Lform and Cis-form to Trans-form isomers and vice-versa. Oxidoreductases catalyze reactions involving oxidation step. E.g., Dehydrogenase, Peroxidase, Oxidase (Participates in drug metabolism). 6. Answer: E. Uracil

Explanation: Uracil is the pyrimidine base found only in RNA. Thymine and Cytosine are also pyrimidine bases but former is found in both DNA and RNA whereas latter is found only in DNA. Adenine and Guanine are purine bases that are found in both DNA and RNA.

"N H ^O

^ tS -T ^ O

"N h f^ O

Adenine (A)

Guanine (G)

Thymine (T)

Cytosine (C)

Uracil (U)

7.

Answer: A. Amino acids.

Explanation: Proteins are polymeric compounds composed o f amino acids (contains both amino group and carboxylic acid group) as their building blocks linked together by peptide bonds. Peptide bonds are links between carbonyl carbons ( C O ) anc| amino nitrogens. Nucleotides are the building blocks o f Nucleic acids. Nucleotides consist o f three different molecules linked with covalent bonds. (1) Organic heterocyclic base: either pyrimidine or purine, (2) Sugar moiety: Pentose (Ribose/deoxy-ribose, 5-carbon monosaccharide) and (3) Phosphoric acid group. Nucleoside contains only organic base and pentose moiety. Organic base + Pentose = Nucleoside. Organic base + Pentose + Phosphoric acid group = Nucleotide. Linear polymers o f Nucleotides = Nucleic acids. Nucleic acid types = DNA and RNA.

1
W'

W H,
HQ

<r

HO

N -

X
\ X
Adenosine mono phosphate (AMP) (Deoxy-nucleotide) (Base + pentose + phosphate)

//

NH'

p
O H Adenosine (Deoxy-nucleoside) (Base + pentose) (Deoxyribonucleoside)

Adenine (Pyrimidine base)

(Ribo-nucleoside) Similarly, Guanine linked to ribose = riboguanosine Thymine linked to ribose = Thymidine Cytosine linked to deoxyribose = Deoxycytidine Uracil linked to ribose = Uridine

(Ribo-nucleotide)

Monosaccharide is the simple carbohydrate, which cannot be further hydrolyzed and is the building block o f Oligosaccharides and Polysaccharides.

8.

Answer: A. Primary structure.

Explanation:

Proteins are polymers o f amino acids that are linked together by peptide bonds (i.e., link between carbonyl carbon and amino nitrogen). Proteins have four structural levels, each level reveals about particular information: Primary structure: Sequence o f amino acids and location o f disulfide bonds present in proteins.

Secondary structure: Spatial arrangement of sequential amino acids (Ex. Helix (aconformation) and Pleated sheet (P-conformation))
Tertiary structure: Three-dimensional structure o f a single protein. Quaternary structure: Arrangement o f individual subunit chains into complex molecules. 9. Answer: B. Heparin. Explanation: Polysaccharides, also called as Glycans, are long chain polymers o f carbohydrates. They are either homo- or hetero- polysaccharides and linear or branched. Starch (composed of two glucose polymers: Amylose (linear and water soluble) and amylopectin (highly branched and water-insoluble)), Glycogen (branched chain o f Dglucose) and Cellulose (Linear, unbranched and water insoluble polymer o f Dglucose) comes under Homo polysaccharides. Heparin, an acid muco polysaccharide, comes under Hetero polysaccharide. It consists o f a variably sulfated repeating disaccharide unit. The main disaccharide units that occur in heparin are 2-O-sulfated iduronic acid and N-sulfated glucosamine. 10. Answer: B. Glycosidic bonds. Explanation: Glycosidic bonds are present in carbohydrates to link monosaccharides and produce Oligosaccharides and polysaccharides. This is a type o f covalent chemical bond that joins two simple sugars via an oxygen atom (-0-). The bond may be either above the plane of the ring as in a beta glycosidic bond or below the plane as in an alpha glycosidic linkage A peptide bond is a chemical bond formed between two molecules when the carboxyl group o f one molecule reacts with the amino group of the other molecule (-CO-NH-), releasing a molecule o f water (H 2 O). Disulfide bonds are also present in proteins. Disulfide bond is a single covalent bond derived from the coupling o f thiol groups. The linkage is also called an SS-bond or disulfide bridge (-C-S-S-C-). E.g., Insulin. Phosphodiester bonds are present in both DNA and RNA to join successive nucleotides between 5'-hydroxyl group o f one nucleotides pentose and S'-hydroxyl group o f the next nucleotides pentose. 11. Answer: B. mRNA. Explanation: DNA and RNA are examples of Nucleic acids. RNA will be in three forms. rRNA (ribosomal RNA): rRNA is a component o f the ribosomes. It consists o f 30S and 50S subunits and acts as framework to bind both messenger and transfer RNA. mRNA (messenger RNA): mRNA is a copy o f the information carried by a gene on the DNA. The role o f mRNA is to move the information contained in DNA to the translation machinery for required protein synthesis and specifies a polypeptides amino acid sequence.

tRNA (transfer RNA): tRNA is the information adapter molecule. It brings the activated amino acids over the growing polypeptide chain at ribosomes. 12. Answer: D. Hyaluronic acid Explanation: Hyaluronic acid is a component o f synovial fluid, and is found in the vitreous humor of the eye, the synovia of joints, and in subcutaneous tissue where it functions is as a cementing agent. Hyaluronic acid is a glycosaminoglycan with alternating units o f Nacetyl-D-glucosamine and N-acetyl-muramic acid. Glycogen (compact branched chain o f D-glucose) and Cellulose (Linear, unbranched & water insoluble polymer o f D-glucose) comes under Homo polysaccharides. Heparin, even though Hetero polysaccharide, is an acid muco polysaccharide, consisting o f sulfate derivatives o f N-acetyl-D-glucosamine and D-iduronate. 13. Answer: A. DNA & RNA Explanation: DNA (Deoxyribonucleic acid) and RNA (Ribonucleic acid) are the two main types of Nucleic acids. They are made up o f Nucleotides (building blocks o f Nucleic acids), which include pyrimidine and purine bases linked to ribose or deoxyribose sugars (nucleosides) and bound to phosphate groups. RNA is o f three types: mRNA (messenger RNA), tRNA (transfer) and rRNA (ribosomal RNA). Pyrimidine bases: Cytosine (present in DNA & RNA) Thymine (present only in DNA) Uracil (present only in RNA) Purine bases: Adenine (present in DNA & RNA) Guanine (present in DNA & RNA) Glycine and Alanine are the amino acids, which are building blocks o f Proteins. 14. Answer: C. Alternating sugar & phosphate units, each one further attached with a base Explanation: Nucleic acids are made up o f Nucleotides, which contain Nucleosides (Pyrimidine or Purine base attached to ribose or deoxyribose sugar moiety) attached to phosphate group. In this the backbone is having alternating sugar (pentose) & phosphate units each one further attached with a purine or pyrimidine base.
Sugar---- C ------- G Sugar

o P^O

i I 0

O P Q

I
I Q

Sugar----- T --------- A Sugar

1 0
O i= G

I O
O P = 0

1 O

I Sugar G ------- C -J-S u g a r 5 End | ~ I 3 End

Proteins are polymers o f amino acids linked together by peptide bonds. Lipids are triglyceride esters o f fatty acids. 15. Answer: C. Explanation: The successive nucleotides are joined by phosphodiester bonds in both DNA and RNA. Nucleotides [Nucleosides (Pyrimidine/Purine base + sugar moiety) + phosphate group] are the building blocks of Nucleic acids Both RNA and DNA are composed o f repeated units. The repeating units o f RNA are ribonucleotide monophosphates and of DNA are 2'-deoxyribonucleotide monophosphates. That means DNA doesnt contains hydroxyl group at the pentose C 2 position and it contains Thymine instead o f Uracil. 16. Answer: B. The strands in DNA are anti-parallel - the 5 1, 31 - inter nucleotide phophodiester bonds are in opposite directions. Explanation: The prime features o f the DNA structure are: two strands o f DNA wrap around each other the strand polarities are opposite to each other and are anti-parallel the sugar-phosphate hydrophilic backbone is on the outside the hydrophobic bases are in the middle it is a right-handed helix there is a 2-fold axis o f symmetry the bases are perpendicular to the axis o f symmetry there is a wide (major) and a narrow (minor) groove between the backbones on opposite strands. The 5 1 , 3 1 inter nucleotide phophodiester bonds (Phosphodiester bonds are present in both DNA and RNA to join successive nucleotides between 5 '-hydroxyl group o f one nucleotides pentose and 3 '-hydroxyl group o f the next nucleotides pentose) are in opposite directions.

ON

?/

The strands are complementary i.e., the base sequence o f one strand determines the base sequence o f the other.

Hydrogen bonds are present between specific base pairs. Adenine and Thymine are linked by double bond ( A = T ) whereas Guanine and Cytosine are linked by triple bond ( G ~ C ) .
< p > ti

j
f'i

residue

-A -.
D eoxvriN *w ? re^kkie n
**C I*jbw p a r

D & H Q ritK ue iwktoe

A -T tea* pair

For each amino acid recognition three codons are required. AUG and GUG are starting codons whereas UAG (opra), UAA (ochra) and UGA (opal) are ending/terminating codons also called as non-sense codons.

17. Answer: A. Anabolism Explanation: Anabolism is the phenomenon o f reactions (build up reactions involving synthesis of complex molecules from simple molecules) that consume energy to form new biochemical compounds e.g., Synthesis of: proteins from aminoacids, Glycogen from glucose etc. Catabolism is the phenomenon o f degradation reactions (break down reactions involving conversion o f complex molecules to simple molecules), which releases energy e.g., Breakdown o f glycogen into glucose moieties, glucose into pyruvic acid (aerobic pathway) or lactic acid (anaerobic pathway) etc. Amphibolic pathways are those, which are used for both anabolic and catabolic processes e.g., Krebs cycle involves both synthesis (Anabolism) o f new amino acids or heme (from succinyl CoA) from the metabolites as well as breakdown o f molecules (Catabolism) to yield major part o f the energy. Since metabolites are being used for the synthesis o f amino acids or heme, the metabolite has to be replaced by intermediates from other sources (e.g., glutamate from the breakdown o f protein forms a-ketoglutarate) also called as Anaplerotic reactions. 18. Answer: D. Gluconeogenesis. Explanation: Gluconeogenesis: Formation o f glucose from non-carbohydrate sources like lactate, pyruvate, krebs cycle metabolites and amino acids. Fatty acids cannot form glucose. Glycolysis: Breakdown o f sugar phosphates (glucose, fructose) into pyruvate (aerobic pathway) or lactae (anaerobic pathway). It takes place in cytoplasm. Glycogenesis: Formation o f glycogen from glucose. It takes place in liver and muscles and is controlled by pancreatic hormone insulin. Glycogenolysis: Breakdown o f glycogen into glucose phosphate. It takes place in liver and skeletal muscle and is controlled by hormones glucagons and epinephrine 19. Answer: B. Oxidative phosphorylation

Explanation: Oxidative phosphorylation, which requires oxygen, involves formation of ATP (Adenosine triphosphate) from the metabolite produced by oxidoreductase enzymes e.g., dehydrogenases; that uses FAD (Flavin adenine dinucleotide: obtained from vitamin riboflavin) or NAD (Nicotinamide adenin dinucleotide: obtained from vitamin nicotinamide) and coupled with electron transport system and the energy produced is used to form ATP in the mitochondria. Electron transport system accepts electron and hydrogen from the metabolites of Krebs cycle upon oxidation and utilizes the energy produced to synthesize ATP in the mitochondria. Substrate level phosphorylation doesnt need oxygen and involves the formation o f ATP (Adenosine triphosphate) from metabolite e.g.. phosphoenol pyruvate to pyruvate, succinyl CoA to succinate. Anabolism is the phenomenon o f reactions (build up reactions involving synthesis of complex molecules from simple molecules) that consume energy to form new biochemical compounds e.g., Synthesis of: proteins from aminoacids, Glycogen from glucose etc. Catabolism is the phenomenon o f degradation reactions (break down reactions involving conversion o f complex molecules to simple molecules), which releases energy e.g., Breakdown o f glycogen into glucose moieties, glucose into pyruvic acid (aerobic pathway) or lactic acid (anaerobic pathway) etc. 20. Answer: A. Fatty acids & glycerol Explanation: Triglycerides are metabolized (hydrolysis) by the enzymes lipases into fatty acids and glycerol. In that, fatty acids undergo beta oxidation and gets breakdown into acetyl CoA, which further enters into Krebs cycle to complete the oxidation with the release o f energy finally producing carbon dioxide and water. Excess breakdown o f fatty acids may leads to Ketogenesis (release o f ketone bodies) whereas glycerol enters glycolysis cycle and gets oxidized to pyruvate and through Krebs cycle gets oxidized to carbon dioxide and water. Upon metabolism proteins release amino acids whereas complex polysaccharides release oligo- or mono- saccharides. Purines with the action o f xanthine oxidase enzyme releases uric acid in humans. 21. Answer: B. Insulin Explanation: Upon metabolism steroids are converted to bile acids, vitamin-D or steroidal hormones like estrogens, androgens, cortisone. Anyhow steroids wont undergo complete broken down. Insulin is a pancreatic hormone (polypeptide containing 51 amino acids with two chains A (21 amino acids) and B (30 amino acids) linked by disulfide bond) that controls glucose uptake by the cells. 22. Answer: D. Linoleic acid Explanation:

Linoleic acid is essential fatty acid that means it is not synthesized by the human body, so it has to be taken by diet. Bile acids, pyruvic acid, succinic acid and glycogen are formed within the body. 23. Answer: E. Vitamin C Explanation: Terpenes are synthesized from acetyl CoA via mevalonate pathway and include: Cholesterol, other steroids, Fat soluble vitamins (A, D, E & K) and Bile acids. They contain isoprene units as monomers Vitamin C also called as Ascorbic acid is a water soluble vitamin that doesnt contain any isoprene unit, hence w ont come under Terpenes. 24. Answer: C. Nucleic acids & amino acids Explanation: Nitrogen metabolism involves metabolism o f amino acids and nucleic acids (both anabolism and catabolism)._________ _______ ______________________________________

Anabolism Substrates
Citric acid cycle intermediates Carbonyl phosphate, aspartate, glutamate, glycine, carbon dioxide and formyl tetra hydrofolate. Aspartate and carbamoyl phosphate

Products
Aspartate, glutamate Purines

Pyrimidines

Catabolism Product
Amino acids

Metabolites
Acetyl CoA (ketogenic amino acids), Krebs cycle intermediates (glycogenic amino acids) and finally gets oxidized to carbon dioxide and water Uric acid Carbon dioxide, ammonia and (3-alanine

Purines Pyrimidines

25. Answer: B. Leucine Explanation: Amino acids can be classified as Essential and Non-essential amino acids. Essential amino acids are those that cannot be synthesized by our body and hence to be taken in diet. These include Histidine, Arginine, Methionine [HArM], Leucine, Lysine, Phenylalanine [LLIP], Valine, Isoleucine, Threonine, Tryptophan [VITT] Non-essential amino acids are those that are synthesized within our body. These include Glycine, Alanine, Serine [GAS], Glutamine, Asparagine, Aspartic acid, Tyrosine [GAAT], Glutamic acid Cystine, and Proline [GCP]. 26. Answer: E. Cyanocobalamine Explanation:

In amino acid metabolism after removal o f amino group, the carbon skeleton will be metabolized into acetyl CoA (ketogenic amino acids) or to Krebs cycle intermediates (glycogenic amino acids) and finally get oxidized to carbon dioxide and water for the generation of energy. Gluconeogensis involves formation o f glucose from non-carbohvdrate sources like glycogenic amino acids. Cyanocobalamine is a water-soluble vitamin also designated as Vitamin B12.

27. Answer: A. Purines Explanation: Purines are synthesized from complex reactions involving carbonyl phosphate, aspartate, glutamate, glycine, carbon dioxide and formyl tetra hydrofolate. Pyrimidines are synthesized from aspartate and carbamoyl phosphate. Steroids are synthesized from acetyl CoA via mevalonate pathway. Proteins are synthesized from amino acids whereas carbohydrates are synthesized from monosaccharide units. 28. Answer: E. Urea Explanation:

Krebs-Henseleit pathway involves synthesis of urea mainly in the liver. Carbamoyl phosphate synthesized from Glutamine (produced from glutamate and ammonia) and carbon dioxide, enters urea cycle and produces urea. Ammonia is obtained from amino acids by the action o f enzyme, amino acid transferase (transaminase) using pyridoxal phosphate (Vitamin B6) as coenzyme. Phosphatidyl choline is a lipid compound that is important in cell membrane. Sphingolipids contain sphingenine formed from palmitoyl CoA and serine. Sphingenine is the backbone for various compounds like cerebrosides, gangliosides or sphingomyelin.

29. Answer: C. Holoenzyme Explanation: Enzymes are biocatalysts that enhance the rate o f a specific reaction by lowering its activation energy. An enzyme may be a complex one in which the protein part is called Apoenzyme. A cofactor firmly bound to Apoenzyme is referred as Prosthetic group. Cofactor may be an inorganic component (metal ion) or a non-protein organic component. The organic cofactor that is not firmly bound to Apoenzyme but requires its participation during enzyme catalysis is called as Coenzyme. An enzyme that is complete and catalytically active is called as Holoenzyme. All enzymes are proteins but all proteins are not enzymes. 30. Answer: B. Hydrolysis Explanation:

Drugs undergo biotransformation under two phases. Phase I metabolism include Oxidation, Hydrolysis and Reduction. Phase II metabolism include conjugation reactions like Glucuronization, Sulfation, Acetylation, Methylation, Glutathione conjugation and Amino acid conjugation. Drugs like Nitroglycerine and Aspirin undergo degradation mostly by Hydrolysis.

Biopharmaceutics

Fortune knocks but once, but misfortune has much more patience.

Laurence Peter

D. Types 1. Biopharmaceutics is the study o f the relation o f the Physical and chemical properties o f a drug in relation to its: A. B. C. D. E. Bioavailability Pharmacokinetics Pharmacodynamics Toxicologic effects All o f the above

6. Which one of the following represents a WRONG pair? A. Pharmacodynamics - relation o f the drug concentration or amount at the site o f action and its pharmacologic response as a function o f time. B. Pharmacokinetics - time course of drug movement in the body during absorption, distribution, and elimination C. Bioavailability - the amount o f drug entering cells D. A and C

2. A drug product contains the active ingredient in association with which o f the following: A. B. C. D. Excipients Impurities Adulterants Containers

7. A cell membrane is composed primarily o f A. Proteins and lipids B. Polysaccharides and monosaccharide C. Alkaloids and terpenes D. Tannins and Xanthenes E. None

3. The concept that includes the drug formulation and the dynamic interaction among the drug, its formulation matrix, its container, and the patient. A. B. C. D. Bioavailability Drug product Drug delivery system Dosage form

8. Which one o f the following is a means o f transport o f drugs? A. B. C. D. E. Passive diffusion Carrier mediated transport Vesicular transport Para cellular transport All of he above

4. Bioavailability is a measurement o f the rate and extent o f which o f the therapeutically active drug A. B. C. D. Distribution Elimination Metabolism Systemic absorption

9. Which one o f the following drugs can easily cross cell membranes as compared to the others? A. B. C. D. Polar drug Drugs bound to Proteins Drugs having high molecular weight Non polar lipid -soluble drugs having low molecular weight

5. What is studied in pharmacokinetics about the drug movement in the body during absorption, distribution, and elimination is studied. A. Time course B. Mechanism C. Receptors

10. Within the cytoplasm or in interstitial fluid, most drugs undergo transport by: A. B. C. D. Simple diffusion Carrier mediated transport Facilitated diffusion Vesicular transport

A. The surface area o f the plane across which transfer occurs. B. Thickness o f the region across which diffusion occurs. C. The difference in concentration o f drug between the two points. D. Diffusion coefficient o f the drug. E. All o f the above

11 .Passive transport across cell membranes involves: A. Successive partitioning o f a solute between aqueous and lipid phases as well as diffusion within the respective phases. B. Only diffusion across the lipid bilayer C. Only partitioning between aqueous and lipid phases D. Dissolution and disintegration.

15.Carrier mediated transport includes: A. B. C. D. E. Active transport Facilitated diffusion Para cellular transport Vesicular transport A and B

16. Which o f the following the statements is incorrect about active transport? A. The drug moves with the direction o f concentration gradie B. The process requires energy C. The carrier system may be saturated at high concentration. D. The transport process may be competitive.

12. Which o f the following have effect on the ionization o f a weak electrolyte? A. PH o f the media in which the drug is dissolved. B. PKa o f the drug C. Crystallinity o f the drug D. A and B

17.Para cellular transport involves the following across Para cellular channels 13. Which one o f the following statements is true? A. Nonionized species o f drugs are more lipid soluble than the ionized species B. Ionized species partition more readily than nonionized species o f drugs across cell membranes. C. Ionization o f drugs does not affect lipid solubility. D. Only lipid soluble molecules readily cross cell membranes. A. Diffusion and the convective flow o f water and accompanying water soluble drug molecules B. Dissolution and disintegration C. Ionization and dissolution D. Crystallization and digestion

18. All o f the following are TRUE about facilitated diffusion EXCEPT: A. It is a carrier mediated transport B. It occurs with the direction o f concentration gradient. C. The process does not require energy.

14. According to Ficks law o f diffusion the rate o f diffusion depends up on:

D. It occurs against the direction o f concentration gradient 23.The side effects with the intravenous bolus injection are: 19.The two forms o f vesicular transport are A. Active transport and Para cellular transport B. Phagocytosis and pinocytosis C. Carrier mediated transport and Passive diffusion D. Partitioning and distribution E. None A. B. C. D. Intense pharmacological response Anaphylaxis Overt toxicity All o f the above

20. Which one o f the following statements is true? A. Vesicular transport is the only transport mechanism that doesnt require a drug to be in aqueous solution to be absorbed. B. A carrier is involved in vesicular transport. C. Pinocytosis is the engulfment o f large particles or macromolecules. D. Phagocytosis is the engulfment o f small solutes or fluids by cells.

24. A drug has low molecular weight but it is water soluble. Which one of the following routes is the most likely mechanism o f entry for the drug across a cell membrane? A. B. C. D. Passive diffusion Carrier mediated transport Para cellular transport Vesicular transport

25. Which o f the following injections is used for diagnostic agents and occasionally for chemotherapy. A. B. C. D. E. Intraarticular injection Intradermal injection Intra-arterial injection Intramuscular injection Intravenous injection

21 .An example o f transporter proteins which are embedded in the lipid bilayer o f cell membranes is: A. B. C. D. P-glycoprotein Cytochrome P 450 3A4 Adenosine triphosphate Alanine

26. Which one o f the following statements is true? A. Intra-articular injection maintains a relatively constant plasma drug concentration once the infusion rate is approximately equal to the drugs elimination rate from the body. B. In subcutaneous injection the drug is injected beneath the skin. C. Subcutaneous region o f the skin is more vascular than muscle tissues, so the drug absorption is more rapid by subcutaneous injection. D. In intravenous injection the drug is given intravenously at a constant 'Tate.

22. All o f the following are true regarding transporter proteins except: A. They are ATP dependent pumps. B. They facilitate efflux o f drug molecules from the c e ll. C. They are found in conjunction with metabolizing enzymes such as Cytochrome P450 3A4 D. They are involved in the translation o f genetic code

E. B and D

27. A given drug is known to be metabolized by liver and in gastrointestinal tract enzymes. The drug is non polar, very lipid soluble and its absorption rate in the epithelial tissues o f the mouth is very high. If the metabolites of the drug do not have pharmacological activity which route o f administration is the best candidate for the drug to be administered to achieve the desired outcome o f drug therapy? A. Sublingual and Buccal administration B. Oral administration C. Respiratory tract administration D. Ophthalmic route o f administration

31 .Which one o f the following drug classes does not affect gastrointestinal tract motility? A. B. C. D. Anticholinergics Narcotic analgesics Prokinetic agents Antiseptics

32.The absorption rate o f a drug administered by the oral route may be erratic because of: A. Delayed gastric emptying B. Changes in intestinal motility C. Changes in temperature o f the stomach D. The absorbing cells are few. E. A and B

28.In the gastrointestinal tract the most common mechanism o f absorption is: A. B. C. D. Passive diffusion and partitioning Carrier mediated transport Vesicular transport Facilitated diffusion

33.In intramuscular injection,the rate o f drug absorption depends on: A. B. C. D. Vascularity o f the muscle site Lipid solubility o f the drug The formulation matrix All o f the above

29.The duodenal region is the primary absorption site in the gastrointestinal tract for drugs administered orally because: A. It has large surface area because o f the villi and microvilli B. The large blood supply provided by the mesenteric vessels allows the drug to be absorbed more efficiently. C. There are many phagocytic cells D. There are many enzymes E. A and B

34. Which one o f the following is not a type o f enteral route o f administration? A. B. C. D. E. Sublingual administration Per oral administration Respiratory tract administration Rectal administration Buccal administration

30.Gastric emptying time is affected by: A. Food content B. Drugs that alter gastrointestinal tract motility. C. pH o f the stomach

35.One drug used in the treatment of pulmonary infection is to be designed in the form o f an aerosol. What should be the particle size o f the formulation so that the drug can reach the site o f action? A. Between 100 to 150 pm

B. Between 20 to 30 (am C. Between 15 to 20 ^m D. Between 1 and 2 fim

hydrophobic drug) by reducing the particle size o f the active ingredient .The result was reverse, i.e. the dissolution rate o f the drug was decreased . What could be the reason for this result ? A. Surface area o f the drug particles is always inversely proportional to the dissolution rate. B. After excessive reduction, the small particles may have aggregated to form larger particles and the aggregates are less soluble. C. The drug is completely insoluble in the GIT fluids. D. A and B

36. Which one of the following drugs is not readily absorbed from the skin when administered by transdermal route? A. B. C. D. Nitroglycerin Clonidine Nicotine Paracetamol

37.The major factors in the design of dosage forms include: A. Route o f administration B. Absorption site o f the drug C. Bioavailability o f drug from dosage form D. All o f the above

41 .Which one o f the following statements best describes partition coefficient? A. It is the ratio o f drug soluble in a given volume o f water. B. It is the ratio of the solubility of the drug, at equilibrium, in a non aqueous solvent to that in an aqueous solvent. C. It is the partition o f a drug molecule in to its polar and non polar portions. D. It is a constant related to the thermodynamic properties o f a drug.

38.The Noyes-Whitney equation describes: ' A. The change in solubility o f drug with respect to temperature B. The change in amount of drug in solution with respect to time. C. The change in physicochemical properties o f the drug with respect to PH D. The extent o f Ionization with respect to PH E. None

42. All o f the following statements are correct EXCEPT: A. Molecular dispersion o f Griseofulvin in PEG 4000 decreases dissolution and bioavailability o f the drug. B. The potassium salts o f weakly acidic drugs are more soluble than their divalent or trivalent cation salts. C. Drug solubility in a saturated solution is a static (equilibrium property) property. D. The dissolution rate o f a drug is a dynamic property related to the rate o f absorption.

39. As the particle size o f solid drugs decreases, the particle surface area A. B. C. D. E. Increases Decreases Doesnt change A and C None

40. A formulation scientist thought o f increasing the dissolution o f Griseofulvin (a

aspirin formulation. What could be the reason for the better dissolution profile? 43.If the pKa o f a weakly acidic drug equals the pH o f the medium, then according to Henderson- Hasselbalch equation the amount o f ionized and nonionized species will be: A. B. C. D. 50 40 40 70 % % % % ionized and 50 % nonionized nonionized and 60 % ionized ionized and 60 % nonionized nonionized and 30 % ionized A. The buffering agent increases the surface area o f the aspirin particles. B. The alkaline medium produced by the buffering agent makes the aspirin molecules more polar. C. The buffering agent forms an alkaline medium in the gastrointestinal tract and the drug dissolves in situ. D. A and B

44. The correct form of the HendersonHasselbalch equation for a weak base is

47.The effervescence in effervescent tablets results from: A. The gas molecules included during compression. B. The sodium bicarbonate included in the formulation results in the formation o f carbonic acid when dissolved in water and carbonic acid decomposes to form carbon dioxide. C. The glidants in the tablet. D. A and C

A. pH = pKa + Log {_[salt]____ } [Nonionized base] B. pH = pKa + Log {Tnonionized base] I [Salt] C. pH = pKa + Log {Tnonionized acidl } [Base] D. B and C

45. Which one o f the following statements is WRONG? A. Certain salts are designed to provide slower dissolution, slower bioavailability and longer duration o f action. B. Sodium aspirin is more stable than aspirin. C. The choice o f salt form for a drug depends on the desired physical, chemical or pharmacological properties. D. Some salts o f drugs are selected for greater stability. 46.Aspirin was formulated into a solid dosage form with buffering agents.The dissolution rate in the gastrointestinal tract was better as compared with an ordinary

48. All o f the following salts o f weakly basic drugs are very soluble in water except: A. B. C. D. Hydrochlorides Sulfates Stearates Citrates

49.A drug in its crystalline form was formulated into a drug product. Quality control tests have shown that the amount of the active ingredient was within the pharmacopieal specifications ,however the dissolution rate was not satisfactory as compared to that o f a standard product. Assuming there is no problem with the non active ingredient part o f the formulation what could be the reason for the slower rate o f dissolution?

A. The crystals have changed to insoluble forms during the process o f dissolution. B. The drug may have different polymorphs with different physico chemical properties such as melting point and dissolution rate. The polymorph which has relatively slower rate o f dissolution was included in the formulation. C. The crystalline form o f the drug has been changed to amorphous form during dissolution. D. A and C

A. complexes with ring like structure formed by the interaction between a partial ring o f atoms and a metal. B. precipitates formed as result o f a reaction between anions and cations C. Byproducts in reaction between anions and cations D. Organic compounds formed as a result o f a reaction between two inorganic molecules E. None

53.In which o f the following formulations is the probability for a bioavailability problem greater? A. B. C. D. E. Controlled release tablet Transdermal patch Conventional tablet A and B None

50. All o f the following statements are true EXCEPT: A. Different polymorphs have different physical properties, including melting point and dissolution rate. B. Amorphous or non crystalline forms o f a drug have faster dissolution rates than crystalline forms C. Individual enantiomers may not have the same pharmacokinetic and pharmacodynamic properties D. In ibuprofen only the R-enantiomers is pharmacologically active E. None

54.The rate limiting step in the bioavailability o f a drug from a sustained release product is: A. The dissolution rate B. The release o f the drug from the delivery system C. The rate o f disintegration D. The disaggregation o f granules to fine particles

51 .An analyst compared the dissolution rates o f anhydrous and hydrated ampicillin .What results do you expect from the experimental work? A. The anhydrous form o f ampicillin dissolves faster than hydrated form. B. The hydrated form dissolves faster the anhydrous form C. The two forms have equal rates of dissolution D. B and C E. None

55.For most conventional solid drug products (e.g. Capsules, tablets), the rate limiting step in the bioavailability o f the drug is: A. The dissolution rate B. The rate o f disintegration C. The release o f the drug from the delivery system D. A and B

52. Which one o f the following statements best describes chelates?

56. Which one o f the following statements is WRONG?

A. Compared with other oral formulations a drug dissolved in an aqueous solution is in the most bioavailable form. B. Per oral drug solutions are often used as reference preparation for solid per oral formulations. C. In aqueous solutions no dissolution step is necessary before systemic absorption occurs. D. A drug dissolved in a hydro alcoholic solution does not have good bioavailability.

D. To decrease the rate o f dissolution E. All except D

60. Which one the following statements is WRONG about highly viscous suspensions? A. They prolong gastric emptying time. B. They have slower rate o f dissolution C. They decrease the absorption rate o f the drug D. Viscous suspensions o f drug provides better bioavailability than less viscous suspensions

57. Which one o f the following formulations provides the slowest rate of drug absorption as compared with the others? A. B. C. D. Syrup Elixir Aqueous solution Tablet

61 .All o f the following statements are TRUE except: A. Soft gelatin capsules are the preferred dosage forms for early clinical trials o f new drugs. B. Lanoxicaps have better bioavailability than a compressed tablet formulation (lanoxin). C. Soft gelatin capsules may contain a nonaqueus solution, a powder, or drug suspension. D. Soft gelatin capsules that contain a drug dissolved in a hydrophobic vehicle (e.g. vegetable oil) may have poorer bioavailability than a compressed tablet formulation.

58. Which one o f the following represents a CORRECT sequence for the processes involved in drug release from a per oral dosage form? A. Attrition -disintegration dissolution- disaggregation absorption Convection diffusion B. Dissolution - disaggregationdisintegration- Attrition dissolution- absorption C. Disintegration - Dissolution disaggregation- Attrition -absorption D. Attrition- disintegration disaggregation - dissolutionConvection diffusion - absorption

62. Which one o f the following statements is true? A. Aging and storage conditions of a capsule do not affect the bioavailability o f the drug. B. At low moisture levels, the capsule shell becomes brittle and is easily ruptured. C. High moisture levels do not affect the capsule shell. D. A and C are correct

59.The role suspending agents in suspensions is : A. To increase viscosity B. To inhibit agglomeration C. To decrease the rate at which particles settle

63.Which of the following statements is/are true about Excipients: A. They permit the efficient manufacture o f compressed tablets B. They affect the physical and chemical properties o f the drug. C. They affect the bioavailability o f the drug. D. The higher the ratio o f excipients to active drug in a given formulation, the greater the likelihood that the excipients affect the bioavailability. E. All o f the above

dissolution or bioavailability o f the drug. C. It is a water insoluble substance. D. None

67. Which one o f the following is WRONG about glidants? A. Glidants improve the flow properties o f a dry powder blend before it is compressed. B. They slow the dissolution rate o f drug from a tablet by reducing wetting o f the surface o f the solid particles. C. They may reduce tablet to tablet variability and improve product efficacy. D. Colloidal silicon dioxide is an example o f glidants 68.Surfactants enhance drug dissolution rates and bioavailability by: A. Increasing the surface area o f solid drug particles. B. Reducing the particle size o f the solid drug particles. C. Reducing interfacial tension at the boundary between solid drug and liquid and improving the wettability (contact) ofthe solid drug particles by the solvent. D. Enhancing the hydrophobicity o f the drug particles.

64.Disintegrants vary in action depending on their: A. Their concentration B. The method by which the disintegrant is mixed with the powder formulation. C. The degree o f tablet compaction. D. All o f the above

65. All o f the following are used as disintegrants EXCEPT: A. B. C. D. Acacia Starch Croscarmellose Sodium starch glycolate

66. A formulation development section o f a company used one hydrophobic waterinsoluble substance as a lubricant. However, the dissolution rate o f the tablet and its bioavailability was not satisfactory. The lubricant was replaced by another one and the rate o f dissolution and its bioavailability was better. What do you comment on the nature o f the second lubricant. A. It is hydrophobic lubricant B. The lubricant was water soluble, thus it does not interfere with the

69.The coating o f coated compressed tablets may have the following properties EXCEPT: A. It protects the drug from moisture, light, and air. B. It masks the taste or odor of the drug. C. It improves the appearance o f the tablet. D. It enhances the disintegration o f tablet.

70.Enteric coatings are used to: A. Minimize irritation o f the gastric mucosa by the drug. B. Prevent inactivation o f the degradation o f the drug in the stomach. C. Delay release o f the drug until the tablet reaches the small intestine, where conditions for absorption may be optimal. D. All o f the above 71 .Dose dumping is: A. Abrupt or uncontrolled release of a large amount o f a drug from a modified release dosage form . B. A decrease in the dissolution rate of conventional dosage form. C. A delay in release o f the drug from a modified release dosage form. D. A decrease in the amount o f drug which reaches the site o f action. 72.Extended release dosage forms include: A. B. C. D. E. Controlled release dosage Sustained release dosage Long acting drug delivery system Delayed release dosage forms A, B and C

73.In extended release dosage forms, the extended, slow release o f controlled release products produces: A. A randomly fluctuating plasma drug concentration B. A lower than average level of concentration C. An abnormally high concentration o f the drug which is out o f the therapeutic window. D. Sustained plasma drug concentration that avoids toxicity.

ANSWERS

Biopharmaceutics
1. Answer: E. All o f the above Explanation: Biopharmaceutics is the study o f the relation o f the Physical and chemical properties o f a drug to its Bioavailability, Pharmacokinetics, pharmacodynamics and toxicologic effects. 2. Answer: A. Excipients Explanation: A drug product contains the active ingredient in association with excipients , that make up the vehicle or formulation matrix .Examples o f a drug product include tablets ,capsules, solutions etc. 3. Answer: C. Drug delivery system Explanation: The phrase Drug delivery system is used interchangeably with the term drug product. However,Drug delivery system is a more comprehensive concept that includes the drug formulation and the dynamic interaction among the drug, its formulation matrix , its container , and the patient. 4. Answer: D. Systemic absorption Explanation: Bioavailability is a measurement o f the rate and extent o f Systemic absorption of the therapeutically active drug. 5. Answer: A. Time course Explanation: Pharmacokinetics is the study o f time course o f the drug movement in the body during absorption, distribution, and elimination. The main parameter studied is time. 6. Answer: C. Bioavailability - the amount o f drug entering cells Explanation: Bioavailability is a measurement o f the rate and extent o f systemic absorption o f the therapeutically active drug. It is not the measurement o f the amount o f drug entering cells. The other pairs are correct hence the correct definitions are given. 7. Answer: A. Proteins and lipids Explanation: Cell membranes are primarily composed o f lipids and proteins. 8. Answer: E. All o f the above Explanation: Drugs may be transported by passive diffusion, partitioning, Carrier mediated transport, Para cellular transport or Vesicular transport. 9. Answer: D. Non polar lipid -soluble drugs having low molecular weight

Explanation: Usually proteins, drugs bound to proteins, and macromolecules do not cross membranes easily. Non polar lipid -soluble drugs having low molecular weight traverse membranes more easily than ionic or polar drugs. 10.Answer: A. Simple diffusion

Explanation; Within the cytoplasm or in interstitial fluid, most drugs undergo transport by simple diffusion .All the others are used in the transport o f drugs across the cell membrane. 11 .Answer: A. Successive partitioning o f a solute between aqueous and lipid phases as well as diffusion within the respective phases Explanation: Passive transport across cell membranes involves successive partitioning o f a solute between aqueous and lipid phases as well as diffusion within the respective phases. 12.Answer: D. A and B Explanation: The extent o f Ionization o f a weak electrolyte depends up on its pKa and pH o f the solution in which it is dissolved 13. A. Nonionized species o f drugs are more lipid soluble than the ionized species

Explanation: Nonionized species are non polar so they are lipid soluble and they easily cross cell membranes. Small water soluble molecules may cross cell membranes by passing through the pores which are larger than their diameters. 14. Answer: E. All o f the above Explanation: Ficks law o f diffusion is dQ =DAK dt h ( Cl - C2}

Where dQ is rate o f diffusion D = Diffusion coefficient o f the drug dt A= surface area o f the plane across which transfer occurs (Cl - C2) = the difference in concentration o f drug between the two points h= Thickness o f the region across which diffusion occurs. 15.Answer: E. A and B Explanation: Active transport and facilitated diffusion are types o f Carrier mediated transport. 16. Answer: A. The drug moves with the direction o f concentration gradient

Explanation: Active transport o f the drug across a membrane is a carrier mediated transport that has the following characteristics: 1. The drug moves against the direction o f concentration gradient 2. The process requires energy 3. The carrier may be selective for certain drugs that resemble natural substrates, or metabolites that are actively transported. 4. The carrier system may be saturated at high concentration.

5. The transport process may be competitive (i.e. drugs with similar structures may compete for the same carrier). 17. Answer: A. Diffusion and the convective flow o f water and accompanying water soluble drug molecules Explanation: Para cellular transport involves both diffusion and the convective flow of water and accompanying water soluble drug molecules through the para cellular channels. 18. Answer: D. It occurs against the direction o f concentration gradient Explanation: Facilitated diffusion occurs with the direction o f concentration gradient and does not require energy. 19. Answer: B. Phagocytosis and pinocytosis Explanation: Phagocytosis and pinocytosis are two forms o f vesicular transport. 20. Answer: A. Vesicular transport is the only transport mechanism that doesnt require a drug to be in aqueous solution to be absorbed Explanation: Vesicular transport is process o f engulfing particles or dissolved materials by a cell. Vesicular transport is the only transport mechanism that does not require a drug to be in an aqueous solution to be absorbed. Pinocytosis is the engulfment o f small solutes or fluids by cells while Phagocytosis is the engulfment o f large particles or macromolecules, generally by macrophages. 21 .Answer: A. P-glycoprotein Explanation: Various transporter proteins are embedded in the lipid bilayer o f cell membranes e.g. P-glycoprotein 22. Answer: D. They are involved in the translation o f genetic code Explanation: Transporter proteins are adenosine triphosphate dependent pumps which facilitate the efflux o f drug molecules from the cell. Because these transmembrane efflux pumps are often found in conjunction with metabolizing enzymes such as Cytochrome P450 3A4, their net effect is to substantially reduce intracellular drug concentrations. Thus, they determine, to a large extent, the pharmacokinetic disposition and circulating drug concentrations o f drugs (e.g cyclosporine, nifedipine)that are substrates for these proteins. 23. Answer: D. All o f the above Explanation: In intravenous bolus injection the drug injected directly in to the blood stream, distributes throughout the body. Any side effects including an intense pharmacological response, anaphylaxis, or overt toxicity, also occur rapidly. 24.Answer: A. Passive diffusion Explanation: Low molecular weight drugs diffuse across a cell membrane more easily than drugs having high molecular weight.

25.Answer: C. Intra-arterial injection Explanation: Intra-arterial injection is used for diagnostic agents and occasionally for chemotherapy. 26.Answer: E. B and D Explanation: In intravenous injection the drug is injected at a constant rate.Constant intravenous injection maintains a relatively constant plasma drug concentration once the infusion rate is approximately equal to the drugs elimination rate from the body (i.e. steady state is reached ). In subcutaneous injection the drug is injected beneath the skin. Subcutaneous region o f the skin is less vascular than muscle tissues so the rate o f drug absorption is less rapid as compared with the absorption in muscle tissues.

27.Answer: A. Sublingual and Buccal administration Explanation: In Sublingual routes o f administration a tablet or lozenge is placed under the tongue (Sublingual) or in contact with the mucosal (Buccal) surface o f the cheek .This type of administration allows non polar, lipid soluble drug to be absorbed across the epithelial lining of the mouth .After Buccal or sublingual administration, the drug is absorbed directly into the systemic circulation, by passing the liver and any first pass effects. 28.Answer: A. Passive diffusion and partitioning Explanation: Most drugs are xenobiotics or exogenous molecules and consequently are absorbed from the gastrointestinal tract by passive diffusion and partitioning. Carrier mediated transport, Vesicular transport, facilitated diffusion play smaller but critical roles, particularly for exogenous molecules. 29. Answer: E. A and B

Explanation: Drug molecules are absorbed out the gastrointestinal tract, but the duodenal region, which has a very large surface area because o f the villi and the microvilli, is the primary absorption site. The large blood supply provided by the mesenteric vessels allows the drug to be absorbed more efficiently 30.Answer: D. A and B Explanation: Altered gastric emptying affects arrival o f the drug in the duodenum for systemic absorption. Gastric emptying time is affected by food content, emotional state and drugs that alter gastrointestinal tract motility. 31. Answer: D. Antiseptics

Explanation :Examples o f drugs that affect gastrointestinal tract motility are Anticholinergics, Narcotic analgesics, Prokinetic agents. 32. Answer: E .A and B

Explanation: The absorption rate o f a drug administered by the oral route may be erratic because o f delayed gastric emptying or changes in intestinal motility.

33. Answer: D. All o f the above Explanation: In intramuscular injection the rate o f drug absorption depends on Vascularity o f the muscle site, lipid solubility o f the drug and the formulation matrix. 34.Answer: C. Respiratory tract administration Explanation: Enteral route o f administration includes sublingual administration, Per oral administration, rectal administration, and Buccal administration. 35.Answer: D. Between 1 and 2 |um Explanation: In general particles larger than 60 jam are primarily deposited in the trachea. Particles larger 20 |im do not reach the bronchioles, and particles smaller than 0.6 [*m are not deposited and are exhaled. Particles between 2 to 6 fim can reach the alveolar ducts, although only particles o f 1 and 2 |um are retained in the alveoli. 36.Answer: D. Paracetamol Explanation: Small lipid soluble molecules such as Nitroglycerin, Clonidine, nicotine, Fentanyl and steroids (e.g. testosterone), are readily absorbed from the skin. 37. Answer: D. All o f the above

Explanation: The route o f administration, absorption site, bioavailability o f drug from dosage form,are the major factors in the design o f dosage forms. 38. Answer: B. The change in amount o f drug in solution with respect to time Explanation: The Noyes-Whitney equation describes the change in amount o f drug in solution with respect to time . dm = DA_(CS- C b) dm = change in amount o f drug in solution with respect to time dt 5 dt D= Diffusion coefficient o f the solute A= surface area o f the solid undergoing dissolution, d = is the thickness o f the Diffusion layer, Cs= the concentration o f the solvate at saturation, and C b is the concentration of drug in the bulk solution phase. 39.Answer: A. Increases Explanation: Particle size and surface area are inversely proportional .As solid drug particle size decreases, particle surface area increases. 40.Answer: B. after excessive reduction, the small particles may have aggregated to form larger particles and the aggregates are less soluble

Explanation: With certain hydrophobic drugs, excessive reduction does not always increase the dissolution rate. Small particles reaggregate into larger particles to reduce the high surface free energy produced by particle size reduction. 41. Answer: B. It is the ratio o f the solubility o f the drug, at equilibrium, in a non aqueous solvent to that in an aqueous solvent Explanation: Partition coefficient is the ratio o f the solubility o f the drug, at equilibrium, in a non aqueous solvent to that in an aqueous solvent. 42.Answer: A. Molecular dispersion o f Griseofulvin in PEG 4000 decreases dissolution and bioavailability o f the drug Explanation: To prevent the formation o f aggregates, small drug molecules are dispersed in polyethylene glycol (PEG) dextrose or other agents.For example Molecular dispersion of Griseofulvin in PEG 4000 enhances dissolution and bioavailability o f the drug. 43.Answer: A.50 % ionized and 50 % nonionized Explanation: when pKa o f a weakly acidic drug equals the pH o f the medium, then according to Henderson- Hasselbalch equation } 0 ~ Log { .[salt]___ [Nonionized base] Antilog 0 = { [salt]___ _ } -= 1 [salt] = [Nonionized base] [Nonionized base] So 50 % ionized and 50 % nonionized.

44.Answer: B Explanation: The correct form o f the Henderson- Hasselbalch equation for a weak base is pH = pKa + Log {[nonionized base] } [Salt] 45.Answer: B. Sodium aspirin is more stable than aspirin Explanation: Some soluble salt forms are less stable than the nonionized form. For example sodium aspirin is less soluble than aspirin in the acid form. 46. Answer: C. The buffering agent forms an alkaline medium in the gastrointestinal tract and the drug dissolves in situ Explanation: A solid dosage form containing buffering agents may be formulated with the free acid form o f the drug (e.g buffered aspirin). The buffering agent forms an alkaline medium in the gastrointestinal tract and the drug dissolves in situ.The dissolved salt form o f the drug diffuses into the bulk fluid o f the gastrointestinal tact, forms a fine precipitate that redissolves rapidly, and becomes available for absorption. 47. Answer: B. The sodium bicarbonate included in the formulation results in the formation of carbonic acid when dissolved in water and carbonic acid decomposes to form carbon dioxide

Explanation: Effervescent tablets containing the acid drug in addition to sodium bicarbonate, tartaric acid, citric acid, or other ingredients are added to water just before oral administration .The excess sodiilm bicarbonate forms an alkaline solution in which the drug dissolves. Carbon dioxide is also formed by the decomposition o f carbonic acid.

48.Answer: C. Stearates Explanation: For weak bases, common water soluble salts include the hydrochlorides, Sulfates, citrates and Gluconates .The estolate, napsylate and Stearates are less water soluble. 49. Answer: B. The drug may have different polymorphs with different physico chemical properties such as melting point and dissolution rate. The polymorph which has relatively slower rate o f dissolution was included in the formulation Explanation: Polymorphism is the ability o f a drug to exist in more than one crystalline form. Different polymorphs have different physical properties, including melting points and dissolution rate. 50. Answer: D. In ibuprofen only the R-enantiomers is pharmacologically active

Explanation: Amorphous forms o f a drug have faster dissolution rate than crystalline forms. Individual enantiomers may not have the same pharmacokinetic and pharmacodynamic properties. Ibuprofen exists as the R and S enantiomers; only the S enantiomer is pharmacologically active. 51 .Answer: A. The anhydrous form o f ampicillin dissolves faster than hydrated form Explanation: Drugs may exist as hydrated or solvated form or as an anhydrous molecule. Dissolution rates differ for hydrated and anhydrous forms. For example the anhydrous form o f ampicillin dissolves faster and is more rapidly absorbed the than hydrated form 52.Answer: A. complexes with ring like structure formed by the interaction between a partial ring o f atoms and a metal Explanation: Chelates are complexes with ring like structure formed by the interaction between a partial ring o f atoms and a metal. 53.Answer: D. A and B Explanation: The more complicated the formulation o f the finished product (e.g. Controlled release tablet, enteric coated tablet, transdermal patch), the greater the potential for a bioavailability problem. 54. Answer: B. The release o f the drug from the delivery system

Explanation: The rate limiting step in the bioavailability o f a drug from a sustained release or controlled release drug product is the release o f the drug from the delivery system.

1 Biopharmaceutics

hydrophobic vehicle (vegetable oil) may have poorer bioavailability than a compressed tablet fnrmiilntinn

55.Answer: A .The dissolution rate Explanation: For most conventional solid drug products (e.g. Capsules, tablets), the rate limiting step in the bioavailability o f the drug is the dissolution rate.

56.Answer: D. A drug dissolved in a hydro alcoholic solution does not have good bioavailability Explanation: Compared with other oral formulations a drug dissolved in an aqueous solution is in the most bioavailable and consistent form. Because the drug is already in solution, no dissolution step is necessary before systemic absorption. A drug dissolved in a hydro alcoholic solution has good bioavailability. Alcohol aids drug solubility. 57.Answer: D. Tablet Explanation: A drug dissolved in hydro alcoholic solution (e.g. Elixir) has good bioavailability. Alcohol aids drug solubility. Compared with other oral formulations a drug dissolved in an aqueous solution is in the most bioavailable and consistent form. Because the drug is already in solution, no dissolution step is necessary before systemic absorption 58. Answer: D. Attrition- disintegration - disaggregation - dissolution- Convection diffusion absorption Explanation: The release o f a drug from per oral dosage form and its subsequent bioavailability depends on a succession o f the rate processes .These processes include 1. Attrition -disintegration or disaggregation o f the drug product. 2. Dissolution o f the drug in an aqueous environment. 3. Convection and dissolution o f the drug molecules to absorbing surface. 4. Absorption o f the drug across cell membranes into the systemic circulation. 59. Answer: E. All except D Explanation: Suspending agents are hydrophilic colloids ( e.g. cellulose derivatives , acacia, xanthine g u m ) added to increase viscosity, to inhibit agglomeration, and decrease the rate at which particles settle. They are not added to decrease the rate o f dissolution. 60. Answer: D. Viscous suspensions o f drug provides better bioavailability than less viscous suspensions. Explanation: Highly viscous suspensions may prolong gastric emptying time, slow rate o f dissolution, and decrease the absorption rate of the drug. They decrease bioavailability o f the drug. 61 .Answer: A. Soft gelatin capsules are the preferred dosage forms for early clinical trials of new drugs Explanation: Soft gelatin capsules may contain anonaqueus solution, a powder, or drug suspension .The vehicle may be water miscible (e.g. PEG).The cardiac glycoside digoxin, dispersed in a water miscible vehicle (Lanoxicaps), has better bioavailability than a compressed tablet formulation (lanoxin).However, a Soft gelatin capsules that contains a drug dissolved in a

hydrophobic vehicle (vegetable oil) may ha formulation. Hard gelatin capsules are usually filled with a powder blend that contains the drug, Typically the powder blend is simpler and 1ess compacted than the blend in a compressed tablet formulation. Encapsulated drugs are release d rapidly and dispersed easily, and the bioavailability is good. Hard gelatin capsules are the preferired dosage forms for early clinical trials o f new drugs. 62.Answer: B. At low moisture levels, the capsule shell becomes brittle and is easily ruptured. Explanation: Aging and storage conditions affect the moisture content o f the gelatin component o f the shell and the bioavailability o f the drug. At low moisture levels, the capsule shell becomes brittle and is easily ruptured.At high moisture levels, the capsule shell becomes moist, soft, and distorted .Moisture may be transferred to the capsule contents, particularly if the contents are hydroscopic.

63.Answer: E. None Explanation: Excipients including diluents disintegrants, lubricants, glidants, surfactants, dye, and flavoring agents, have the following p toperties. 1. They permit the efficient manufacture o compressed tablets, 2. They affect the physical and chemical properties o f the drug 3. They affect the bioavailability o f the di ug. The higher the ratio o f excipients to active drug in a given formulation, the greater the likelihi )od that the excipients affect the bioavailability. 64. Answer: D .All o f the above

Explanation: Disintegrants vary in action depending on their concentration, the method by which the disintegrant is mixed with the powder formulation and the degree o f tablet compression. Although tablet disintegration is usually not a problem because it often occurs more rapidly than drug dissolution, it is necessary for dissolution in immediate release formulations. Inability to disintegrate may interfere with bioavailability. 65.Answer: A. Acacia Explanation: Starch, croscarmellose, and Sodium starch glycolate are disintegrating agents, Acacia is not a disintegrant; it is used as a suspending agent. 66. Answer: B. The lubricant was water soluble, thus it does not interfere with the dissolution or bioavailability of the drug. Explanation: Lubricants are hydrophobic , water insoluble substances such as stearic acid, magnesium steartate, hydrogenated oil, an d talc. They may reduce wetting o f the surface o f the solid particles, slowing the dissolution and bioavailability o f the drug. Water soluble lubricants, such as L - leucine, do not interfere with dissolution or bioavailability. 67.Answer: B. they slow the dissolutior rate o f drug from a tablet by reducing wetting o f the surface o f the solid particles

Explanation: Glidants improve the flow properties o f a dry powder blend before it is compressed Rather than posing a potential problem with bioavailability, glidants may reduce tablet to tablet variability and improve product efficacy. 68. Answer: C. Reducing interfacial tension at the boundary between solid drug and liquid and improving the wettability (contact) o f the solid drug particles by the solvent. Explanation: Surfactants enhance drug dissolution rates and bioavailability by reducing interfacial tension at the boundary between solid drug and liquid and improving the wettability (contact) o f the solid drug particles by the solvent. 69. Answer: D. It enhances the disintegration o f tablet Explanation: Coated compressed tablets have a sugar coat, a film coat, or an enteric coat with the following characteristics: - It protects the drug from moisture, light, and air - It masks the taste or odor o f the drug. - It improves the appearance o f the tablet. - It may affect the release rate o f the drug 70. Answer: D .All o f the above Explanation: Enteric coatings are used to: - Minimize irritation o f the gastric mucosa by the drug - Prevent inactivation o f the degradation o f the drug in the stomach - Delay release o f the drug until the tablet reaches the small intestine, where conditions for absorption may be optimal.

71 .Answer: A. Abrupt or uncontrolled release o f a large amount o f a drug from a modified release dosage form Explanation: Dose dumping is an abrupt or uncontrolled release o f a large amount o f a drug from a modified release dosage form. 72.Answer: E. A, B and C Explanation: Extended release dosage forms include Controlled release dosage, Sustained release dosage and long acting drug delivery system.

73.Answer: D. Sustained plasma drug concentration that avoids toxicity Explanation: In extended release dosage forms, the extended, slow release o f controlled release products produces relatively flat sustained plasma drug concentration that avoids toxicity ( from high drug concentration ) or lack o f efficacy ( from low drug concentrations).

Biotechnologic Products

For every failure, theres an alternative course of action. You just have to find it. When you come to a roadblock, take a detour.

Mary Kay Ash

1. The immunoglobulins whose production is induced when the hosts lymphoid system comes in contact with foreign molecules are A. B. C. D. E. antigens antibodies cytokines lymphokines haptens

B. it is produced by fusing B cells to myeloma cancer cells C. it can grow indefinitely like the cancer cells, yet also produce and secret antibodies like the B cell D. a single hybridoma can produce a variety o f antibodies E. none

8. What is the class o f glycoproteins produced by animal cells in response to viral infection? A. B. C. D. E. interferon interleukin lymphokine colony stimulating factors all but D

2. What is the molecule, which contains the genetic instructions of a cell? A. B. C. D. E. antisense DNA gene genome DNA All the above

9. Which o f the following is NOT correct about plasmids? [3-6] For each statement below, choose the best enzyme that it most closely describes. A. B. C. D. E. DNA ligase DNA polymerase Restriction endonuclease Reveres transcriptase DNA topoisomerases A. they are small, circular, extrachromosomal DNA molecules B. they can replicate independently C. they carry genetic information D. they can be used as vectors fro the transfer o f DNA in recombinant DNA technology E. they are found in some species of bacteria only

3. The enzyme, which enables DNA fragments from different sources to be joined. 4. The enzyme that cleaves double stranded DNA into smaller fragments. 5. The enzyme that catalyzes the synthesis o f DNA, 6. The enzymes responsible for removing supercoils in the helix, 7. Which o f the following is NOT true about hybridoma? A. it is a hybrid cell

10. Which of the following is a WRONG match between a protein and its function? A. hemoglobin; oxygen transport B. myosin; confer elasticity and contractility to muscles C. globulins; drug carriers D. Albumin; binds to many drugs E. None

11 .Which o f the following is NOT true about immunoglobulin? A. it is a protein

Biotechnologic Products

B. it is involved in immunity and allergic response C. therapeutically it is used to modulate or replace antibody in various immunodeficiency and disease states D. immunoglobulin preparations are given either IM or IV E. none

B. prolonging the survival o f neutrophilis C. induce megakaryocyte formation D. enhance the phagocytic activity o f neutrophilis E. increase the cytotoxic activity o f neutrophilis

15. Which o f the following is NOT true about glycoproteins? 12. Which o f the following is NOT correct about the recombinant human granulocyte colony-stimulating factor? A. they are glycoproteins B. they produce many type o f blood cells and components in the body C. they can be used to treat congenita] disease D. they are used to treat certain forms o f cancer E. none A. They are proteins to which oligosaccharides are covalently attached B. They form the natural structural membranes in cells o f unicellular and multicellular organisms C. It is the extent o f glycosylation of a protein molecule only, which determines the physicochemical properties, stability and specificity o f surface receptor in a cell D. Glycoproteins in the cells surface o f RBC participate in the determination o f specific blood type E. B and D

13. Which o f the following is NOT true about filgrastim and lenograstim? A. both o f them selectively promote the proliferation, differentiation, and maturation o f blood cell precursor B. lenograstim is more potent than filgrastim C. both are glycosylated at the same site as natural HuG-CSF D. lenograstim can reduce the duration o f neutropenia and the severity o f infection in patients who are receiving cytotoxic chemotherapy fro nonmyeloid malignanc E. B and D

16. The carbohydrates in glycoproteins are responsible for the following functions EXCEPT A. they determine which amino acid will be glycosylated B. they participate in cell surface recognition C. they participate in cells surface antigenecity D. they participate in recognition o f sialylated, fucosylated lactosaminoglycans on leukocytes by E-selection o f endothelial cells E. none

14. All o f the following activities are shared by both natural and recombinant granulocyte CSF EXCEPT A. stimulating the release o f mature neutrophilis from hematopoietic tissue

17.Single stranded DNA are available in A. all viruses B. some viruses C. some bacteria

D. some fungi E. none

21 .What is the biotechnologic drug that is used to treat metastatic renal cell carcinoma? A. B. C. D. E. aldesleukin abciximab edobacomab muromonab-CD3 nebacumab

] 8.DNA is the genetic material o f all the following EXCEPT A. B. C. D. E. humans some bacteria some fungi some viruses none

22.All the following are correct about inerIeukin-3 EXCEPT A. it is a hematopoietic growth factor B. it is be used to treat bone marrow failure C. it improves neutrophil and platelet count in patients who have chemotherapy-related bone marrow failure D. used alone it is effective in improving hematopoiesis in patients who have Aplastic anemia E. none

19. Which o f the following is NOT correct about antisense drugs? A. they are single stranded, synthetic oligonucleotides, which could be used to inhibit gene expression B. the advantage is that, the antisense DNA could be made without first elucidating the nucleotide base sequence o f a gene that controls a specific body function C. the disadvantage is that, it is not possible to affect the stability and potency o f these drugs D. they may be used to treat cancer and viral diseases E. B and C

23.Campath-l is clinically used to treat all the following EXCEPT A. for immunosuppression in patients who undergo organ transplant B. to treat refractory autoimmune disorders C. vasculitis D. to treat lymphoid malignancy caused by immonusuppression in patients who undergo organ transplant E. none

20. Which o f the following is NOT true about alteplase? A. it is a thrombolytic agent B. it is effective in producing recanalization o f occluded coronary arteries after acute myocardial infarction C. it is effective in the treatment o f acute massive pulmonary embolism D. it can cause reperfusion arrhythmias as an adverse effect E. it is more liable to cause systemic fibrinolysis than streptokinase

24.zolimomab aritox may be used for the treatment o f A. rheumatoid arthritis B. insulin-dependent diabetes mellitus C. steroid resistant graft-versus-host disease after allogeneic bone marrow transplant fo hematopoietic neoplasm

D. A and B only E. All the above

25.Betaseron may administered through all the following routes o f administration EXCEPT A. B. C. D. E. intravenously intramuscularly orally topically intrathecally

26.Betaseron is indicated for the treatment of A. B. C. D. multiple sclerosis AIDS Malignant melanoma Herpes virus and papilloma virus infections E. All the above

Answers Biotechnologic Products


1. Answer: B. Antibodies Explanation: Antibodies are a special kind o f blood proteins (chemically they are proteins o f the globulin type), which are synthesized in the lymphoid tissue in response to the presence o f foreign particles (antigens) and they circulate in the blood to attack the antigen and render it harmless. Cytokines are special type o f proteins released by cells to affect the action o f other cells. Haptens are small particles that are not capable o f inducing immune response by them selves. But they may become antigenic by combining with and modifying the bodys own proteins.

2. Answer: D. DNA Explanation: DNA is the genetic material o f nearly all living organisms, which controls heredity. It is the molecule that contains the genetic information o f a cell. Antisense DNA is a complementary strand o f DNA that is specifically synthesized to attach to the sense DNA and prevent genetic prescription. Gene is the basic genetic material, which is carried at a particular place on a chromosome. It is the segment o f DNA that codes for a specific polypeptide. Genome is the basic haploid set o f chromosomes o f an organism and make up the genetic information content o f a cell.

3. Answer: A. DNA ligase. Explanation; DNA ligase is the enzyme that catalyzes the final phosphodiester linkage between the 5phosphate group on the DNA chain made by polymerase II and the 3-hydroxyl group on the chain made by polymerase I. In doing so, the enzyme is capable o f joining DNA fragments from different sources. DNA 4/208. The enzyme that cleaves double stranded DNA into smaller fragments.

4. Answer: C. restriction endonuclease. Explanation: One o f the major obstacles to molecular analysis o f genomic DNA is the immense size o f the molecules involved. The discovery o f restriction endonucleases (restriction enzymes) that cleave the double stranded DNA at sequence-specific site into smaller fragments opened the way for DNA analysis. 5. Answer: B. DNA polymerase. Explanation:

DNA polymerases are the enzymes that form the sugar phosphate bond (the phosphodiester bond) between adjacent nucleotides in a nucleic acid chain. This way they synthesize DNA molecules.

6. Answer: E. DNA topoisomerase.

7. Answer: D. A single hybridoma can produce a variety o f antibodies Explanation; The first production o f monoclonal antibodies represents the convergence o f three areas o f basic medical reseach: immunochemistry, the in vitro cultivation o f cancer cells and the molecular biology o f malignant transformations. For many years this approach was not technically feasible because the plasma cells have a short life span and can not be maintained in tissue cultures. In 1975, Georges Kohler and Cesar Milstein devised a solution to this problem by fusing a normal B cell (plasma cell) with a myeloma (a cancerous plasma cell), called a hybridoma or heterokaryons, that possessed the proliferating growth properties o f the myeloma cells but secreted the antibody product o f the B cell. A single hybridoma is capable o f producing a single type o f antibody only.

8. Answer: A. interferon Explanation; Interferone is a substance that is produced by cells infected with a virus and has the ability to inhibit viral growth. Interleukin is a group of proteins synthesized by macrophages and T lymphocytes in response to antigens and other stimulation. Lymphokine is any o f a class o f soluble proteins produced by some white blood cells. These proteins stimulate other white blood cells as part o f the immune response. Colony stimulating factors are a class o f glycoprotein hormones that regulate the differentiation and formation o f blood cells from precursor cells.

9. Answer: E. they are found in some species o f bacteria only Explanation: Plasmids are found in most species o f bacteria.

10.Answer: C. globulins; drug carriers Explanation: Globulins are one group o f simple proteins that are soluble in dilute salt solutions and can be coagulated by heat. A range o f different globulins is present in the blood (the serum globulins including alpha, beta and gamma globulins). They are involved in immunological response and antibody formation. Albumins are the ones that can function as drug carriers.

11 .Answer: A. it is a protein Explanation: Immunoglobulin is one o f a group o f structurally related glycoproteins that act as antibodies.

12.Answer: B. they produce many type o f blood cells and components in the body Explanation: These factors are involved in regulating the production o f blood cells and other components but they cannot produce them.

13.Answer: C. both are glycosylated at the same site as natural HuG-CSF Explanation;

Lenogratism is a recombinant human granulocyte CSF derived from Chinese hamster ovary cells, which is glycosylated at the same site as natural HuG-CSF. Filgrastim on the other hand,
is obtained from Escherichia coli and is not glycosylated.

14.Answer: C. induce megakaryocyte formation Explanation; In addition to the activities it share with natural CSF, rHuG-CSF shows synergism with interleukin-3 to induce megakaryocyte formation. It also shows synergism with GM-CSF to stimulate granulocyte-macrophage colonies.

15. Answer: C. It is the extent o f glycosylation o f a protein molecule only, which determines the physicochemical properties, stability and specificity o f surface receptor in a cell. Explanation; Glycoproteins contain highly variable amount o f carbohydrates. The extent as well as the site o f this glycosylation o f a protein determine the physicochemical properties, stability and specificity o f surface receptor in a cell.

16.Answer: A. they determine which amino acid will be glycosylated Explanation; In glycoproteins, the oligosaccharides are covalently attached to specific amino acid R-groups p f the protein. It is the three dimensional structure o f the protein which determines whether or not a specific amino acid R-group is glycosylated.

17.Answer: B. some viruses Explanation; With the exception o f some few viruses that contain single-stranded DNA, DNA exists as a double stranded molecule, where the strands wind each other forming a double helix.

18.Answer: D. some viruses

Biotechnologic Products

Explanation; With the exception o f some viruses, where the genetic material is contained in RNA, DNA is the genetic material o f all organisms.

19.Answer: E. B and C Explanation; For antisense DNA to be synthesized, the sense DNA that carries the information that affects the disease process is usually elucidated before antisense drug could be designed. It is possible to modify the antisense drugs so that they will have better potency and stability. For example, phosphodiesters (which are susceptible to the esterase enzymes) can be chemically converted to phosphothioates. This increases the stability o f the drug.

20.Answer: E. it is more liable to cause systemic fibrinolysis than streptokinase Explanation; Increased fibrinolysis is effective therapy for thrombolic disease, for which streptokinase and alteplase are indicated. Systemic fibrinolysis can occur as adverse effect o f both agents. However, it is more pronounced in streptokinase than alteplase 21 .Answer: A. aldesleukin Explanation; Aldesleukin is alymphokine, which is a human recombinant interleukin-2 product that is used to treat metastatic renal cell carcinoma. Abciximab is a chimeric monoclonal antibody Fab fragment that is specific fro platelet glycoprotein Ilb-Iia receptors. It is effective in reducing fatalities in subjects who have unstable angina after they undergo angioplasty. Edobacomab is an immune globulin directed against gram-negative bacterial endotoxins. Muromonab-CD3 is an immunosupprresive agent with specific targeting, which effective in reversing acute renal allograft rejection. Nebacumab is n immune globulin directed against gram-negative bacterial endotoxins.

22.Answer: D. used alone it is effective in improving hematopoiesis in patients who have Aplastic anemia. Explanation: If used alone it is not effective in improving hematopoiesis in patients who have Aplastic anemia. Enhanced response can be obtained with sequential combined use o f recombinant human interleukin-3 and other hematopoietic growth factors such as GM-CSF.

23.Answer: C. vasculitis Explanation: Campath is used only experimentally in vasculitis.

24.Answer: E. All the above

Explanation; ; Zolimomab aritox is an immunoconjugate o f monoclonal anti-CD5 murine IgG and the ricin Achain toxin. It is primarily used fro the treatment of steroid resistant graft-versus-host disease after allogeneic bone marrow transplant fo hematopoietic neoplasm. It may also be used in the treatment o f rheumatoid arthritis and insulin-dependent diabetes mellitus.

25.Answer: C. orally Explanation; ; Betaseron is administered intravenously!, intramuscularly, topically, subcutaneously, intrathecally, or intralesionally for a variety o f indications. However, it is ineffective when administered orally. ;

26.Answer: E. All the above Explanation; Betaseron is a glycoprotein with antiviral, antiproliferative, and immunomodulatory activity. Therefore, it may be used in the treatment o f multiple sclerosis, AIDS, Malignant melanoma, and Herpes virus and papilloma virus infections.

Biotransformation, Prodrugs and Pharmacogenetics

D w e()

If you can imagine it, you can achieve it. If you can dream it, you can become it.

William Arthur Ward

1. Which o f the following is correct about metabolism? A. metabolism leads always to different metabolites that are inactive B. metabolism refers exclusively to normal anabolic and catabolic reactions of the body (protein, fat, carbohydrate, nucleic acids) C. all substances entering the body are finally changed to new substances before being excreted D. most o f the time metabolism results in more than one metabolites E. all o f the above

D. includes unmasking polar functional groups E. none

5. Xenobiotics are A. B. C. D. E. drugs prodrugs inactive metabolites toxic substances any chemical that is foreign to the body

6. Which o f the following is the main organ o f metabolism? 2. Which o f the following is true about metabolites? A. metabolites may be inactive B. metabolites may be less active than the parent substance C. metabolites may be more active than the parent substance D. metabolites can show activity not shown by the parent substance E. all o f the above A. B. C. D. E. kidney liver intestines pancrease heart

7. What is the most common phase I biotransformation? A. B. C. D. E. reduction oxidation hydrolysis hydrogen bond formation acetylation

3. Prodrugs are A. inactive metabolites B. bioactivated metabolites C. substances whose metabolites have decreased activity D. substances whose metabolites are very toxic E. all

8. Which o f the following is not true about cytochrome P450 enzymes? A. they carry out the majority o f the oxidation reactions in the phase I reaction B. because they are enzymes, CPY450 oxidases can only be metabolized a specific type o f substrates C. they are found bound to the smooth endoplastic reticulum D. they require both NADPH and a porphyrin prosthetic group. E. none o f the above

4. All of the following are true about the Phase 1 reactions, exccpt A. convert the parent drug into a more polar metabolite B. involves introducing polar functional groups C. the activity o f the drugs is not modified

9. In the CYP3A4, the number 3 and the letter A indicate respectively A. B. C. D. E. individual gene and subfamily family and subfamily family and individual gene subfamily and family individual gene and family

10. Which of the following is true about the phase I oxidation reactions? A. all oxidation reactions are catalyzed by the CYP450 oxidases B. some oxidations are catalyzed by enzymes other than the CYP450 oxidases but located within the endoplasmic reticulum o f the liver C. some oxidations are catalyzed by enzymes other than the CYP450 oxidases which are nonmicrosomal but located in cytosol and mitochondria o f liver cells D. some oxidations are catalyzed by nonmicrosomal oxidases located in cytosol and mitochondria of extrahepatic tissues. E. none o f the above

A. the overall goal is to create polar functional groups so that their elimination in the urine will be facilitated/reduced B. like the oxidation reactions, CYP450 play the major role in carrying out reduction reactions C. bacteria resident in the GIT are also involved in reduction reactions D. reduction reactions are not as common as oxidation reactions E. none

13. Which o f the following is not true about the esterase enzymes? A. they are usually present in plasma and various tissues B. they are very specific C. they catalyze de-esterification, hydrolyzing relatively non-polar esters into two polar, more water soluble compounds; an alcohol and an acid D. they are responsible for converting many prodrugs into their active drugs E. none o f the above

11. The metabolites produced after phase I oxidation reactions A. have decreased polarity than the parent drugs B. have enhanced water solubility than the parent drugs C. their tubular reabsorption in the kidneys is increased leading to their reduced excretion D. do not need to go further biotransformation by phase II pathways E. none o f the above

14. Which o f the following is NOT true about the enzymatic hydrolysis o f ester and amide drugs? A. amidase enzymes hydrolyze amides into amines and acids B. ester drugs are usually longer acting than structurally similar amide drugs C. amidase enzymes are mainly located in the liver D. lactones are hydrolyzed by esterases while lactams are hydrolyzed by amidase

12.All o f the following are correct statements about reduction phase I reactions except one

15.All o f the following statements about the phase II reactions are true, except A. most phase II conjugates are very polar

B. during phase II reactions, only the metabolites formed in phase I reaction are conjugated C. the metabolites o f phase II are most o f the time pharmacologically inactive D. phase II conjugates can be excreted in urine or bile E. none

E. liver

20. Which of the following is not true about the conjugates produced after the phase II reaction A. they are highly polar B. they are unable to cross cell membranes C. they are almost always pharmacologically inactive D. they could be toxic E. they are easily excreted from the body

16.The high-energy molecule required for the conjugation reaction consists o f a coenzyme bound to A. the parent drug B. the endogenous substrates like the glucuronic acid C. the drugs phase 1 conjugates D. the enzyme E. all but D

21. Which of the six conjugation pathways is the most common one? A. B. C. D. E. glucuronidation sulfate conjugation amino acid conjugation glutathione conjugation methylation

17.All o f the following are natural endogenous constituents involved in phase II reaction except A. B. C. D. E. cytosine glucuronic acid Glycine Glutamine Glutathione

22. The high-energy form o f glucuronic acid is A. uridine diphosphate glucuronic acid B. uridine triphosphate glucuronic acid C. uridine monophosphate glucuronic acid D. B and C

18.The enzymes that catalyze conjugation reactions are called A. B. C. D. E. conjugases esterases transferases amidases reductases

23. Which drugs glucuronidation?

readily

undergo

19. The enzymes responsible for catalyzing conjugation reactions are found mainly in A. B. C. D. intestine kidneys blood pancreas

A. drugs that possess amide functional groups B. drugs that posses a ketone functional group C. drugs that possess a carboxyl functional group D. drugs that possess a hydroxyl functional group E. C and D

24.The high-energy form o f sulfate reacts with all of the following except A. B. C. D. E. alcohols arylamines phenols N-hydroxy] compounds Carboxyl acids

C. fluorine D. sulfur E. none

29. What are the conjugation reactions in which the unaltered drug is more polar than the metabolites? A. sulfate conjugation and amino acid conjugation B. sulfate conjugation and methylation C. sulfate conjugation and glucuronidation D. sulfate conjugation and acetylation E. acetylation and methylation

25.Amino acid conjugation involves the reaction o f either Glycine or glutamine with which o f the following to form amides. A. B. C. D. E. carboxylic acids phenols arylamines alcohols A and C

30. Which o f the following is not correct about methylation reaction? A. the enzyme responsible for catalyzing the reaction is called methyl transferase B. methylation plays major role in the elimination o f drugs C. it has a major role in the biosynthesis of endogenous compounds such as epinephrine D. it can inactivate certain compounds like cathecholamine neurotransmitters E. none

26. Which o f the six conjugation reactions is extremely important in preventing toxicity from a variety o f harmful electrophilic agents? A. B. C. D. E. Amino acid conjugation Glutathione conjugation Methylation Glucuronidation Sulfate conjugation

27. What is the final product o f glutathione conjugation? 31 .Acetylation can occur with A. B. C. D. E. urea C 02 Mercapturic acid derivative Carboxylic acid derivative A dipeptide derivative glutathione I .primary amides II. sulfonamides III. hydrazides of A. B. C. D. E. I only I and II I, II and 111 11 and III I and III

28.Methylation is most suitable with drugs containing functional groups that have the following atoms, except A. oxygen B. nitrogen

32. In one o f the following, there is a danger of tissue accumulation that can lead to crystalluria and subsequent tissue damage.

A. mercapturic acid derivative B. N-acetylated metabolites of sulfonamides C. Glucuronides with high molecular weight D. Acetyl-CoA

D. a difference in a particular endogenous substrate E. a difference in the extent o f competing reactions

37. Which o f the following is likely to affect the metabolism o f drugs? A. B. C. D. E. liver disease congestive heart failure abnormal albumin level in the blood A and C all o f the above

33. The high-energy acetylation is A. B. C. D.

molecule

for

N-acetyl transferase S-adenosylmethionine Acetyl-CoA B-phosphoadenosine^phosphoac ety 1 ate E. ATP

3 8 .Which o f the following statements is correct? I. slow acetylators are more prone hepatotoxicity from isoniazid II. fast acetylators are less prone to toxicities from isoniazid III.slow acetylators are less prone to toxicities of isoniazid hepatotoxicity A. B. C. D. E. I and II II only II and III Ill only None o f the above to all all but

34. Which o f the following is not among the factors that affect drug metabolism? A. B. C. D. E. chemical structure o f the drug drug administration route nutritional status age none o f the above

35.Qualitative species difference in the metabolism o f drugs occur primary with A. B. C. D. phase 1 phase II both phase I and phase II with some people phase I and with others phase II

39. Which o f the following is true about the influence o f dosage upon drug metabolism?

A. an increase in drug dosage always results in increased drug concentrations and hence increased drug metabolism 36. Which o f the following is not a cause of B. at 50% enzyme saturation, quantitative type o f species difference in metabolism via the enzyme follows the metabolism o f drugs? zero-order kinetics A. difference in the enzyme level C. at 100% enzyme saturation, metabolism via the enzyme will be B. the presence o f species specific mixture o f both first-order and zeroisozymes order kinetics. C. a difference in the amount o f D. An increase in drug dosage can endogenous inhibitor result in increased drug

concentration but the metabolism increases up to a certain level only E. A and C

C. vitamin C D. vitamin D E. vitamin E

40.Low protein diet can lead to A. decreased oxidative drug metabolism capacity B. decreased amino acid conjugation C. decreased methylation o f drugs D. A and B E. B and C

44.Which o f the following is not true statement about the effect o f age up on drug metabolism? A. since metabolizing enzymes are not fully developed at birth, all infants and children require smaller doses o f drugs than adults in order to avoid toxic side effects B. drugs metabolized by glucuronide conjugation require special attention when given to infants and children C. In general the rate o f drug elimination is lower in elderly D. In older children, the metabolism o f some drugs is faster than in adults E. B and D

41 .Which o f the following is true about the metabolism of ethyl-morphine and hexobarbital? A. diet deficiency in essential fatty acids reduces the metabolism of these drugs B. low-protein dies results in decreased metabolism o f these drugs C. essential fatty acids content o f diet does not have influence on the metabolism o f these drugs D. high-protein diets results in increased metabolism o f theses drugs E. A and B

45. The oxidative propranolol is A. B. C. D.

metabolism

of

faster in men than in women faster in women than in men not influenced by gender sometimes faster in men sometimes in women E. none o f the above

and

42.A diet deficient in the mineral calcium results in A. increased drug-metabolizing capacity B. variable effect in the drug metabolizing capacity C. decreased drug metabolizing capacity D. no change in the drug metabolizing capacity E. A & B

46.Which o f the following routes o f administration does not bypass first-pass effect? A. B. C. D. E. I .V . administration Oral administration Rectal administration Sublingual administration None o f the above

43.DealkyIation and hydroxylation o f drugs is retarded by deficiency in A. B. vitamin A vitamin B

47.Which o f the following is true about first-pass effect? A. It is o f little clinical significance

B. It causes the inactivation o f drugs before they reach their site o f action C. It cannot be offset by increasing the dose o f the drug D. A and C E. A and B

D. doesnt show individuals E. B and C

variation

among

52. Which o f the following affect intestinal bacteria] flora? A. B. C. D. E. age disease state diet drugs all o f the above

48.Extrahepatic metabolism takes place A. B. C. D. E. in the GI mucosa only kidneys only lungs only throughout the body B and C

53.Ulcerative colitis causes 49. Which o f the following is not true about the metabolism that takes place in the plasma? A. the enzymes responsible for metabolism in the blood are primarily the esterases B. simple esters are rapidly hydrolyzed in the blood C. metabolism in the blood always results in loss o f activity D. A and B E. None A. B. C. D. increased bacterial growth in intestine decreased bacterial growth in intestine no effect upon the bacterial growth in intestine sometimes increases and some times decreases bacterial growth in intestine none o f the above

E.

54.Which o f the following statements is false about the enterohepatic circulation o f bile acids? A. It occurs as a result o f the action o f P-glucuronidase enzyme secreted by the bacterial flora in the intestine enzyme upon the polar glucuronide conjugates o f bile B. allows free, non-polar bile to be reabsorbed C. partially maintains the pools o f bile acids D. it applies to the glucuronide conjugates of bile acids only and not to conjugates o f drugs. E. None o f the above

50. Metabolizing enzymes in the intestinal mucosa are especially important for drugs undergoing A. B. C. D. E. microsomal oxidation glucuronide conjugation amino acid conjugation sul fate conj ugati on all but C

51.Drug mucosa

metabolism

in

the

intestinal

A. is similar but not comparable in capacity to a first-pass effect B. makes the drugs more polar before they enter the blood C. occurs during drug absorption

55. Which o f the following is/are caused by the action o f bacterial flora in the intestine?

A. conversion o f vitamin precursors to their active forms B. conversion of some drugs to toxic substances C. conversion o f certain prodrugs to their active forms D. conversion o f some drug conjugates to non-polar free drugs E. all o f the above

56.The acidic environment o f the stomach contributes to the non-enzymatic degradation o f all except A. B. C. D. E. protein and peptide drugs penicillin G erythromycin carbenicillin acetaminophen

A. the metabolizing enzymes in lungs have similar specific activities but are less in amount compared to those in the liver B. the metabolizing enzymes in the lungs are comparable to those found in the liver in both their specific activity and amount C. the metabolizing enzymes in the lungs are similar in amount to those found in the liver, but their specific activity is appreciably different D. the metabolizing enzymes found in the liver and the lungs are different in their specific activity as well as their amount

60.All o f the following statements about placenta] metabolism are true except A. if a drug is lipid soluble enough to be absorbed into the systemic circulation, then it can easily pass the placenta o f a pregnant woman without being metabolized B. the placenta present no physical or metabolic barrier to xenobiotics C. many drugs get metabolized in the placenta before passing into the fetus D. the only enzyme activity present in the placenta is that aryl aromatic hydroxylase, which is inducible in pregnant women who smoke cigarettes E. all but C

57. Which o f the following is not true about the metabolism o f drugs in the nasal passages? A. the metabolism occurs mainly due to the presence of high level of CYP450 activity in the nasal mucosa B. it does not result in significant reduction in the blood level o f drugs C. nasal decongestant and anesthetics are examples o f those metabolized in the nasal passages D. none

58.The lung is responsible for the first-pass metabolism o f drugs administered A. B. C. D. E. Intravenously Transdermally Subcutaneously Intramuscularly All o f the above 61.The major deficient enzyme activity in fetus and the neonate is A. B. C. D. E. sulfate conjugating activity glucuronic acid conjugating activity oxidative activity amino acid conjugating activity A and B

59. Which o f the following is true about the metabolizing enzymes found in lungs and liver?

62.Gray baby syndrome results from

A. decrease in bilirubin glucuronide formation B. decrease in erythromycin glucuronidation C. decrease in isoniazid glucuronidation D. decrease in chloramphenicol glucuronidation E. A and D

B. a pharmacological strategy o f managing drug metabolism C. a chemical strategy o f managing drug metabolism D. both pharmaceutical as well as pharmacological strategy of managing drug metabolism E. none

63. Which o f the following is/are true about the strategies of managing drug metabolism? A. the strategies try to circumvent the rapid metabolism o f drugs B. the aim is to improve drug therapy C. they result in increased duration of action D. they can provide increased site specificity E. all o f the above

66. Which o f the following is not a correct match between the examples given and the strategies o f managing drug metabolism? A. enteric-coated omeprazole preparations; pharmaceutical strategy B. clavulanic acid used in conjunction with penicillin; pharmacological strategy C. extended-release transdermal patches and ointment formulations o f nitroglycerin; pharmaceutical strategy D. chlorpropamide, a structurally similar compound to tolbutamide, has a much longer duration o f action; pharmacological strategy. E. none

64.The pharmaceutical strategy managing drug metabolism involves

of

A. the concurrent use o f enzyme inhibitors to drug metabolism B. the use o f different dosage forms to either avoid or compensate for rapid metabolism C. the addition, deletion, or isosteric modification o f key functional groups D. the use o f additional agents that prevents the toxicity caused by metabolites o f the therapeutic agent E. A and D

67.The concurrent use o f levodopa and carbidopa, is an example o f A. pharmacological strategy of managing drug metabolism B. pharmaceutical strategy of managing drug metabolism C. physical strategy o f managing drug metabolism D. chemical strategy o f managing drug metabolism E. B and C

65.Nitroglycerin, a rapidly acting antianginal agent, is essentially ineffective when given orally, but is very effective in treating acute attacks o f angina if given sublingually. This is an example o f A. a pharmaceutical strategy managing drug metabolism of

68.Ifosfamide and mesna make a typical example o f pharmacological strategy to avoid toxicity because A. mesna is a non-toxic derivative o f ifosfamide

B. mesna prevents the metabolisnf o f ifosfamide C. mesna shortens the action o f ifosfamide D. mesna reacts with toxic metabolite o f ifosfamide E. C and D

69.Ritonavir and lopinavir constitute A. a pharmacological strategy of extending the action o f ritonav r by coadministering lopinavir a pharmacological strategy of enhancing the pharmacolo jical action o f lopinavir by concurrent administration o f ritonavir a chemical strategy, where lopihavir is the long-acting derivative of ritonavir a pharmacological strategy, \ 'here lopinavir prevents the metabolism of ritonavir. A chemical strategy, where the metabolism o f lopinavir rebases less toxic metabolites than th|at o f ritonavir.

A. metaproterenol is orally active while isoproterenol is not B. metaproterenol has longer duration o f action C. metaproterenol is much more potent than isopreterenol D. metaproterenol is less susceptible to metabolism by catechol O-methyl transferase (COMT) E. none o f the above

B.

72. Which o f the following can be considered as advantages gained from the use o f prodrugs instead o f the active form o f the drug? A. B. C. D. E. increased water solubility increased lipid solubility site specificity increased shelf-life all o f the above

C.

D.

E.

73. Which o f the following ,esters are not involved A. in making some water soluble steroidal produgs B. in making lipid soluble prodrugs of estradiol, which have longer duration o f action C. in producing nabumetone, a prodrug with decreased GI irritation than the other NSAIDs D. in making steroids which have increased topical absorption E. none

70. Addition o f 17a-methyl groub to testosterone results in the new corrijound methyltestosterone. Which o f the following is not true about testosterone and methyltestosterone? A. they make up an example o f a chemical strategy o f managing drug metabolism B. methyltestosterone is only h^lf as potent as testosterone C. methyltestosterone is subject to rapid first-pass metabolism D. methyltestosterone can be used orally but not testosterone E. none

74. Which o f the following is true about enalaprilat and enalapril? A. enalaprilat is the prodrug, which is converted to the active enalapril by plasma esterases. B. Enalapril is less water soluble than enalaprilat C. Enalaprilat is active orally, while
enalapril is not

71. Which o f the following is not a eason for developing metaproterenol from isoproterenol?

D. Enalapril is used administration E. None

for parenteral

E. none o f the above

79.An anti-prostate cancer agent with less systemic side effect is 75. The reason for esterification sulfisoxazole to acetyl sulfisoxazole is A. B. C. D. of A. B. C. D. E. olsalazine sulfasalazine diethylstilbesterol diethylstilbeterol diphosphate B and D

to increase oral bioavailability to increase the duration o f action to avoid certain adverse effects to overcome the bitter taste of sulfisoxazole E. A and D

80,Cyclophosphamide is different other nitrogen mustards because A. B. C. D. E. it is less toxic it is site specific it has longer duration o f action it is more stable all o f the above

from

76.The prodrug nabumetone is employed to overcome the GI irritation caused by some NSAIDs. This is because A. it has the ability to get dissolved in the stomach and neutralize the acid there B. nabumetone is a ketone C. it does not inhibit the synthesis of prostaglandins
D . all o f the ab ove E .B and C

81 .Which o f the following is not true about genes? A. they are discrete segments o f DNA B. B. they are capable o f reproduction when the cell replicates C. C. they are responsible for guiding the biosynthesis o f specific proteins D. sometimes they may also be found in the RNA E. none o f the above

77. Which o f the following is not true about the prodrug methenamine? A. it is stable and nontoxic at norma] physiological pH B. it is best if it is used as enteric coated formulations C. it is more potent than formaldehyde D. it hydrolyzes and forms formaldehyde in the acidic pH o f the urine E. none

82.Genes are involved in A. metabolism o f drugs B. determining drug response and toxicity C. absorption and transports o f drug molecules D. in the production o f drug receptors E. all o f the above

78. Which o f the following prodrugs is not developed for its site specificity? A. B. C. D. methyldopa diethylstilbesterol cefamandole olsalazine

83.A patient may not respond to or suffer adverse effects from a drug prescribed for his/her condition, because o f which o f the following?

A. B. C. D. E.

inappropriate dosing drug allergies drug-drug interaction medication errors all of the above

87 .An SNP that could alter the transcription rate, resulting in either an increase or decrease in the production o f the target protein if found in which region? A. B. C. D. E. coding splicing control promoter outside any o f the above regions B and C

84. Which o f the following is not true about pharmacogenetics? A. it involves identifying the individual genetic differences B. it tries to select the right drug for the right patient C. it tries to identify individual predisposition D. it makes use o f genetic information to improve drug response and limit side effects E. it studies the genetics o f humans

88.Which o f the SNP located within the coding region would have a significant effect? I. an SNP that did not alter the amino acid sequence ]]. an SNP that resulted in one amino acid being replaced by a similar amino acid III. an SNP that resulted in one amino acid being replaced by a significantly different amino acid A. B. C. D. E. I only 11 and III Ill II I, II, III

85.The genetic variation in the DNA sequence o f certain individuals can lead them to which o f the following ? A. to be more likely to develop specific disease states B. to be more likely to follow a specific path o f disease progression C. to be more likely to respond to specific drug therapy D. to be more likely to develop certain adverse drug effects E. all o f the above

86. The genetic variation between any two unrelated individuals is approximately A. two base pair change in every 100 base pairs B. one base pair change in every 100 base pairs C. three base pair change in every 100 base pairs D. one base pair change in every 1000 base pairs E. three base pair change in every 1000 base pairs

ANSW ERS

Biotransformation, Prodrugs and Pharmacogenetics


1. Answer: D. most o f the time metabolism results in more than one metabolites Explanation: Drug metabolism (also called biotransformation) refers to the biochemical changes that drugs and other foreign chemicals undergo in the body, leading to the formation o f different metabolites with different effects. Often a mixture o f intermediate metabolites and excreted products, including unchanged parent drug are produced. Rarely is one metabolite produced from a single drug.

2. Answer: E. all o f the above Explanation: Some metabolites are inactive (i.e., their pharmacologically active parent compounds become inactivated or detoxified). For example, the oxidation o f 6-mercaptopurine to 6-mercapturic acid results in a loss o f anticancer activity. Certain metabolites retain the pharmacological activity of their parent compounds to lesser or greater extent (e.g., imipiramine is demethylated to the essentially equiactive antidepressant, desipramine). Some metabolites develop activity different from that o f their parent drugs (e.g., the antidepressant iproniazid is dealkylated to the antitubercular, Isoniazid).

3. Answer: B. bioactivated metabolites Explanation: Prodrugs are molecules that are either inactive or very weakly active and require in vivo biotransformation to produce the physiologically active drug.

4. Answer: C. the activity o f the drugs is not modified Explanation: Phase I reactions are those in which polar functional groups are introduced into the molecule or unmasked by oxidation, reduction, or hydrolysis. After the phase 1 reaction the drugs are converted to more polar metabolites that may or may not retain their activity. 5. Answer: E. any chemical that is foreign to the body Explanation: Xenobiotics include any compound (drugs, toxic substances, etc) that enter the body and thus is foreign to it.

6. Answer: B. liver

Explanation: Since it contains the majority o f the metabolizing enzymes, liver is the main organ o f metabolism.

7. Answer: B. oxidation Explanation: The types o f biotransformations that occur during the phase I reactions include oxidation, reduction and hydrolysis. Among this oxidation is the most common one.

8. Answer: B. because they are enzymes, CPY450 oxidases can only metabolized a specific type o f substrates Explanation: CYP450, unlike most enzymes uses a variety o f oxidase biotransformations to metabolize a diverse group o f substrates. It exists in multiple isoforms or families. The presence o f these different isoforms is responsible for the large substrate variation seen with CYP450.

9. Answer: B. family and subfamily Explanation: CYP450 isoforms are named using the root CYP followed by an Arabic number designating the family, a letter designating the subfamily, and a second Arabic number indicating the individual gene.

10.Answer: D. some oxidations are catalyzed by nonmicrosomal oxidases located in cytosol and mitochondria o f extrahepatic tissues Explanation: The vast majority o f oxidations are catalyzed by a group o f mixed-function oxidases known as cytochrome Plso (CYP450). These oxidases are bound to the smooth endoplasmic reticulum of the liver and require both NADPH and a porphyrin prosthetic group. Unlike most enzymes, CYP450 uses a variety o f oxidative biotransformation to metabolize a diverse group of
substances.

11 .Answer: B. have enhanced water solubility than the parent drugs Explanation: The metabolites produced after phase I oxidation reactions have increased polarity, which enhances their water solubility and reduces their tubular reabsorption to some extent, thus favoring their excretion in the urine. Most o f the time these metabolites undergo further biotransformation by phase II pathways.

12.Answer: B. like the oxidation reactions, CYP450 play the major role in carrying out reduction reactions Explanation: Although there is evidence suggesting that the CYP450 system might be involved in some reduction reactions, it cannot be considered to play the major role.

13.Answer: B. they are very specific Explanation: Esterase enzymes are generally non-specific when catalyzing de-esterification reactions.

14.Answer: B. ester drugs are usually longer acting than structurally similar amide drugs Explanation: Since esterases are mainly located in the plasma, ester drugs are in general shorter acting than structurally similar amide drug, which are not hydrolyzed until they reach the liver (because amidase enzymes are mainly found in the liver).

15.Answer: B. during phase II reactions, only the metabolites formed in phase I reaction are conjugated Explanation: During the phase II reactions, the functional groups o f either the original drug or the metabolites o f the phase I reaction are masked by a conjugation reaction.

16.Answer: E. all but D Explanation: Conjugation reactions combine the parent drug (or its metabolite) with certain natural indigenous constituents, such as glucuronic acid. These reactions generally require both a high-energy molecule and an enzyme. The high energy molecule consists o f a coenzyme bound to the endogenous substance, the parent drug, or the drugs phase I metabolite.

17.Answer: A. cytosine

Explanation: The natural endogenous constituents involved in phase 11 reactions include, glucuronic acid, Glycine, glutamine, sulfate, glutathione, the two-carbon acetyl fragment, and the one-carbon methyl fragment.

18.Answer: C. transferases Explanation: The enzymes, which catalyze the conjugation reactions during the phase II reactions are called transferases.

19.

Answer: E. liver

Explanation: The enzymes responsible for catalyzing conjugation reactions are found mainly in liver and to lesser extent in the intestines and other tissue.

20. Answer: D. they could be toxic Explanation: In genera], conjugates are polar molecules that are readily excreted and unable to cross the cell membrane and thus they are often pharmacologically inactive and non-toxic.

21.Answer: A. glucuronidation Explanation: Glucuronidation is the most common conjugation pathway because o f a readily available supply o f glucuronic acid as well as large variety o f functional groups, which can enzymatically react with this sugar derivative.

22.Answer: A. uridine diphosphate glucuronic acid Explanation: The high-energy form o f glucuronic acid is uridine diphosphate glucuronic acid, and reacts with variety o f functional groups under the influence o f glucuronyl transferase.

23.Answer: E. C and D Explanation: Drugs that possess hydroxyl or carboxyl groups readily undergo glucuronidation to form ethers and esters, respectively. In addition, N-, S-, and C-glucuronides are also possible.

24.Answer: E. Carboxyl acids

Explanation: The high-energy form o f sulfate, 3-phosphoadenosine-5phophosulfate (PAPS), react with phenols, alcohols, arylamines, and N-hydroxyl compounds under the influence o f sulfotransferase to form highly polar metabolites.

25.Answer: A. carboxylic acids Explanation: Amino acid conjugation involves the reaction o f either Glycine or glutamine with aliphatic or aromatic acids to forms amides. A drug molecule is first converted to an acyl coenzyme A intermediate. An N-acyltransferase enzyme then catalyzes the conjugation o f the activated drug molecule with the amino acid.

26. Answer: B. Glutathione conjugation Explanation: Under the influence o f glutathione S-transferase, glutathione can react with halides, epoxides and other electrophilic compounds to form harmless inactive products.

27.Answer: C. Mercapturic acid derivative Explanation: When glutathione has reacted with an electrophile, it undergoes a series o f reaction to produce a mercapturic acid derivative, which is eliminated.

28.Answer: C. fluorine Explanation: Methylation occurs with drugs that have functional groups containing oxygen, nitrogen, and sulfur and result in metabolites that are usually less polar than the unaltered drugs.

29.Answer: E. acetylation and methylation Explanation: Acetylation and methylation o f drugs results in metabolite, which are less polar than the parent drugs and can retain some pharmacological activity.

30.

Answer: B. methylation plays major role in the elimination o f drugs

Explanation: Methylation can inactivate certain compounds, but overall it plays a minor role in the elimination o f drugs.

flir

31 .Answer: C. I, II and III Explanation: Acetylation can occur with primary amides, sulfonamides, hydrazides and, occasionally, amides. It leads to the formation o f N-acetylated products.

COOH

Q
Alkane

H3c %
h 3c c

o 1 1

^ ^ COOH

II

ococh

o
Alkyl, and occasionally aryl (aromatic) functions are represented by the RMethyl: C H 3Ethyl: CH3CH2Propyl: CH3CH2CH2Isopropyl: (CH3)2CHPhenyl: C 6H 5Alkyl halides [haloalkanes] consist o f an alkyl group attached to a halogen: F, Cl, Br, 1. Chloro, bromo and iodo alkyl halides are often susceptible to elimination and/or nucleophilic substitution reactions. Primary alcohols have an -OH function attached to an R-CH2group. Primary alcohols can be oxidised to aldehydes and on to carboxylic acids. (It can be difficult to stop the oxidation at the aldehyde stage.) Primary alcohols can be shown in text as: RCH 20H Secondary alcohols have an -OH function attached to a R2CHgroup. Secondary alcohols can be oxidised to ketones. Secondary alcohols can be shown in text as: R2CHOH Tertiary alcohols have an -OH function attached to a R3Cgroup. Tertiary alcohols are resistant to oxidation with acidified potassium dichromate(VI), K. Tertiary alcohols can be shown in text as: R3COH Aldehydes have a hydrogen and an alkyl (or aromatic) group attached to a carbonyl function. Aldehydes can be shown in text as: RCHO Aldehydes are easily oxidised to carboxylic acids, and they can be reduced to primary alcohols. Ketones have a pair o f alkyl or aromatic groups attached to a carbonyl function.

Alkyl halide R -X
X = F, Cl, Br, I

Primary alcohol
II 1 R|- O H

Secondary alcohol
R R | ' OH H

Tertiary alcohol
r | :

oh

Aldehyde 1 ?
R H

Ketone

if
r'

Ketones can be shown in text as: RCOR

\
O
Carboxylic acids have an alkyl or aromatic groups attached to a hydroxy-carbonyl function. Carboxylic acids can be shown in text as: RCOOH Carboxylic acids are weak Bronsted acids and they liberate C 02 from carbonates and hydrogen carbonates. The carbonyl group is a super function because many common functional groups are based on a carbonyl, including: aldehydes, ketones, carboxylic acids, esters, amides, acyl (acid) chlorides, acid anhydrides Esters have a pair o f alkyl or aromatic groups attached to a carbonyl linking oxygen function. Esters can be shown in text as: RCOORjDrJoccasioually)_____ ROCOR. carboxylic acid alcohol -> ester water This is an acid catalysed equilibrium. Primary amides (shown) have an alkyl or aromatic group attached to an amino-carbonyl function. Primary amides can be shown in text as: RCONH2 Secondary amides have an alkyl or aryl group attached to the nitrogen: RCONHR Tertiary amides have two alkyl or aryl group attached to the nitrogen: RCONR2

Carboxylic acid

OH

Carbonyl function

o II / C \
Ester

O II /C \

O -R

~ +

Amide

O II c r ' xnh2
Primary amine

r~ ~ n h 2
Secondary amine

,N H

Tertiary amine
R

R\ N O II

RX

Acid chloride

Cl

Primary amines have an alkyl or aromatic group and two hydrogens attached to a nitrogen atom. Primary amines can be shown in text as: RNH2 Primary amines are basic functions that can be protonated to the corresponding ammonium ion. Primary amines are also nucleophilic Secondary amines have a pair o f alkyl or aromatic groups, and a hydrogen, attached to a nitrogen atom. Secondary amines can be shown in text as: R2NH Secondary amines are basic functions that can be protonated to the corresponding ammonium ion. Secondary amines are also nucleoghilic. Tertiary amines have three alkyl or aromatic groups attached to a nitrogen atom. Tertiary amines can be shown in text as: R3N Tertiary amines are basic functions that can be protonated to the corresponding ammonium ion. Tertiary amines are also nucleophilic. Acid chlorides, or acyl chlorides, have an alkyl (or aromatic) group attached to a carbonyl function plus a labile (easily displaced) chlorine. Acid chlorides highly reactive entities are highly susceptible to attack by nucleophiles. Acid chlorides can be shown in text as: ROC1

Acid anhydride

I Ry

? V nr

Acid anhydrides are formed when water is removed from a carboxylic acid, hence the name. Acid anhydrides can be shown in text as: (R 0 )2 0

Nitrile

R *C=N
Carboxylate ion or salt

P
R 0
r
Ammonium ion

Nitriles (or organo cyanides) have an alkyl (or aromatic) group attached to a carbon-triple-bond-nitrogen function. Nitriles can be shown in text as: RCN Carboxylate ions are the conjugate bases o f carboxylic acids, ie. the deprotonated carboxylic acid. Carboxylate ions can be shown in text as: R CO O When the counter ion is included, the salt is being shown. Salts can be shown in text as: RCOONa Ammonium ions have a total o f four alkyl and/or hydrogen functions attached to a nitrogen atom. [NH4]+ [RNH3]+ [R2NH2]+ [R3NH]+ [R4NJ+ Quaternary ammonium ions are not proton donors, but the others are weak Bronsted acids (pKa about 10). Amino acids, strictly alpha-amino acids, have carboxylic acid, amino function and a hydrogen attached to a the same carbon atom. There are 20 naturally occurring amino acids. All except glycine (R = H) are chiral and only the L enantiomer is found in nature. Amino acids can be shown in text as: R-CH(NII2)COOH Alkenes consist o f a C=C double bond function. Alkenes can be shown in text as: Mono substituted: RCH=CH2 1.1-disubstituted: R2C=CH2 1.2-disubstituted: RCH=CHR Alkanes are planar as there is no rotation about the C=C bond. Alkenes are electron rich reactive centres and are susceptible to electrophilic addition. Ethers have a pair o f alkyl or aromatic groups attached to a linking oxygen atom. Ethers can be shown in text as: ROR

i+

L R X r
Amino acid

yCOOH R - C H

\N h2

Alkene
R\

C= C

/H
XH

H7
Ether

/(X

32. Answer: B. N-acetylated metabolites o f sulfonamides Explanation: N-acetylated metabolites can accumulate in tissue or in the kidneys, as in the case o f certain antibacterial sulfonamides. Crystalluria and subsequent tissue damage may result. Sulfonamide Structure

33.Answer: C. Acetyl-CoA Explanation: The high-energy molecule for acetylation is acety]-CoA. The reaction is catalyzed by N-acetly transferase. S-adenosylmethionine is the high-energy molecule for methylation.

Acetyl-CoA 34. Answer: E. none o f the above Explanation: The factors which influence drug metabolism include: chemical structure o f the drug, species difference, physiological or diseases state, genetic variation, drug dosage, diet, age, gender, drug administration route.

35.Answer: B. phase II Explanation: In general qualitative difference occurs primary with phase 1 1 reactions and quantitative differences occur primary with phase I reactions.

36.Answer: D, a difference in a particular endogenous substrate Explanation: Species difference in drug metabolism could be qualitative difference in the actual metabolic pathway, which could result from a genetic deficiency o f a particular enzyme or a difference in a particular endogenous substrate. Species differences, which are quantitative, are differences in the extent to which the same type o f metabolic reaction occurs. The causes include difference in the

enzyme level, the presence o f species specific isozymes, a difference in the amount o f endogenous inhibitors or inducer or a difference in the extent o f competing reactions.

37. Answer: E. all o f the above Explanation: Because the liver is the major organ involved in the metabolism o f drugs any disease that may affect its function is likely to affect the metabolism o f drugs. Congestive heart failure affect drug metabolism through the effect it has on hepatic blood flow. CHF decrease the hepatic blood flow and thus the extent o f drug metabolism in the liver.

3 8. Answer: E. None o f the above

Explanation: The acetylation rate depends on the amount o f N-acetyltransferase present, which is determined by genetic factors. The general population can be divided into fast acetylators and slow acetylators. Fast acetylators are more prone to hepatotoxicity from isoniazid than slow acetylators, whereas slow acetylators are more prone to isoniazids other toxic effects.

39.Answer: D. An increase in drug dosage can result in increased drug concentration but the metabolism increases up to a certain level only. Explanation: An increase in drug dosage results in increased drug concentrations and can saturate certain metabolic enzymes. As drug concentration exceeds 50% saturation for a particular enzyme, drug elimination via this path no longer follows solely first-order kinetics, but rather is a mix o f zeroand first-order kinetics. At 100 % saturation, metabolism via this enzyme follows zero-order kinetics.

40.Answer: D. A and B. Explanation:

The level o f some conjugating agents (or endogenous substrates) such as sulfate, glutathione, and (rarely) glucuronic acid, are sensitive to body nutrient levels. For example, a low-protein diet can lead to a deficiency o f certain amino acids such as Glycine and decreased oxidative drug metabolism capacity. 41 .Answer: A. diet deficiency in essential fatty acids reduces the metabolism o f these drugs. Explanation: Diets deficiency in essential fatty acids reduces the metabolism o f ethylmorphine and hexobarbital by decreasing synthesis o f certain drug-metabolizing enzymes.

42.Answer: C. decreased drug metabolizing capacity. Explanation: A deficiency o f certain dietary minerals affects drug metabolism. Calcium, magnesium, and zinc deficiencies decrease drug-metabolizing capacity, whereas iron deficiency appears to increase it. A copper deficiency leads to variable effects.

43.Answer: E. vitamin E Explanation: Deficiencies o f vitamins (particularly vitamins A, C, E, and B group) affect drug metabolizing capacity. For example, a vitamin C deficiency can result in a decrease in oxidative pathway, whereas a vitamin E deficiency can retard dealkylation and hydroxylation. 44.Answer: A. Since metabolizing enzymes are not fully developed at birth, all infants and children require smaller doses of drugs than adults in order to avoid toxic side effects Explanation: Since the enzyme systems are not fully developed, all infant and young children require smaller doses o f drugs than adults. This is particularly true o f drugs that require glucuronide conjugation. In older children, some drugs are metabolized faster than in adults, particularly if the dosage is based on weight. The liver develops faster than the increase in general body weight and thus represents a greater fraction o f total body weight. In the elderly, metabolizing enzyme systems decline, resulting in decreased metabolism o f drugs and thus slower rate o f drug elimination. Elimination o f acetaminophen is principally by liver metabolism (conjugation) and subsequent renal excretion o f metabolites. Approximately 85% o f an oral dose appears in the urine within 24 hours o f administration, most as the glucuronide conjugate, with small amounts o f other conjugates and unchanged drug. In neonates and children (3 9 years), acetaminophen is excreted primarily as the sulfate conjugate. The difference in methods o f clearance may be due to a deficiency in glucuronide

formation in younger age groups N-acetylcysteine is used to treat neonatal acetaminophen toxicity.
45.Answer: B. Faster in women than in men.

Explanation: Metabolic differences between the sexes have been observed for a number o f compounds, suggesting that androgen, estrogen, and/or adrenocorticoid activity might affect the activity o f certain CYP450 enzyme isozymes. The metabolism of diazepam, prednisolone, caffeine, and acetaminophen is faster in women, whereas that o f propranolol, chlordiazepoxide, lidocaine, and some steroids is faster in men.

46.Answer: B. Oral administration. Explanation: After oral administration, drugs are absorbed from the GIT and transported to the liver through the hepatic portal vein before entering the systemic circulation. Thus, the drugs are subject to hepatic metabolism (first-pass effect or presystemic elimination) before they reach their site o f action. 47. Answer: B. It causes the inactivation o f drugs before they reach their site o f action.

Explanation: During first-pass effect drugs are metabolized in the liver from their active forms to their inactive forms. This leads to decreased plasma levels of the drug as well as inactivation o f the drugs before they reach their site o f action and this can cause significant clinical problems. Therefore, this effect must be counteracted if the drug is to be effective. The most common way to do this is to increase the oral dose o f the drug.

48.Answer: D. Throughout the body. Explanation: Extrahepatic metabolism means the biotransformation o f drugs that takes place in tissues other than the liver. The most common sites are portals o f entry (GI mucosa, nasal passages, lungs) and the portals o f excretion (kidneys). However, metabolism can occur throughout the body.

49.

Answer: C. Metabolism in the blood always results in loss o f activity.

Explanation: Plasma contains the enzyme esterases, which hydrolyze drugs like procaine and succinylcholine that are simple esters. Additionally plasma esterases can activate a variety of ester prodrugs in the blood. So, not all blood metabolisms result in loss o f activity.

50. Answer: E. all but C. Explanation: Microsomal oxidation, glucuronide conjugation and sulfate conjugation are the most important types o f metabolisms that occur in the intestinal mucosa.

51 .Answer: E. B and C.

Explanation:

Drugs are metabolized as they are absorbed from the intestinal mucosa into polar or inactive metabolites before entering the blood. This intestinal drug metabolism is similar to and comparable in capacity to first-pass effect, but it shows greater individual variation as it is exposed to the environment.

52. Answer: E. all o f the above Explanation: Age, disease state, diet, and exposure to chemicals and drugs are the factors which can affect the intestinal bacterial flora, and hence they may also modify drug activity.

53.Answer: A. increased bacterial growth in intestine. Explanation: Certain diseases, particularly intestinal diseases, affect intestinal flora. Ulcerative colitis, for example, promotes bacterial growth while diarrhea reduces the number o f bacteria.

54. drugs.

Answer: D. It applies to the glucuronide conjugates o f bile acids only and not to conjugates o f

Explanation: The principle o f enterohepatic circulation applies to certain glucuronide conjugates o f drugs as well.

55. Answer: E.all of the above Explanation: Certain bacterial flora converts vitamin precursors to their active form, as with vitamin k. Bacterial flora can also convert some drugs to their toxic form, as with the conversion o f the artificial sweetener cyclamate to produce cyclohexylamine, a suspected carcinogen. Intestinal bacteria produce the enzyme azoreductase, which reduces the prodrug sulfasalazine to the active anti-inflammatory aminosalicylic acid and the active antibacterial sulfapyridine. The intestinal bacteria can also secret the enzyme p-glucuronidase, which can hydrolyze glucuronide conjugate o f some drugs resulting less polar drugs that can be reabsorbed to the systemic circulation.

56.Answer: E. acetaminophen. Explanation: Acetaminophen is not degraded in the stomach.

57.

Answer: B. it does not result in significant reduction in the blood level o f drugs.

Explanation:

Drug metabolism in the nasal passages can result in significant reduction in the blood levels of drugs.

58.Answer: E. All o f the above


Explanation:

Drugs administered intravenously, intramuscularly, subcutaneously or transdermally have their first-pass metabolism in the lungs.

59. Answer: A. the metabolizing enzymes in lungs have similar specific activities but are less in amount compared to those in the liver Explanation: The total amount o f the metabolizing enzymes found in the lungs is less than in the liver; however, the specific activities o f the enzymes are comparable to those in the liver. Moreover, the lung provides second-pass metabolism for drugs leaving the liver.

60. Answer: C. many drugs get metabolized in the placenta before passing into the fetus Explanation: The placenta is not a physical or metabolic barrier to xenobiotics. Very little metabolizing enzyme activity has been demonstrated in the placenta. Drugs present in their active form in the maternal circulation likely pass unchanged into the fetal circulation. An exception to this lack of enzyme activity in the placenta is the presence o f a small amount o f aryl aromatic hydroxylase, which is inducible in pregnant women who smoke cigarettes.

61 .Answer: B. glucuronic acid conjugating activity. Explanation: In terms o f fetal metabolism, there are varying degrees o f drug-metabolizing activity depending upon a number o f factors including fetal age. A major deficiency is that o f glucuronic acid conjugating activity both in fetus and the neonate.

62.Answer: D. decrease in chloramphenicol glucuronidation Explanation: Two consequences o f decreased glucuronic acid conjugating activity in the fetus and neonate are the gray baby syndrome, resulting from decreased chloramphenicol glucuronidation, and neonatal hyperbilirubinemia, resulting from a decrease in bilirubin glucuronide formation.

63.Answer: E. all o f the above Explanation:

A variety o f strategies have been used to circumvent the rapid metabolism o f drugs, which results in increased duration o f action and thus, improve drug therapy. In some instances, these methods have provided increased site specificity as well.

64.Answer: B. the use o f different dosage forms to either avoid or compensate for rapid metabolism. Explanation: The strategies used to manage drug metabolism can be pharmaceutical, pharmacological or chemical ones. Pharmaceutical strategies involve the use o f different dosage forms to either avoid or compensate for rapid metabolism. Pharmacological strategies involve the concurrent use o f enzyme inhibitors to drug metabolism. In some cases, the concurrent use o f an additional agent does not prevent metabolism but rather prevents the toxicity caused by metabolites o f the therapeutic agents. And the chemical strategies involve the addition, deletion, or isosteric modification o f key functional groups.

65.Answer: A. a pharmaceutical strategy o f managing drug metabolism. Explanation: Sublingual tablets are useful for delivering drugs directly into the systemic circulation and bypassing hepatic first-pass metabolism. Nitroglycerin is ineffective when administered orally due to an extremely high first-pass-effect but is very effective in treating acute attacks o f angina if given sublingually.

Hepatic first-pass metabolism:


The first-pass effect (or first-pass metabolism) is a phenomenon o f drug metabolism. After a drug is swallowed, it is absorbed by the digestive system and enters the hepatic portal system. The absorbed drug is carried through the portal vein into the liver.

Oral Medication

/
* 'intestinal
Tract
The liver is responsible for metabolizing many drugs. Some drugs are so extensively metabolized by the liver that only a small amount o f unchanged drug may enter the systemic circulation, so the bioavailability o f the drug is reduced. e.g., isoproterenol, meperidine, pentazocine, morphine

Intravenous, intramuscular, sublingual routes avoid the first-pass effect.

66.Answer: D. chlorpropamide, a structurally similar compound to tolbutamide, has a much longer duration o f action; pharmacological strategy. Explanation: Pharmaceutical strategies try to make use o f different dosage forms to either avoid or compensate for rapid metabolism. For example, enteric coated formulations can protect acid sensitive drugs (such as omeprazole, erythromycin) as they pass through the acidic environment o f the stomach; transdermal patches and ointment formulations provide a continuous supply o f drug over an extended period o f time and are useful for rapidly metabolized compounds such as nitroglycerin. The use o f clavulanic acid along with (3-lactam antibiotics to inhibit p-lactamase, the enzyme secreted by certain bacteria and capable o f hydrolyzing the P-lactam ring and inactivate these antibiotics, is an example o f pharmacological strategy o f overcoming drug metabolism, where the concurrent use o f enzyme inhibitors is made use o f to decrease drug metabolism. Chemical strategy involves the addition, deletion or isomeric modification o f key functional groups. For example, tolbutamide is an oral hypoglycemic and rapidly undergoes oxidation o f its para-methyl group. Chlorpropamide is similar to tolbutamide but has a nonmetabolizable para-chloro group and as a result has a much duration o f action.

67. Answer: A. pharmacological strategy o f managing drug metabolism. Explanation: Levodopa (L-dopa), the amino acid precursor of dopamine, is used in the treatment o f parkinsonism. Unlike dopamine, L-dopa can penetrate blood-brain barrier an reach the CNS. When in brain, it is decarboxylated to dopamine. To ensure that adequate concentrations o f Ldopa reach the CNS, peripheral metabolism o f the drug must be blocked. The concurrent use o f carbidopa, a dopa carboxylase inhibitor that cannot penetrate the blood-brain barrier, prevents peripheral formation o f dopamine and allows site-specific delivery o f dopamine to the CNS. So this is a typical example o f a pharmacological strategy o f managing drug metabolism.

dopamine

levodopa

68. Answer: D. mesna reacts with toxic metabolite o f ifosfamide. Explanation: Ifosfamide is an alkylating agent that must undergo in vivo metabolism to produce active nitrogen mustard. In the process o f this metabolic activation, significant concentrations o f acrolein are produced. These acrolein molecules react with nucleophiles on renal proteins and produce hemorrhagic cystitis. To prevent this toxicity, ifosfamide is always coadministered with mesna, a sulfydryl-containing compound that reacts with and neutralizes any acrolein that is present I the kidney.

69. Answer: B. a pharmacological strategy o f enhancing the pharmacological action o f lopinavir by concurrent administration o f ritonavir.

Explanation: Ritonavir is an HIV protease inhibitor that is ineffective if used alone due to rapid oxidation by CYP3A isozymes. A combination o f a low dose o f ritonavir with a therapeutic dose o f lopinavir, results in an inhibition o f CYP3A, the establishment o f adequate levels o f lopinavir, enhancement of the pharmacological action o f lopinavir, and better therapeutic efficacy without hepatotoxicity (since at therapeutic doses, ritonavir is known to cause hepatic toxicity).

70. Answer: C. methyltestosterone is subject to rapid first-pass metabolism. Explanation: Testosterone is not orally active due to rapid oxidation o f its 17-hydroxyl group to a ketone. Addition o f a 17a-methyl group converts the labile secondary alcohol to a stable tertiary alcohol. The resulting compound, methyltestosterone, is only half as potent as testosterone; however, it is not subject to rapid first-pass metabolism and can be used orally. A similar strategy has been used to make orally active estradiol analogues.

71 .Answer: C. metaproterenol is much more potent than isoproterenol. Explanation: Isoproterenol is a potent )3-adrenergic agonist used for the relief o f bronchospasm associated with bronchial asthma. Because it is a catechol (3,4-dihydroxy-substituted benzene ring), isoproterenol is subject to rapid metabolism by catachol O-methyl transferase (COMT) and thus, has poor oral activity. Alteration o f the 3,4-dihydroxy substitution to a 3,5-dihydroxy substitution produces metaproterenol, a bronchodilator that is not susceptible to COMT, is orally active, and has a longer duration o f action than isoproterenol. This is an example o f chemical strategy o f managing drug metabolism.

72. Answer: E. all o f the above Explanation: Prodrugs are molecules that are either inactive or very weakly active and require in vivo biotransformation to produce the physiologically active drug. The advantages that can be gained form produgs include; increased water solubility, which is useful for the preparation o f ophthalmic and parenteral preparations. Another advantage is increased lipid solubility, which leads to increased oral and topical absorption, increased duration o f action, and increased palatability. Site specificity, which is useful for increasing the concentration of drug at the active site and for decreasing side effects is also one of the advantages o f prodrugs. Increased shelf life o f drug products can be obtained by the use o f prodrugs. GI irritation with some drug could also be decreased by making use of prodrugs o f the drugs.

73.Answer: C. in producing nabumetone, a prodrug with decreased GI irritation than the other NSAIDs. Explanation: Esterification is the common method o f making prodrugs o f various drugs. For example, sodium succinate esters and sodium phosphate esters have been used to make a number o f water-soluble steroidal prodrugs. Lipid-soluble esters o f estradiol, such as benzoate, valerate and cypionate, are

used to prolong estrogenic activity. Increased topical absorption of steroids is obtained by masking hydroxyl groups as esters or acetonides. Unlike other NSAIDs nabumetone does not have irritant effect on the GI tract because the intestinal mucosa are not exposed to high concentration o f the active drug during oral administration, plus it is a ketone, not an acid, and lacks any direct irritant effects.

74.Answer: B. Enalapril is less water soluble than enalaprilat.


Explanation:

Enalaprilat is a potent angiotensin-converting enzyme (ACE) inhibitor that is used for parenteral
administration, but due to its high polarity, it is orally inactive. Its monomethyl ester, enalapril, is considerably more lipophilic and, thus, provides good oral absorption. This strategy has been successfully used for a variety o f other compounds, including additional ACE inhibitors, fibric acid derivatives, ampicillin, and several cephalosporins.

75.

Answer: D. to overcome the bitter taste o f sulfisoxazole

Explanation: Antibiotics such as sulfisoxazole have a bitter taste and are not suitable for administration to young children who cannot yet swallow tablets or capsules. Esterification to produce sulfisoxazole acetyl decreases the water solubility o f the antibiotics and, thus, decreases the interaction with bitter taste receptors on the tongue. Similar strategies have been used to mask the bitter taste o f chloramphenicol and other antibiotics.

76. Answer: E. B and C Explanation: NSAIDs produce gastric irritation via two mechanisms. A direct irritant effect o f the acidic molecule and inhibition of gastroprotective prostaglandin production. The prodrugs sulindac and nabumetone produce less gastric irritation because the gastric and intestinal mucosa are not exposed to high concentrations o f active drug during oral absorption. Additionally, nabumetone is a ketone, not an acid, and lacks any direct irritant effects.

77. Answer: C. it is more potent than formaldehyde Explanation: Methenamine is the prodrug for the active drug formaldehyde, an effective urinary tract antiseptic, which due to significant toxicity cannot be given orally. Therefore, methenamine, which is stable and nontoxic at normal physiological pH but hydrolyzes to form formaldehyde in the acid urine pH, cannot be more potent than the active drug. It just results in the release o f the active drug in the desired place. In order to prevent activation before absorption, it should be given as enteric-coated formulation.

78. Answer: C. cefamandole Explanation:

Cefamandole is a second generation cephalosporin that is unstable solid dosage forms. Esterification o f the a-hydroxyl group with formic acid produces cefamandole, a stable prodrug that is hydrolyzed by plasma esterases to produce the parent antibiotic. Thus, it is developed to increase stability and shelf life. All the others are developed to deliver the parent drug to its site o f action and thus, increase site specificity and decrease the adverse effects.

79.Answer: D. diethylstilbeterol diphosphate. Explanation: Diethylstilbesterol is a synthetic estrogen that can produce undesirable, feminizing side effects when used in the treatment o f prostate cancer. These side effects can be avoided by the use o f the ester prodrug, diethylstibesterol diphosphate. This prodrug is inactive until dephosphorylated by acid phophatase, an enzyme that is highly active in prostate tumor cells. This allows for a localized release o f active compound and a decrease in systemic side effects.

80.

Answer: D. it is more stable

Explanation: Cyclophosphamide is a prodrug that is requires in vivo oxidation, followed by non enzymatic decomposition, to produce the active phosphoramide mustard. As a result, aqueous solutions o f cyclophosphamide are much stable than those o f other nitrogen mustards (i.e., mechloethamide). Mechlorethamide is highly reactive, does not require in vivo activation, and can rapidly decompose in aqueous environmental before administration.

81 .Answer: D. sometimes they may also be found in the RNA Explanation: Genes can be defined as discrete segments o f DNA that are capable o f reproducing during cell replication and that are responsible for guiding the biosynthesis o f specific proteins and enzymes.

82.Answer: E. all o f the above Explanation: Genes encode proteins involved in the absorption, transport, metabolism, and elimination o f drug molecules. Additionally, they encode proteins that serve as drug receptors. It is obvious then that a genetic disposition that would result in either an over- or under-expression o f these genes could significantly alter drug response and toxicity.

83.

Answer: E. all o f the above

Explanation: Besides the above, genetic predisposition is also a major factor.

84.Answer: E. it studies the genetics ofhum ans.

Explanation: In its simplistic form, pharmacogenetics can be defined as the use o f genetic information to select the right drug for the right patient. This area o f study primary seeks to identify the individual genetic differences and predisposition that influence drug response and safety.

85.Answer: E. all o f the above Explanation: All o f the above mentioned may be caused by genetic variations in the DNA sequence o f certain population o f individuals.

86.

Answer: D. one base pair change in every 1000 base pairs.

Explanation: The genetic variation between any two unrelated individuals is approximately one base pair change in every 1000 base pair. These changes are referred to as single nucleotide polymorphism (SNPs) and are the most common form o f genetic variation.

87.Answer: C. promoter. Explanation: The effects o f SNPs vary based upon the type and location o f the variation. An SNP located within the coding region o f a gene could produce no discernible effects, negligible effect, or a significant alteration in effects depending upon how the SNP affected the amino acid sequencing. An SNP in a splicing control region could result in the formation o f a novel protein that is either larger or smaller in size than that which is naturally occurring. An SPN in a promoter region could alter the transcription rate, resulting in either an increase or decrease in the production o f the target protein. An SNP residing outside o f any o f the above location is genetically silent and does not produce any observable effects.

88.Answer: C. III. Explanation: An SNP located within the coding region o f a gene could produce no discernible effects, negligible effect, or a significant alteration in effects depending upon how the SNP affected the amino acid sequencing. An SNP that did not alter the amino acid sequence in a protein would produce no discernible effects. An SNP that resulted in one amino acid being replaced by a similar amino acid would have a negligible effect (e.g., changing a portion o f the genetic code from AUC to GUU would result in isoleucin being replaced by valine, a similar hydrophobic amino acid). An SNP that resulted in one amino acid being replaced by one with significantly different chemical properties would cause a significant alteration o f effects. E.g., changing a portion o f genetic code from GUU to GAU would result in valine being replaced with acidic, and more hydrophilic, aspartic acid).

Cardiac Arrhythmias

Success Is a Process for Those with More Heart than Talent

1. All o f the following are included under the term cardiac arrhythmias EXCEPT: A. abnormalities in heart rate B. conduction disturbances C. abnormalities in site o f impulse origin D. narrowing o f the major epicardial coronary arteries E. none o f the above

5. Which one o f the following statements is not true about the impulse generated by the sinoatrial (SA) node? A. The SA node initiates 60-100 beats/min B. The impulses generated by the SA node trigger atrial contraction. C. The SA node is located in the left atrium. D. SA node predominates except when it is depressed or injured. E. none o f the above

2. Which o f the following statements describe the conduction system o f the heart? A. The conduction system o f the heart is comprised o f tissues that are able only to contract B. It is comprised o f tissues that can generate electrical impulses. C. It is composed o f tissues that can conduct electrical impulses. D. B and C E. none o f the above

6. At the atrioventricular (AV) node the impulses generated by the Sinoatrial (SA) node are delayed in order to: A. permit completion o f atrial contraction before ventricular contraction begins. B. block the conduction o f the impulse thus limiting it to the atrial tissues only. C. to change the number o f beats per second set by the sinoatrial node D. B and C E. none o f the above

3. The two electrical sequences that cause the heart chambers to fill with blood and contract are: A. B. C. D. E. impulse generation impulse transmission depolarization A and B B and C

7. Which one o f the following are true about latent pacemakers? . A. They contain AV junction, bundle o f His, and Purkinje fibers. B. They contain cells capable o f generating impulses C. They have a faster firing rate than the SA node D. They are not predominant unless the SA node is depressed or injured. E. A ,B and D

4. Part o f the conduction system o f the heart that serves as main pace maker o f the heart is: A. B. C. D. E. sinoatrial (SA) node atrioventricular node bundle o f His Purkinje fibers none o f the above

8. All o f the following are latent pacemakers EXCEPT: A. bundle o f his B. Purkinje fibers
C. atrioventricular node

D. sinoatrial node E. all o f the above 13. Potassium ions are pumped out of the cell as the cell rapidly completes repolarization and resumes its initial negativity.

9. When the Sinoatrial node (SA) is depressed or injured, the latent pacemakers predominate, this is known as A. B. C. D. E. overdrive suppression impulse formation impulse transmission Underdrive suppression none o f the above

14. Calcium ions enter the cell through slow channels while potassium ions exit. As the cell membranes electrical activity temporarily stabilizes, the action potential reaches a plateau.

10. Depolarization and repolarization result from changes in the electrical potential across the cell membrane, caused by the exchange o f which o f the following? A. B. C. D. E. sodium and potassium phosphate and bicarbonate magnesium and phosphorous iron and barium none o f the above

15. The cell returns to its resting state with potassium ions inside the cell and sodiumand calcium ions outside.

16. A period when a cardiac muscle cannot respond to any stimulus is:

A. B. C. D. E.

absolute refractory period rapid depolarization slow repolarization relative refractory period none o f the above

(From Questions 11-15) Direction: Match the following phases o f action potential (for a cardiac muscle) with their description mentioned in questions 11 15 A. B. C. D. E. Rapid repolarization (phase 0) Early rapid repolarization (phase 1) Plateau (phase 2) Final rapid repolarization (phase 3) Slow depolarization (phase 4) 17. Which one o f the following statements is not true? A. A cardiac cells ability to respond to stimuli increases as repolarization continues B. During the relative refractory period, which occurs during phase 3, the cell can respond to a strong stimulus C. Cells in different cardiac regions depolarize at various speeds, depending on whether fast or slow channels D. A cardiac cell can not respond to a stimuli even after it has completely repolarized
Direction: Match the following patterns in a normal ECG (Electrocardiograph) for a

11. As fast sodium channels close and potassium ions leave the cell, the cell rapidly repolarizes i.e. the cell returns to resting potential. 12. Takes place as sodium ions enter the cell through fast channels; the cell membranes electrical charge changes
from negative to positive.

cardiac muscle) with their description for questions from (18-22) A. B. C. D. E. The The The The The P wave PR interval QRS complex ST segment T wave

C. the cardiac muscle ventricular cells become pace makers D. B and C

25. All o f the following may precipitate cardiac arrhythmias EXCEPT: A. heart disease such as infection, valvular heart diseases, ischemic heart disease B. myocardial infarction C. decreased sympathetic tone D. hyperkalemia E. hypokalemia

18. The wave that shows phase 3 o f the action potential-ventricular repolarization

19. The wave that reflects ventricular depolarization is 26. Abnormal impulse formation, abnormal impulse conduction, or a combination of both may give rise to arrhythmias. Abnormal impulse formation may result from: A. B. C. D. E. depressed automaticity increased automaticity depolarization and triggered activity B and C all o f the above

20. The segment that represents phase o f 2 o f the action potential-the absolute refractory period

21. The wave that represents the spread o f the impulse from the atria through the purkinje fibers

22. The wave that reflects atrial depolarization

27. Which one o f the following occurs in tachycardia (increased heart beat)? A. B. C. D. E. depressed automaticity depolarization and triggered activity A and B increased automaticity none o f the above

23. Arrhythmias are generally classified by: A. the type o f action potential generated B. severity C. origin D. none

24. Supraventricular arrhythmias stem from: A. enhanced automaticity o f the SA node or another pace maker region B. an ectopic (abnormal) pacemaker triggers a ventricular contraction before the SA node fires

28. One cause o f abnormal impulse conduction (in cardiac arrhythmias) is reentry. Which o f the following statements are true about reentry? A. It occurs when an impulse is rerouted through certain regions in which it has already traveled. B. The rerouted impulse depolarizes the same tissue more than once, producing an additional impulse.

C. It occurs when an impulse does not reach a cardiac tissue and the tissue generates an impulse by itself. D. A and B E. All o f the above

E. Syncope

29. The conditions, which must exist for reentry to occur are; A. slow conduction area for depolarization to occur B. markedly shortened refractoriness C. unidirectional conduction D. all o f the above E. None o f the above

33. A patient with cardiac arrhythmia had serum calcium level of4.00m Eq/L; which o f the following changes are most likely to be present in the ECG o f the patient as compared to a normal ECG? A. B. C. D. E. prolonged QT intervals flattened T waves inverted T waves all o f the above E. none o f the above

30. Reentry may occur in all o f the following EXCEPT: A. B. C. D. sinoatrial node (SA) atrioventricular node (AV) in all cardiac muscle cells accessories pathways o f the conducting system located in the atria and ventricles. E. None o f the above

34. The treatment objectives for cardiac arrthymias include which o f the following? A. terminate or suppress the arrhythmia if it causes hemodynamic compromise or disturbing symptoms. B. maintain adequate cardiac output and tissue perfusion C. correct or maintain fluid balance D. A, B and C E. increase heart beat above 100 beats per second regardless o f the type o f arrthymias

31. One sign of cardiac arrhythmias is anxiety and confusion. This occurs due to A. reduced brain perfusion B. the effect o f the electrical impulses generated in the heart on brain cells. C. the overall response o f the body to the cardiac arrhythmias D. B and C E. All o f the above

35. Which o f the following are Class 1A antiarrythmic drugs EXCEPT: A. B. C. D. E. Quinidine Procainamide Disopyramide All o f the above none o f the above

32. All o f the following are signs and symptoms that typically accompany arrhythmias EXCEPT: A. B. C. D. Chest pain Skin pallor or cyanosis Palpitations Increased urinary output

36. Proacinamide is used more frequently than Quinidine in the treatment o f arrhythmia because: A. Procainamide can be administered intravenously

B. Procainamide can be administered in sustained-release oral preparations C. Procainamide can be useful in the treatment o f more than one type of arrhythmia as compared to Quinidine. D. B and C E. none o f the above

B. C. D. E.

Propafenone Moricizine Phenytoin None o f the above

41. A class IC drug reserved for patients with refractory life-threatening ventricular arrhythmias who do not have coronary artery disease is: A. B. C. D. E. Propafenone Moricizine Flecainide Quinidine None o f the above

37. Which o f the following antiarrythmic drugs result in strong depression o f conduction? A. B. C. D. E. Flecainide Mexiletine Moricizine Both A and C Both B and C

42. The mechanism o f action o f Class I antiarrhythmic agents is: A. They block the rapid inward sodium current and thereby slow down the rate o f the rise o f the cardiac tissues action potential B. They enhance the entrance of sodium to its channels. C. -They block the inward flow o f calcium D. They enhance the inward flow o f calcium E. none o f the above

38. An anti-epileptic drug commonly used in the treatment o f digitalisinduced ventricular and supraventicular arrhythmias is: A. B. C. D. E. Phenobarbitone Phenytoin Carbamazepine Valproic acid none o f the above

39. A drug closely related to lidocaine, most commonly used in the treatment of patients in whom a Class 1 agent has failed is A. B. C. D. E. Tocainide Phenytoin Mexiletine Quinidine none o f the above

43. Which o f the following statements is not true about Class I antiarrhythmic agents? A. Class IA drugs moderately reduce the depolarization rate and prolong repolarization (refractory period) B. Class IB drugs shorten repolarization (refractory period); they also weakly affect the repolarization rate. C. Class I agents are sub classified based on their structural similarity D. Class 1 C drugs depresses depolarization but have a negligible effect on the duration o f repolarization or refractoriness.

40. An antiarrythmic agent which has the properties o f all three class I antiarrythmic drugs is: A. Flecainide

E. None o f the above

D. 20-25 pg/mL E. None o f the above

44. Which o f the following statements is not true about the dosage and administration o f procainamide? A. The usual effective dose is 500 1000 mg B. In rapid Intravenous administration 1-1.5 g is given at a rate o f 20-50 mg/min. C. For acute therapy, intramuscular therapy is preferred. D. Procainamide is available for oral, intravenous, or intramuscular use. E. None o f the above

48. Which o f the following drugs can be used in the management o f quinidine induced ventricular tachyarrhythmias: A. B. C. D. E. catecholamines glucagon sodium lactate lidocaine A, B and C

45. Which one o f the following Class 1A drugs is given only orally? A. B. C. D. E. Procainamide Quinidine Disopyramide Lidocaine All o f the above

46. The most important risk associated with the use o f antiarrhythmic drug therapy is Proarrythmia. Proarrythmia is:

49. A patient suffering from atrial tachyarrhytmias was taking quinidine. The physician in charge observed the increased ventricular response and the increased AV node conduction. To counteract the response he ordered administration of a drug that slows AV conduction .Unfortunately the nurse gave the patient an overdose o f the drug and there were signs o f ventricular and supraventricular arrhythmias. The physician started intravenous administration o f phenytoin and the ventricular and supraventricular arrhythmias subsided. The drug, which was given to counteract the increased ventricular response and the increased AV node conduction induced by quinidine, is: A. B. C. D. E. Mexiletine Propafenone Moricizine Digoxin none o f the above

A. the ability to cause arrhythmia B. inability to correct the arrhythmia for which they are given C. an increased incidence of cardiovascular adverse effects. D. decreasing the heartbeat more than normal. E. None o f the above

50. Anticoagulants may be administered before quinidine therapy begins, because

47. The therapeutic range for serum levels o f quinidine is: A. 2-6 jig/mL B. 1-5 pg/mL C. 6-lO^ig/mL

They enhance the therapeutic effects o f quinidine B. They reduce the elimination of quinidine

C. They prevent or minimize the embolism that may occur D. They enhance the gastrointestinal absorption o f quinidine. E. none o f the above

B. C. D. E.

diarrhea urinary retention A and C All o f the above

51. Cinchonism due to high serum concentration o f quinidine is manifested by A. B. C. D. E. tinnitus hearing loss blurred vision gastrointestinal (GI) disturbances All o f the above

55. A class IB anti-arrhythmic drug with few untoward cardiovascular effects, known for its central nervous system reactions is: A. B. C. D. E. Mexiletine Phenytoin Lidocaine Tocainide None o f the above

52. Which o f the following statements are true about procainamide? A. Procainamide may cause systemic lupus erythematosus B. Procainamide is contraindicated in patients with hypersensitivity to procaine and related drugs. C. Hypotension may occur with rapid intravenous administration. D. GI adverse effects are less common than quinidine therapy. E. allof the above

56. A class IB antiarrhythmic drug contraindicated in patients with hypersensitivity to lidocaine and related drugs is: A. B. C. D. E. Phenytoin Mexiletine Tocainide Flecainide none o f the above

53. Procainamide toxicity may cause all o f the following EXCEPT: A. SA node block B. ventricular tachycardia C. enhanced conduction in all regions o f heart D. asystole E. all o f the above

57. An antiarrhythmic drug contraindicated in patients with sinus bradycardia or heart block and its chronic use may lead to vestibular and a cerebellar effect is: A. B. C. D. E. Phenytoin Mexiletine Tocainide Flecainide none o f the above

54. A patient with ventricular arrhythmia was taking disopyramide. Which o f the following effects are likely to be seen in the patient taking disopyramide? A. dry mouth

58. The hematological effects o f phenytoin include which o f the following? A. B. C. D. agranulocystosis megaloblastic anemia leukopenia thrombocytopenia

E. all of the above

63. Phenytoin decreases the therapeutic efficacy o f disopyramide. The possible mechanism is: A. Phenytoin decreases the absorption o f disopyramide B. Phenytoin inhibits the metabolism o f disopyramide C. Phenytoin enhances the metabolism o f disopyramide D. Phenytoin decreases the metabolism o f disopyramide E. none o f the above

59. Treatment o f arrythmia with which o f the following drugs requires prior anticoagulant therapy? A. B. C. D. E. Disopyramide and Mexiletine Flecainide and tocainide Propafenone and Moricizine Procainamide and quinidine none of the above

60. All o f the following drugs antagonize the activity o f quinidine EXCEPT: A. B. C. D. E. Phenytoin Rifamipicin Barbiturates Nitroglycerin none o f the above

64. Which one o f the following is not true about the drug interactions o f phenytoin? A. Phenytoin may increase the cardiodeppressant effects o f lidocaine. B. Phenytoin accelerates disopyramide metabolism. C. Carbamazepine may enhance phenytoin metabolism and thus reduce plasma phenytoin levels and therapeutic efficacy D. Phenytoin deceases the metabolism o f carbamazepine E. Phenytoin may reduce plasma Mexiletine levels and may decrease therapeutic efficacy.

61. All o f the following drugs increase the plasma concentration o f quinidine EXCEPT: A. B. C. D. E. Nifedipine Antacids Sodium bicarbonate Sodium acetazolamide one o f the above

62. The effect o f cimetidine and amiodarone on plasma level o f procainamide is: A. They increase the plasma concentration o f procainamide. B. They decrease the plasma concentration o f procainamide. C. They do not have any effect on the plasma concentration of procainamide. D. B and C E. none o f the above

65. All o f the following are class II * antiarrhythmic drugs EXCEPT: A. B. C. D. E. Esmolol Propranolol Acebutolol Amiodarone none o f the above

66. Which o f the following is not the action o f class II antiarrhythmic drugs? A. They reduce sympathetic stimulation o f the heart

B. They decrease the conduction o f impulse through the AV node C. They increase the sinus rhythm D. They lengthen the refractory period E. none o f the above

charge ordered propranolol for the patient. The possible reason for the continuation o f the antiarrhythmic therapy with propranolol is: A. Esmolol was not effective in controlling the supraventricular tachycardia. B. The adverse effects o f esmolol could have been troublesome. C. Esmolol is for short-term use only and should be replaced by a longacting antiarrhythmic drug once the patients heart stabilizes. D. A and B E. none o f the above

67. The blocking effects o f propranolol may lead to all o f the following EXCEPT: A. B. C. D. E. hypotension hypertension left ventricular failure cardiac arrest none o f the above

68. Which o f the following statements are not true about propranolol? j

71. Which o f the following adverse effects are common to esmolol and propranolol? A. B. C. D. E. hypotension dizziness headache vomiting all of the above

A. It is contraindicated in patientsjwith sinus bradycardia, severe CHF| (congestive heart failure) or asthma B. It may depress AV node conduction and ventricular pacemaker activity, resulting in AV block or asyst6le C. Sudden withdrawal o f propranolol may lead to acute MI, arrhythmias, or angina in cardiac patients i D. The dose is normally lOOOmgiday E. none o f the above

72. Severe vasoconstriction can occur if propranolol is given concomitantly with: A. B. C. D. E. Epinephrine Digitalis Dilitazem Quinidine None o f the above

69. A class II antiarrhythmic drug), with a short half life that has been used!in the treatment o f supraventricular tachycardia and to control ventricular response to atrial fibrillation or flitter during or after surgery is: A. B. C. D. E. Esmolol Propranolol Metaprolol Acebutolol none o f the above

73. Which o f the following statements best describes the interaction o f esmolol with morphine? A. Morphine decreases the plasma levels o f esmolol B. Morphine does not have any effect on the plasma levels o f esmolol C. Morphine raises the plasma level of esmolol. D. Morphine decreases the plasma ~ levels o f esmolol if given by the oral

70. A patient with supraventricular tachycardia was taking esmolol. After his heart stabilized the physician in

route, and vice versa if given by the intravenous route. E. None of the above

fibrillation, that have not responded to other agents is: A. B. C. D. E. Satolol Ibutilide Dofetilide Bretylium none o f the above

74. The property o f satolol that distinguishes it from other adrenergic blockers and classified as a type III antiarrhythmic drug rather than a type II agent is that: A. It antagonizes both (31 and (3 2 adrenergic receptors B. It prolongs the phase 3 o f action potential (in cardiac muscles) C. It has different therapeutic effects D. It has different clinical and safety profile E. none o f the above

78. Which o f the following statements are true about the mechanism o f action o f class III antiarrhythmic drugs? A. they prolong the refractory period B. they prolong the action potential C. they increase the force of myocardial contractility D. they increase the conduction time E. A and B

75. Which o f the following statements is not true about amiodarone? A. It is given to control malignant ventricular arrhythmias B. It is recommended in the treatment o f ventricular fibrillation and pulse less ventricular tachycardia. C. It is used prophylactically against both atrial and ventricular tachycardia and fibrillation. D. It is associated with more arrhythmic deaths in patients after an MI (myocardial infarction) E. none o f the above

19. Which one of the following class III antiarrhythmic drugs is not available for oral administration? A. B. C. D. E. Ibutilide Dofetilide Satolol Amiodarone none o f the above

80. Which o f the following statements are NOT true about dofetilide? A. It is only available for oral administration. B. Dofetilide should not be given to those patients with creatinine clearance values less than 20 mL/min C. Dofetilide can be given to outpatients D. All o f the above E. None o f the above

76. All of the following are class III antiarrhythmic agents EXCEPT: A. B. C. D. E. Amiodarone Bretylium Ibutilide Adenosine Dofetilide

77. A class 111 antiarrhythmic drug used in the treatment o f life-threatening ventricular arrhythmias, including ventricular tachycardia and ventricular

81. A nurse wanted to give Dofetilide tablets to a patient who had atrial fibrillation. The creatinine clearance o f

88. The main mechanism o f class IV antiarrhythmics is: A. They inhibit action potential generation in all cardiac muscle cells. B. They inhibit AV node conduction by depressing the SA and AV nodes C. They inhibit cardiac muscle cell contractility. D. They selectively inhibit the sodium channels. E. none o f the above

D. Felodipine E. A and B

92. The mechanism o f action o f atropine, which enables it to be used as an antiarrhythmic in the treatment o f sinus bradycardia is: A. It blocks vagal effects on the SA node, thus blocking conduction of through the AV node and increasing the heart rate B. It enhances effects o f the vagus nerve on the heart C. It increases the pace maker rhythm D. It blocks the vagal effects on the SA node, thus promoting conduction through the AV node and increasing the heart rate E. none o f the above

89. The most commonly used class IV antiarrhythmic drugs are: A. B. C. D. E. Verapamil and Diltiazem Nifedipine and nicardipine Amlodipine and felodipine Bepridil and felodipine none o f the above

93. Artopine belongs to which class o f antiarrhymics? A. B. C. D. E. Class IA Class HI Class IB Class 11 It is unclassified

90. Which o f the following statements are WRONG about verapamil and Diltiazem? A. They are contraindicated in patients with AV block; left ventricular dysfunction, concomitant intravenous U-blockers; and atrial fibrillation. B. They have positive chronotropic effect C. They should be used cautiously in patients with CHF, MI and hepatic or renal impairment D. Constipation and nausea have been reported with verapamil E. none o f the above

94. A patient with a problem o f sinus bradycardia was admitted to an intensive care unit o f a hospital. The physician in charge ordered administration of atropine by intravenous push. When the first dose o f 0.4 mg was given, the bradycardia worsened but the symptom subsided with subsequent doses o f the drug. What could be the possible reason for bradycardia, which occurred at the beginning o f the antiarrhythmic therapy? A. The metabolite o f atropine has the reverse pharmacological activity and this phenomenon is result o f that.

91. Diltiazem may inhibit the metabolism of: A. Theophyline B. Cyclosporine C. Verapamil

B. It is a reflex bradycardia, which resulted from incomplete suppression o f vagal impulses. C. The patients heart responded the opposite way D. A and C E. none o f the above

95. Which o f the following statements is not true about adenosine? A. It is indicated for the conversion o f acute supraventricular tachycardia to normal sinus rhythm. B. It is a naturally occurring nucleoside, which is normally present in all cells o f the body C. It enhances conduction through the AV node D. It restores normal sinus rhythm in patients with PSVTs E. none o f the above

Cardiac Arrhythmias

Explanation: . The atrioventricular (AV) node, situated in the lower interatrial septum, the impulses are delayed briefly to permit completion of atrial contraction before ventricular contraction begins.

Answers Cardiac Arrhythmias


1. Answer: D. Narrowing o f the major epicardial coronary arteries Explanation: Cardiac arrhythmias are deviations from the normal heart rate baet pattern. They include abnormalities o f impulse formation, such as heart rate, rhythm, or site o f impulse origin, which disrupt the normal sequence o f atrial and ventricular activation. Narrowing o f the major epicardial coronary arteries is known as coronary artery disease.

2. Answer: D. B and C Explanation: Conduction system o f the heart comprises tissues that can generate and transmit electrical impulses signaling the heart to contract.

3. Answer: D. A and B Explanation: Impulse generation, the first sequence, takes place when an electrical impulse is generated automatically. Impulse transmission, the second sequence, occurs once the impulse has been generated, signaling the heart to contract.

4. Answer: A. Sinoatrial (SA) node


Explanation:

The Sinoatrial (SA) node, in the wall o f the right atrium, contains cells that spontaneously initiate an action potential.

5. Answer: C. The SA node is located in the left atrium Explanation: The sinoatrial node is located in the right atrium. The impulses generated by the SA node trigger atrial contraction. SA node predominates except when it is depressed or injured. In case o f injuries or when the SA node is not properly working other parts o f the conducting system take charge.

6. Answer:A. Permit completion of atrial contraction before ventricular contraction begins.

17. Answer: D. A cardiac cell can not respond to a stimuli even after it has completely repolarized Explanation: A cardiac cells ability to respond to stimuli increases as repolarization continues. During the relative refractory period, which occurs during phase 3, the cell can respond to a strong stimulus. Cells in different cardiac regions depolarize at various speeds, depending on whether fast or slow channels (i.e when fast channels predominate depolarization occurs quickly and when Slow channels predominate and depolarization occurs slowly) When a cardiac cell has been completely repolarized, it can again respond fully to stimuli.

18.Answer- [E] 19.Answer-[C] 20.Answer-[D] 21.Answer-[B] 22.Answer-[A]

23.Answer:

C. Origin

Explanation: Arrhythmias are generally classified by origin (i.e., supraventricular or ventricular).

24.Answer: A. Enhanced automaticity o f the SA node or another pace maker region Explanation: Supraventricular arrhythmias stem from enhanced automaticity o f the SA node (or another pace maker region).An ectopic (abnormal) pacemaker triggers a ventricular contraction before the SA node fires in ventricular arrhythmias.Cardiac muscle cells do not have the capacity to generate pace maker beats.

25.Answer: C. Decreased sympathetic tone Explanation: Arrhythmias may result from various conditions, including: - An infarction may cause death o f pacemaker cells or conducting tissue -Heart disease such as infection, valvular heart diseases, ischemic heart disease may disrupt the conduction network - Increased sympathetic tone (e.g due to stress, anxiety or smoking) - Decreased parasympathetic tone A. Hypothyroidism, hyperthyroidism, hyperkalemia and hypokalemia or other
electrolyte disturbance.

26. Answer: E. All o f the above Explanation: All o f the above may result in abnormal impulse formation.

27.Answer: D. Increased automaticity Explanation: Increased automaticity causes tachycardia.

28.Answer: D. A and B Explanation: Reentry occurs when an impulse is rercjuted through certain regions in which it has already traveled. Thus, the rerouted impulse depolarizes the same tissue more than once, producing an additional impulse.

29. Answer: D. All o f the above. Explanation: For reentry to occur, the following con ditions must exist: 1. Markedly shortened refractoriness or slow conduction area that allows an adequate delay so that depolarization occurs. (If the refra tory period is short, the probability of a cardiac cell to respond to the stimuli again increases) 2. Unidirectional conduction (if the im pulse is conducted in one direction the probability that one cardiac cell is stimulated repeated y increases).

30. Answer: C. In all cardiac muscle cells Explanation: Reentry sites include the sinoatrial nod e (SA), the Atrioventricular node (AV) as well as various accessory pathways in the atria and v< elntricles. Cardiac muscle is not involved in impulse conduction, therefore, reentry cannot occur in the cardiac muscle cells. 31 .Answer: A. Reduced brain perfusion Explanation: Arrthymias may decrease cardiac output, reduce blood pressure, and disrupt perfusion o f vital organs. Anxiety and confusion may result from decreased brain perfusion.

32. Answer: D. Increased urinary output Explanation:

Arrthymias may decrease cardiac output, reduce blood pressure, and disrupt perfusion o f vital organs. Kidney is one o f the vital organs and decreased perfusion o f vital organs results in decreased urinary output (urinary output is a directly related to kidney perfusion).

33. Answer: D. All o f the above Explanation: A serum calcium level below 4.5 mEq/L signifies hypocalcaemia. Prolonged QT intervals, Flattened T waves or inverted T waves signal hypocalcaemia.

34.Answer: D. A, B and C Explanation: Increasing the heart rate above the maximum does not have any use in the management o f cardiac arrthymias (the normal heart beat is 60-100 beats per second).

35.Answer: D. all o f the above Explanation: Quinidine, Procainamide and disopyramide are Class IA antiarrythmic drugs.

36.Answer: D. B and C Explanation: Procainamide is used for the same arrhythmias for which Quinidine is given. It is used more frequently than Quinidine because it can be administered intravenously and in sustained-release oral preparations. Quinidine poses added concern when used intravenously because o f increased cardiovascular effects (i.e. hypotension, syncope, myocardial depression).

37.Answer:

D. Both A and C

Explanation: Flecainide, Moricizine and propafenone are Class I C drugs. Use o f all Class IC drugs result in strong depression o f conduction in the cardiac tissues. Mexiletine is a class I B drug and the drugs in this class result in moderate depression o f conduction.

38.Answer: B. Phenytoin Explanation: Phenytoin is anti-epileptic drug commonly used in the treatment o f digitalis-induced ventricular and supraventicular arrhythmias.

39.Answer:

C. Mexiletine

Explanation: Mexiletine is closely related to lidocaine, structurally with modifications. It is commonly used to treat patients in whom a Class I agent has failed and it is moderately effective in suppressing ventricular ectopy.

40.Answer:

C. Moricizine

Explanation: Moricizine is a difficult antiarrhythmic agent to classify because it has properties o f all three class I antiarrhythmic groups. Because it prolongs the QRS interval like other Class IC agents, it is classified as a class IC agent.

41.Answer: C. Flecainide Explanation: Flecainide suppresses premature ventricular arrhythmias and ventricular tachycardia; it may be used to treat some arrhythmias that are refractory to other agents. Flecainide is reserved for patients with refractory life-threatening ventricular arrhythmias who do not have coronary artery disease.

42.Answer: A. They block the rapid inward sodium current and thereby slow down the rate of the rise o f the cardiac tissues action potential

Explanation: All class I agents work by blocking the rapid inward sodium current and thereby slow down the rate o f rise o f the cardiac tissues action potential.

43.Answer:

C. Class I agents are sub classified based on their structural similarity

Explanation: Class I agents are not classified based on their structural similarity. They are classified based up on the differences in EP (electrophysiological) effects.

44.Answer: C. For acute therapy, intramuscular therapy is preferred Explanation: For acute therapy, intravenous route is preferred.

45.Answer: C. Disopyramide Explanation: Disopyramide is available in oral form. Usually, 300-400mg is given as a loading dose to attain an effective plasma level rapidly. For maintenance therapy, doses o f 400-800mg/day are given in

four doses every 6 hours (non-sustained capsule) or in two doses every 12 hours (sustained release capsule)

46. Answer: A. The ability to cause arrhythmia Explanation: Proarrythmia is the ability to cause arrhythmia (e.g. Brady arrhythmias and ventricular tachyarrhythmias)

47. Answer: A. 2-6 |j.g/mL Explanation: Serum levels above the maximum result in symptoms of acute toxicity. Toxicity may cause acute cardiac effects, such as pronounced slowing o f conduction in all heart regions; this in turn, may lead to SA block or arrest, ventricular tachycardia, or asystole.

48.Answer: A, B and C Explanation: Lidocaine is not used in the management o f quinidine induced tachyarrhytmias.

49.Answer: D. Digoxin Explanation: In Patients receiving quinidine for atrial tachyarrhytmias, vagolytic effects may increase impulse conduction at the AV node, resulting in an accelerated ventricular response. To prevent this, agents that slow AV nodal conduction (e.g. verapamil, Digoxin) may be administered. Over dose o f Digoxin results in ventricular and supraventricular arrhythmias and phenytoin is the drug o f choice in digitalis-induced arrhythmias.

50.

Answer: C. They prevent or minimize the embolism that may occur

Explanation: Embolism (formation o f blood clots within the coronary arteries) may occur upon restoration of normal sinus rhythm after prolonged atrial fibrillation. To prevent or minimize this complication, anticoagulants may be administered before quinidine therapy begins.

51 .Answer: E. all o f the above Explanation: Quinidine may cause cinchonism at high serum concentrations, manifested by tinnitus, hearing loss, blurred vision, and gastrointestinal (GI) disturbances. In severe cases, nausea, vomiting, diarrhea, headache, confusion, delirium, photophobia and psychosis occur.

52. Answer: E. All o f the above Explanation: All the given choices are true about the drug procainamide.

53.Answer: C. Enhanced conduction in all regions o f heart Explanation: Procainamide toxicity may cause acute cardiac effects (e.g Pronounced slowing of conduction in all regions o f heart), which, in turn, may lead to SA node block or arrest, ventricular tachycardia, or asystole.

54.Answer: D. A and C Explanation: Anticholinergic effects o f dysopyramide include dry mouth, constipation, urinary retention, and blurred vision.

55.Answer: C. Lidocaine Explanation: Generally Lidocaine has few cardiovascular adverse effects. Central nervous system (CNS) reactions are the most pronounced adverse effects o f lidocaine. These reactions may range from light-headedness and restlessness to confusion, tremor, stupor, and convulsions.

56.Answer: C. Tocainide Explanation: Tocainide is contraindicated in patients with hypersensitivity to lidocaine and relate drugs.

57.

Answer: A. Phenytoin

Explanation: Phenytoin is contraindicated in patients with bradycardia or heart block. Chronic use may lead to vestibular and cerebellar effects, behavioral changes, GI distress, gingival hyperplasia, megablastic anemia, and osteomalalcia.

58.Answer: E. all the above Explanation: Hematological reactions include Agranulocystosis, Megaloblastic anemia, Leukopenia, Thrombocytopenia, and pancytopenia.

59.Answer: D. Procainamide and Quinidine

Explanation: In antiarrhythmic therapy with procainamide and quinidine, embolism may occur upon restoration o f normal sinus rhythm after prolonged atrial fibrillation. An anticoagulant is frequently administered before procainamide or quinidine therapy begins to prevent this complication.

60.Answer: D. Nitroglycerin Explanation: Phenytoin, Rifamipicin and barbiturates may antagonize the activity o f quinidine. Nitroglycerin does not antagonize the activity o f quinidine but it worsens the orthostatic hypertension if given concomitantly with quinidine.

61.Answer: A. Nifedipine Explanation: Antacids, sodium bicarbonate and sodium acetazolamide may increase quinidine levels possibly resulting in toxicity. Nifedipine may reduce plasma quinidine levels.

62.

Answer: A. they increase the plasma concentration o f procainamide

Explanation: Cimetidine and amiodarone may increase plasma procainamide levels, possibly leading to drug toxicity.

63. Answer: C. Phenytoin enchances the metabolism o f disopyramide. Explanation: Phenytoin accelerates the metabolism o f disopyramide, possibly reducing the therapeutic efficacy.

64. Answer: D. Phenytoin decreases the metabolism o f Carbamazepine. Explanation: Carbamazepine may enhance phenytoin metabolism and thus reduce plasma phenytoin levels and therapeutic efficacy. Phenytoin has the same effect on carbamazepine.

65.Answer: D. Amiodarone Explanation: Class II antiarrhythmic drugs are the p-blockers Esmolol, Propranolol, and Acebutolol (EEsmolol, P- Propranolol, A- Acebutolol which can be abbreviated as EPA).Amiodarone is a class-III antiarrhythmic drug.

66 .Answer: C. They increase the sinus rhythm

Explanation: Class II antiarrhythmics reduce sympathetic stimulation o f the heart, decreasing impulse conduction through the AV node and lengthening the refractory period. Additionally, this class o f antiarrhythmics slow the sinus rhythm without significantly changing the QT or QRS intervals, resulting in a reduced heart rate and a decrease in myocardial oxygen demand.

67. Answer: B. Hypertension Explanation: The (3-blocking effects o f propranolol may lead to marked Hypotension, exacerbation o f CHF (congestive heart failure) and left ventricular failure, or cardiac arrest.

68.Answer: D. The dose is normally lOOOmg/day Explanation: For oral therapy, 10-80mg/day is given in three or four doses.

69.Answer: A. Esmolol Explanation: Esmolol is used to treat supraventricular tachycardia: it possesses a very short ( 9 minutes ) half life and has been used to control the ventricular response to atrial fibrillation or flutter during or after surgery.

70. Answer:. C. Esmolol is for short-term use only and should be replaced by a long-acting antiarrhythmic drug once the patients heart stabilizes. Explanation: Esmolol is for short-term use only and should be replaced by a long-acting antiarrhythmic drug once the patients heart stabilizes.

71 .Answer: E. all o f the above Explanation: Hypotension, Dizziness, Headache, nausea, vomiting are common to both esmolol and propranolol.

72.Answer: A. Epinephrine Explanation: Severe vasoconstriction may occur with concomitant epinephrine administration.

73.

Answer: C. Morphine raises the plasma level o f esmolol

Explanation: Morphine raises the plasma level o f esmolol.

74. Answer: B. It prolongs the phase 3 o f action potential(in cardiac muscles). Explanation: Satolol is a P-adrenergic blocker.lt prolongs the phase 3 o f action potential in cardiac muscles. This property distinguishes it from other p-adrenergic blockers and it is the reason why it is classified as a type III antiarrhythmic drug rather than a type II agent.

75.Answer: infarction).

D. It is associated with more arrhythmic deaths in patients after an Ml (myocardial

Explanation: Unlike other agents with the exception o f the p-adrenergic blockers, amiodarone has been shown to reduce arrhythmic deaths in patients after an M I .

76.Answer: D. Adenosine Explanation: Adenosine is not a class III antiarrhythmic drug. It is categorized as unclassified antiarrhythmic drug. The class III antiarrhythmic agents can be abbreviated as ABIDS ( A-Amiodarone, BBretylium, 1- Ibutilide, D- Dofetilide , S-sotalol).

77.Answer: D. Bretylium Explanation: Bretylium is used in the treatment o f life-threatening ventricular arrhythmias, including ventricular tachycardia and ventricular, that has not responded to other agents.

78.Answer: E. A and B Explanation: Class III antiarrhythmic drugs prolong the refractory period and action potential; they have no effect on myocardial contractility or conduction time.

79.Answer: A. Ibutilide Explanation: Ibutilide and bretylium are used for parenteral therapy only.

80.Answer: C. Dofetilide can be given to outpatients

Explanation: Dofetilide is only available for oral administration and it should be initiated only in a hospital setting with trained personnel and equipment necessary to provide continuous cardiac monitoring during initiation o f therapy. It should not be given to those patients with creatinine clearance values less than 20 mL/min.

81 .Answer: B. 0.25 mg twice daily Explanation: A normal dose o f dofetilide for the conversion o f recent onset atrial fibrillation to normal sinus rhythm is 0.5mg twice daily for patients with creatinine clearance values greater than 60 mL/min. 0.25 mg for those with creatinine values o f 40-60 mL/min, 0.125mg for those with creatinine clearance values o f 20-40mL/min.

82.Answer: D. 400 mg/day Explanation: Life threatening pulmonary toxicity may occur during amiodarone therapy, especially in patients receiving more than 400 mg/day. Baseline as well as routine pulmonary function tests reveal relevant pulmonary changes.

83.Answer: D. Hypotension and Brady arrhythmias Explanation: In amiodarone therapy, blood pressure and heart rhythm must be monitored for Hypotension and Brady arrhythmias .

84.Answer: C. Amiodarone has a half-life o f up to 60 hours Explanation: Amiodarone has an extremely long half-life (up to 60 hours). Therapeutic response may be delayed for weeks after oral therapy begins; adverse reactions may persist up to 4 months after therapy ends.

85.Answer:C. sotalol Explanation: The side effects described above are directly related to p -blockade and prolongation o f repolarization and the drug is sotalol.

86.Answer:
F Y n lan atin rv

C. Ibutilide

Cardiac Arrhythmias

93.Answer: E. It is u n classified Explanation:

Atropine does not belong to any o f the existing classes o f antiarrhymics (i.e. it is unclassified)

87.Answer: D . A m iod aron e has been reported to h ave num erous drug-drug interactions am ong all ca tegories o f drugs

Explanation: Amiodarone has been reported to have numerous drug-drug interactions among all categories o f drugs. To avoid the development of a significant drug-drug interaction a thorough patient medication profile should be carried out for each patient having amiodarone therapy initiated, as well as each time a patient currently receiving amiodarone is given an additional drug.

88.Answer: B . T hey inhibit A V n od e conduction b y depressing th e SA and A V n o d es

Explanation: Class IV antiarrhythmics are calcium channel blockers. They inhibit AV node conduction by depressing the SA and AV nodes, where calcium channels predominate.

89.Answer: A . Verapam il and D iltiazem Explanation: V erapam il and D ilita zem are the calciu m channel block ers m ost com m o n ly used as antiarrhythm ics. O ther calcium channel blockers include nicardipine, N ifed ip in e, bepridil, am lodip in e, and felod ip in e, but th ese agents have prim arily been used in the treatm ent o f angina and hypertension.

90.Answer: B. T h ey h ave p o sitiv e chronotropic effect Explanation: Verapamil and Diltiazem have negative chronotropic (a decrease in heart rate) effect, thus they must be used cautiously in patients who have slow heart rates or who are receiving digitalis glycosides.

91 .Answer: E . A and B Explanation: Dilitazem and verapamil inhibit the metabolism o f Theophyline and Cyclosporine. They require dosage administration if concomitantly used.

92.Answer: D . It b lo ck s the vagal e ffe c ts on the SA node,thus prom oting conduction through the A V node and increasing the heart rate

Explanation: Atropine is therapeutic for symptomatic sinus bradycardia and junctional rhythm. An anticholinergic atropine blocks vagal effects (a nerve which has inhibitory effect on the heart rate) on the SA node and increasing conduction through the AV node and increasing the heart rate.

93.Answer: E . It is unclassified Explanation: Atropine does not belong to any o f the existing classes o f antiarrhymics (i.e. it is unclassified)

94.Answer: B . It is a reflex bradycardia, w hich resulted from incom plete suppression o f vagal im pulses Explanation: When the patient took the initial doses o f atropine, reflex bradycardia might have resulted from incomplete suppression o f vagal impulses. Normally effect o f the vagus nerve is to slow down the heart rate, if there is incomplete suppression o f this effect, bradycardia may result from reflex action.

95.Answer: C . It enhances conduction th ro u g h the A V node Explanation: Adenosine is a naturally occurring nucleoside, which is normally present in all cells o f body. It has been shown to: -Slow conduction through the AV nods - Interrupt re-entry pathways through the AV node - Restore normal sinus rhythm in patiqnts with paroxysmal supraventricular tachycardia.

Clinical Toxicology

^>e>ive 0

Hatred is toxic waste in the river o f life.

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1. Which one o f the following is not covered under clinical toxicology? A. Accidental poisoning B. Intentional overdose o f medications C. Intentional overdoses o f drugs of abuse D. The effect o f industrial chemicals on the environment.

B. To increase elimination o f the poisoning agent C. To treat the hypoglycemia associated with poisoning D. A and B

6. A poisoning case has a depressed mental status. Obtaining a history o f exposure for the patient includes all o f the following Except: A. Establishing the identity o f the substance. B. Neurological examination C. Cardiopulmonary examination D. Gastrointestinal decontamination E. Interview with the patient

2. A TOME (toxicologic, occupational medicine and environmental series) provides information on: A. B. C. D. Prescription drugs Poison control centers Industrial chemicals Drugs o f abuse

3. Which one o f the following is not a printed publication that provides information related to poisoning? A. Poison index B. Poisoning and toxicology compendium C. Diagnosis and treatment o f human poisoning D. Toxicologic emergencies

7. Which one o f the following is not true about toxicology laboratory tests? A. all possible intoxicating agents can be screened B. critically ill patients supportive treatment is needed beforelaboratory results o f the toxicology screen are available C. They occasionally help guide therapy. D. None

4. The mandatory first steps in the initial management o f drug ingestions are: A. Evaluating and supporting vital functions B. Identifying the agent responsible for the poisoning. C. Laboratory assessment D. Obtaining past medical history o f the patient

8. A person known to be a narcotic addict was admitted to an emergency ward o f a hospital. The patient had a depressed mental status. In addition to other supportive measures, an IV injection o f a drug was given to the patient and the respiratory depression improved. The drug is most probably: A. B. C. D. Morphine Methadone Naloxone Codeine

5. The purpose o f administering 50% dextrose (IV) in poisoning cases with depressed mental status is: A. To remove the poisoning agent

9. For which o f the following drugs are quantitative levels (in the blood) o f the drug

important to guide therapy (in case o f poisoning by the drugs)? A. B. C. D. E. Acetaminophen Vitamin C Vitamin B Lithium A and D 13. Which one o f the following is NOT TRUE about syrup o f ipecac A. When administered to poisoning cases the onset o f emesis usually occurs within 30 minutes B. Prolonged emesis occurs after administration o f the syrup to poisoned patients (> 1 hour) C. There is evidence that syrup o f ipecac is beneficial even after delayed administration D. None.

10. Which o f the following is contraindicated in a patient exposed to sulphuric acid? A. Removing the patient clothing B. Irrigating the exposed areas with water C. Neutralization o f the acid bums with sodium bicarbonate D. A and B

14. Gastric lavage is used in patients who are: A. Not alert or have a diminished gag reflex B. Seen early following massive ingestions. C. admitted for ingestion o f acids, alkalis, or hydrocarbons D. At risk for GI perforation. E. A and B

11 .All o f the following are GIT decontamination procedures EXCEPT: A. Removal o f the ingested substance by emesis B. Removal o f the toxic substance by gastric lavage. C. Use o f activated charcoal to bind the toxic substance D. Use o f cathartics to hasten removal o f the toxic substance from the GIT. E. By inducing diuresis

15.In gastric lavage a cuffed endotracheal tube is in place to: A. Suck the poison out o f the stomach B. Protect the airways from the ingested poison. C. Push the gastric contents down to the small intestine. D. A and C

12. Induction o f emesis is contraindicated in cases poisoned by which o f the following agents: A. Patients who have ingested a strong alkali or strong acid B. Patients with compromised airway protective reflexes(coma and convulsions) C. Patients with central nervous system depression or seizures D. Patients who have ingested some type o f hydrocarbon or petroleum distillates. E. All o f the above

16. Which one o f the following is a correct order o f the procedures in gastric lavage? A. Protection o f the airway-Aspiration o f GIT contents- instillation and aspiration o f 250 ml o f water or saline B. Aspiration o f GIT contents-250 ml o f water or saline is instilled and aspirated- protect the airway -

C. Protect the airway- 250 ml o f water or saline is instilled and aspiratedAspiration o f GIT contents D. None

procedure, which employs an isoosmotic cathartic solution and shown to be effective under certain conditions particularly when, activated charcoal lacks efficacy is: A. B. C. D. Whole bowel irrigation Emesis Whole bowel irrigation Gastric lavage

] 7. Activated charcoal is available as a colloidal dispersion with: A. B. C. D. E. Water Sorbitol Methanol Strong acids A and B

21 .Multiple doses o f any cathartics should be avoided because: A. It may enhance the GIT absorption o f the poison B. They may interact with some poisons C. They may cause electrolyte imbalance/and dehydration D. A and B

18. Which one o f the following is not TRUE about activated charcoal when used in the management o f poisoning? A. Ethanol, iron, lithium, methanol, strong acids are strongly adsorbed on activated charcoal. B. The adult dose o f activated charcoal is 25-100 g. C. Constipation is commonly observed after administration o f a single dose o f activated charcoal. D. Bowel obstruction may occur when multiple doses o f activated charcoal are given.

22. Which one o f the following is NOT TRUE about forced diuresis and urinary pH manipulation in the management of poisoning? A. They may be used to enhance the elimination o f substances, when their elimination is mainly through the renal route. B. They may be used in the elimination o f substances, which have small volume o f distribution with little protein binding. C. Alkaline diuresis facilitates the excretion o f weak acids D. Alkaline diuresis facilitates the excretion o f weak bases

19.Toxic ingestions with drugs having an enterohepatic circulation (e.g. carbmazepine, theophylline and Phenobarbital) generally require that charcoal be readministered every 6 hours in order to: A. Prevent reabsorption during recirculation B. Facilitate their metabolism by interfering with the function o f liver enzymes C. To induce vomiting after repeated administration. D. B and C

23.A child ingested many aspirin tablets. As a management strategy, the child was given 50 mEq o f sodium bicarbonate in 1L o f 0.25 %-0. 45 % normal saline. But the child developed complications, and was referred to an intensive care unit for close monitoring.

The probable complications o f the alkaline diuresis may include all o f the following EXCEPT: A. Metabolic acidosis B. Hypernatremia C. Hyperosmolarity D. Fluid overload

C. Inhibition o f kidneys metabolic capacity. D. B and C

24. All o f the following are true about dialysis EXCEPT: A. Substances that are removed by hemodialysis generally are lipid soluble. B. Most o f the Substances removed by hemodialysis have low molecular weight and small volume o f distribution. C. It is indicated for life threatening ingestions o f ethylene glycol, methanol or paraquat. D. B and C

27.A patient who overdoses on acetaminophen is admitted to an emergency ward o f a hospital. The patient has ingested 8 grams o f acetaminophen tabs. If the patient came to the hospital 1 hour after ingestion, what is the treatment recommended? A. GI decontamination with syrup o f ipecac or gastric lavage B. Antidotal therapy with Nacetylcysteine. C. Alkaline diuresis D. B and C

28.In acetaminophen poisoning which phase of the clinical presentation is asymptomatic? A. B. C. D. Phase Phase Phase B and 1 II III C

25. Which o f the following statements are not TRUE about hemoperfusion? A. It is a technique in which anticoagulated blood is passed through (perfused) a column containing activated charcoal or resin particles. B. It clears substances from the blood more rapidly than hemodialysis. C. It corrects electrolyte abnormalities associated with poisoning D. It is more effective in removing ethanol or methanol. E. C and D

29.During antidotal therapy with in Acetaminophen poisoning, the purpose of including metaclopramide is: A. To counteract severe nausea secondary to N-acetylcysteine therapy B. To increase the rate o f Nacetylcysteine absorption. C. To synergize the antidotal activity o f N-acety Icy steine D. A and B

26. Acetaminophen can produce fatal hepatotoxicity in untreated patients through: A. Generation o f a toxic metabolite B. Inhibition o f livers capacity to metabolize endogenous compounds.

30.Laboratory data for a patient exposed to ethylene glycol may include all o f the following EXCEPT: A. Severe metabolic acidosis B. Calcium oxalate crystals in urine

C. Hypercalcemia D. None

1 A. It inhibits alcohol dehydrogenase B. It saturates alcohol dehydrogenase thus it inhibits the formation o f toxic metabolites from ethylene glycol. C. It decreases the absorption o f ethylene glycol D. A and C

31 .Which one o f the following represents the correct sequence in the hepatic metabolism o f ethylene glycol? A. Ethylene glycol -Glycoaldehydeglycolic acid -G lyoxylic acid Oxalic acid B. Ethylene glycol - Glyoxylic acidglycolic acid- GlycoaldehydeOxalic acid C. Ethylene glycol - Oxalic acidglycolic acid- GlycoaldehydeGlyoxylic acid D. Ethylene glycol - Oxalic acidGlycoaldehyde- Glyoxylic acidglycolic acid.

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i

35. The most toxic metabolite o f glycolic acid is: A. B. C. D. Carbonic acid Sulphuric acid Oxalic acid Glycoaldehyde.

32. A chemistry laboratory technician drank 2 liters o f ethylene glycol. If he was brought to emergency department after 20 hours with any prior treatment, what are the likely symptoms in the clinical presentation o f the patient? A. B. C. D. Bradycardia Pulmonary edema Pneumonitis All except A

36. Which o f the following is a potent inhibitor o f alcohol dehydrogenase that can prevent the formation o f toxic metabolite from methanol or ethylene glycol. A. B. C. D. Pyridoxine Sodium bicarbonate Fomepizole IV ethanol

37.Pyridoxine and thiamine are used in the management o f ethylene glycol poisoning because: A. They convert glyoxylic acid to nonoxalate metabolites B. They inhibit the metabolism of ethylene glycol to glycoaldehyde. C. They minimize the adverse effects o f concurrently administered drugs D. B and C

33.A man working in a chemical industry was poisoned with ethylene glycol. The laboratory data shows that the serum level o f ethylene glycol was 0.5 mg/dL What treatment do you suggest in the management o f the poisoned patient? A. B. C. D. Gastric lavage within 30 minutes IV ethanol Activated charcoal B and C

38.In the management o f ethylene glycol poisoning, hemodialysis is indicated when: A. Ethylene glycol levels are more than 50mg/dl B. Congestive heart failure is present C. Renal failure is present D. Severe acidosis is present.

34. Intravenous ethanol is used in the treatment o f ethylene glycol poisoning because:

E. All o f the above

the situation as a mild over-anticoagulation. What is the suggested treatment? A. Stopping heparin administration and restarting therapy at a reduced dose after 1-2 hours. B. 60 mg o f protamine is recommended. C. 150 mg o f protamine should be administered in any 10-minute period. D. B and C

39.The laboratory data for methanol may reveal all o f the following EXCEPT: A. B. C. D. Metabolic alkalosis Hyperglycemia. Metabolic acidosis Hyperamylasemia

40.Folic acid is administered at 1 mg/Kg(maximum 50 mg) IV every 4 hours for 6 doses. The possible mechanism o f folic acid in the management o f methanol poisoning is : A. It increases the metabolism o f formate B. It inhibits the formation o f formic acid C. It inhibits the enzyme alcohol dehydrogenase D. None

43. Which o f the following statements are wrong about warfarin? I. The protein binding is 99 %. II. The mean half-life is 35 hours III. Warfarin has poor absorption when administered through the oral route. A. B. C. D. E. i f l only is correct if III only is correct i f l and II are correct if II and III are correct if l, II and III are correct

41 .A patient was admitted to an emergency department o f a hospital because o f methanol poisoning. Laboratory data showed that the serum level o f methanol was 60mg/dL. The patient had severe acidosis, which was resistant to the administration o f sodium bicarbonate. Moreover, the patient had kidney failure. What is the most probable mode o f management for the patient? A. B. C. D. Administration o f activated charcoal Hemodialysis Induction o f emesis IV ethanol

44.The mechanism by which protamine counteracts the action o f heparin is: A. Protamine combines with heparin and neutralizes it B. Protamine induces the synthesis o f vitamin K C. Protamine induces the metabolism of heparin D. B and C

45. Which one o f the following statements is wrong about protamine? A. One milligram o f protamine neutralizes 100 units o f heparin. B. The maximum dose o f protamine is 50mg in any 10-minute period. C. Protamine is a basic drug. D. Protamine is an acidic drug.

42.A patient with coronary disease was taking IV heparin to prevent the threat o f clot formation. Unfortunately a clumsy nurse gave an overdose o f an anticoagulant and the patient showed some signs of bleeding. The physician in charge described

46. Which one o f the following is TRUE about tricyclic antidepressants? i A. Blood level monitoring o f tricyclic antidepressants does not correlate well with clinical sings and symptoms o f toxicity. B. Electrocardiographic monitoring is a better guide for assessing the severity o f ingestion in tricyclic antidepressants. C. Tricyclic antidepressants undergo enterobepatic recirculation D. All o f the above 49.Physostigmine may be used to reverse the severe anticholinergic toxicity due to tricyclic antidepressant poisoning, but the use o f this antidote is declining because: A. It is not effective B. It may cause asystole as an adverse effect. C. It interacts with the other drugs used in the management of tricyclic antidepressants. D. A and C

47. As part o f the treatment modality for TCA poisoning phenytoin was given to the poisoned in order to control the seizures. After measuring the blood pressure, the physician in charge reduced the dose of phenytoin to 50mg/min. Not satisfied with the response after reducing the dose o f the drug, the physician in charge replaced phenytoin by fosphenytoin. What could be the reason for reducing the dose of phenytoin and finally replacing it with fosphenytoin? A. Phenytoin has a hypotensive adverse effect when given in doses exceeding 25mg/min, but fosphenytoin has less hypotensive effect. B. Phenytoin is less effective in controlling seizures. C. Fosphenytoin in addition to controlling seizures it neutralizes the acidic environment created by the poisoning. D. B and C

50.The laboratory data recommended for selective serotonin reuptake inhibitors poisoning is: A. B. C. D. ECG monitoring Blood level monitoring WBC counts Platelet count

51 .Which o f the following are not selective serotonin reuptake inhibitors? A. B. C. D. E. Fluoxetine Sertaline Diazepam Florazepam C and D

48. Which o f the following drugs are used to control seizures as part o f the management o f tricyclic antidepressants? A. B. C. D. Phenytoin Benzodiazepines Physostigmine Sodium bicarbonate

52.A psychiatric patient with a problem of depression took an overdose of a psychotropic drug. The symptoms o f the patient include mydriasis, urinary retention, tachycardia, pulmonary edema and confusion. The most likely cause o f the poisoning is: A. B. C. D. Amitriptyline Fluoxetine Sertaline Diazepam

53.In the treatment o f tricyclic antidepressant poisoning ipecac syrup is not recommended because: A. It has intolerable adverse effect B. It induces vomiting C. Patients may quickly become comatose and increase the risk o f aspiration. A. A and B

D. Flumazenil has a long elimination half-life. E. C&D

57. Epinephrine should be used cautiously in the treatment o f p-blocker overdoses bccause: A. Unopposed a-Receptor stimulation may lead to profound hypertension B. It may aggravate the condition o f poisoning. C. It may aggravate the hypoglycemia associated with the poisoning. D. It decreases the metabolism o f pblocker

54.The importance o f alkalinization with sodium bicarbonate (1-2 mEq/Kg) in the poisoning by tricyclic anti depressants is: A. It maintains an arterial pH o f 7.45 to 7.55 and this decreases the fraction o f absorbed toxins B. Alkalinization reverses some o f the cardiac abnormalities C. To control seizures D. To reverse the anticholinergic toxicity associated with tricyclic antidepressant poisoning.

58.A clinical symptom common to overdose o f all calcium channel blockers is: A. B. C. D. Bradycardia Hypotension Pulmonary edema Atrioventricular block

55. Which one o f the following is not true about benzodiazepine poisonining? A. The clinical presentation includes drowsiness, ataxia and confusion B. Supportive treatment includes gastric emptying, activated charcoal, and a cathartic C. Benzodiazepines are hepatically metabolized D. Seizure is one symptom o f benzodiazepine poisonining

59.Bradycardia and Atrioventricular block are commonly seen with ingestions of: A. B. C. D. E. Verapamil Nifedipine Diltiazem Isradpine A and C

56. Which one o f the following is WRONG about flumazenil? A. It is given 0.2 mg IV over 30 seconds in the treatment o f Benzodiazepine poisoning B. It is contraindicated in mixed overdose patients. C. It is indicated in tricyclic antidepressant poisoning.

60.1n the treatment o f calcium channel blocker poisoning calcium chloride is given for the management of: A. B. C. D. E. Hypotension Bradycardia Heart block All o f the above None o f the above

61 .Cocaine is an alkaloid obtained from: A. B. C. D. Digitalis lanata Papaver somniferum Erthroxylon coca Cephalis ipecacunha

vomiting and seizures. The treatment should include: ! j j A. B. C. D. E. Amyl nitrite Sodium nitrite Oxygen All of the above A and B only

62. Which one o f the following is not TRUE about cocaine? A. Cocaine is well absorbed following oral administration. B. Cocaine is metabolized in the liver C. Cocaine has poor absorption following inhalational administration. D. In cocaine overdoses, death may result from respiratory failure, myocardial infarction, or cardiac arrest. 66.Sodium nitrite is included in a cyanide antidote kit because it: A. Converts hemoglobin to methemoglobin B. It binds to the cyanide ion. C. It neutralizes the acidosis induced by the cyanide. D. B and C

67.For equilibrium between serum digoxin level and myocardial binding, it requires approximately: A. B. C. D. 0.5-0.8 hr 1-2 hr 6-8 hrs 2-3 hrs

63.Which one o f the following drugs is used in the supportive treatment for the hypertension in the management o f cocainei overdose? A. B. C. D. Diazepam Labetolol Flouxetine Calcium chloride

68.In mild cases o f digoxin poisoning confusion, anorexia, are common. In more severe cases which o f the following is common. A. B. C. D. Hypertension Hypoglycemia Cardiac dysrhythmias Seizures

64. Which one o f the following is NOT TRUE about corrosives? A. The available forms include strong acids or alkalis. B. Corrosives are well absorbed following oral and inhalational administration. C. These compounds produce burns on contact. D. all o f the above

69.Supportive therapy for digoxin poisoning includes: A. Managing hyperkalemia or hypokalemia B. Inotropic support C. Removal by inducing emesis D. A and B

65.A man working in a nail polish industry was exposed to traces o f cyanide through inhalation. He had symptoms o f nausea,

70.In the treatment o f digoxin over dosage by digoxin-specific Fab antibodies, the formula used to determine the dosage is: A. Dose(vials)={ingested digoxin (mg)}/0.5 B. Dose= {ingested digoxin (mg) X 0.8 }/0.6 C. Dose = {ingested digoxin (mg) X0.8J/0.9 D. Dose ={ingested digoxin (mg) X 0.5}/0.8

C. Calcium D. Sodium

74.The purpose o f using sodium carbonate in the treatment o f potassium over dosage is A. To increase serum pH and cause an intracellular shift o f potassium. B. To increase renal excretion of potassium. C. To enhance the metabolism o f potassium D. B and C

71 .Which one of the following is not true about magnesium? A. Magnesium is found intracellulary B. Magnesium is eliminated renally. C. Magnesium containing cathartics have been reported to produce hypermagnesmia D. Magnesium poisoning is classified as mild if the its plasma concentration is more than lOmEq/L

75.A hypertensive patient was taking a diuretic regularly .One day the patient took an overdose o f the drug. He was taken to a hospital and the laboratory tests showed severe hypokalemia. The physician in charge ordered IV KC1 for the patient. Unfortunately the nurse in charge administered an overdose o f the potassium, and the patient started showing symptoms o f poisoning. As part o f the treatment plan for the potassium overdose, the patient was given 6 units o f regular insulin. The insulin is given because: A. It decreases the hypoglycemia associated with potassium poisoning. B. It shifts potassium from the extra cellular fluids in to cells C. It stimulates the metabolism o f potassium D. It is given as a supportive therapy; it doesnt affect the concentration o f potassium E. in serum.

72. In the treatment o f magnesium poisoning 10 % calcium chloride is given in order to: A. Enhance the elimination o f magnesium. B. Temporarily antagonize the cardiac effects o f magnesium. C. Stimulate the metabolism o f magnesium o f magnesium ion. D. A and C

73.An intracellular cation, whose serum values depends on the pH o f serum and over dosage o f this cation may result in cardiac irritabilities, and peripheral weakness. The cation is A. Magnesium B. Potassium

76.The mechanism o f action o f cation exchange resins in the treatment of potassium overdosage is: A. They bind potassium in exchange for another cation B. They nullify the charge o f potassium in their porous body.

C. They increase the shift of potassium from extra cellular fluid into cells. D. They absorb potassium in their porous body. I 77.Sodium polystyrene sulfonate (Kayexelate) is given in a dose o f 15 g/60 mL with: A. 50ml o f dextrose B. 50 % ethanol C. 100 ml o f sterile water D. 23.5 % sorbitol

B. Pyridoxine C. Deferoxime D. Sodium bicarbonate

82.The laboratory data for iron poisoning patients should include: A. B. C. D. E. Serum Fe levels Liver function tests Hemoglobin Hematocrit All o f the above

78.Toxicity o f iron is based on the amount o f elemental iron ingested. Which one of the following represents a wrong pair o f a salt and the amount of free elemental iron? A. Sulfate salt- 20 % elemental iron B. Fumarate salt-13% elemental iron C. Gluconate salt-12% elemental iron D. None

83. Which one of the following is NOT TRUE regarding the treatment o f iron poisoning? A. For ingestions greater than 30mg/Kg, ipecac emesis may be used within few minutes o f exposure. B. Gastric lavage using sodium bicarbonate is very effective procedure. C. Whole-bowel irrigation is used for large ingestions D. None

79.Iron is absorbed in the: A. B. C. D. Duodenum Jejunum Colon A and B 84. The maximum dose o f Deferoxime in the treatment o f poisoning is: A. B. C. D. 6 g/day 5g/day 2g/day 1g/day

80.The phase o f clinical presentation in iron poisoning with nausea, vomiting, and hypotension is: A. B. C. D. Phase I Phase II Phase III None

85.A cofactor that reverses Isoniazidinduced seizures is: A. B. C. D. Thiamine NADH Pyridoxine NADPH

81 .A chelator used in the treatment o f iron poisoning is : A. Dimercaprol 86. Emesis should not be used in the treatment o f isoniazid poisoning because:

A. It is ineffective B. Patients at high risk o f developing seizures C. The drug is corrosive, thus it damages the GI mucosa. D. A and C

91 .Which one o f the following represents the range o f concentration in mild lithium toxicity? A. 0.6-1.2m Eq/L B. 1.5-2.5m Eq/L C. 2.5-3.0 mEq/L D. More than 3 mEq/L

87.The laboratory data in isoniazid poisoning shows all o f the following EXCEPT: A. B. C. D. Alkalosis Hypoglycemia Mild hyperkalemia Leukocytosis

92.A patient with manic-depressive disorder took an overdose o f lithium. The plasma concentration o f lithium in the patient was 4 mEq/L .The symptoms likely to be present in the patient are: A. B. C. D. E. Delirium Slurred speech Coma Hypertherima AH except B

88. A child playing with paint drank half a litre o f the paint. The symptoms o f the ingestion include nausea, vomiting, abdominal pain and convulsion. The most likely cause o f the poisoning is: A. B. C. D. Iron Lead Potassium Magnesium

93.In the treatment o f lithium poisoning by hemodialysis, lithium levels may rise after dialysis due to: A. Rebound effect B. Storage o f lithium outside the blood C. Decreased elimination by the kidneys D. B and C

89.The half-life of lead in the human body is: A. B. C. D. 2 3 4 5 months months months months

90. Which of the following are used in the treatment o f lead poisoning? A. B. C. D. E. Edetate calcium disodium Dimercaprol Deferoxamine Cation exchage resins A and B

94.A cancer patient was taking morphine to relieve the pain associated with the malignancy. Hopeless o f his condition the patient took an overdose o f morphine intentionally. When he arrived at the hospital he had symptoms of respiratory depression and bradycardia. Naloxone was given in a dose o f 0.3 mg every 5 minutes. All the symptoms o f poisoning were relieved after he took naloxone, but there was a problem o f resedation long after the occurrence o f poisoning. The most likely cause o f the resedation is : A. The patient may have taken a long acting opiod

B. The patient may have taken a sustained release dosage form o f an opiod C. Naloxone is not effective in relieving the symptoms o f opiod poisoning D. A and B

D. 40-60mg/dL-plasma concentration o f salicylates results in tinnitus.

95,Organophosphates are usually used as: A. B. C. D. E. Pesticides Chemical warfare agents Drugs for human use. A and B None

99.A 30-year-old man was admitted to an emergency ward o f a hospital for aspirin poisoning (after 2 hours o f ingestion). The concentration o f aspirin in his blood was 70mg/dL. The patient had a problem o f GI bleeding, increased prothrombin time, nausea and vomiting. The main treatment for the patient includes: A. Alkaline diuresis B. Hemodialysis C. Induction o f Emesis with syrup o f ipecac. D. None

96.The clinical presentation o f organophosphate poisoning includes A. Excessive anticholinergic stimulation B. Excessive cholinergic stimulation C. Excessive parasympathetic nervous system stimulation. D. None 100. Which o f the following is not TRUE about snake bite? A. Onset o f symptomatolgy depends on the species of snake and the patients underlying medical conditions. B. More severe envenomation can lead to severe tissue injury, and shock. C. Bradycardia is one o f the most common clinical symptoms. D. Pain and edema become evident at the site o f snakebite.

97.The antidote used to reverse the peripheral muscarinic effects of organophosphate is: A. B. C. D. Naloxone Atropine Nalmefene Dimercaprol

101. Which one o f the following is correct regarding the supportive treatment o f snakebites? A. Move the patient away from the striking distance o f the snake. B. Constrictive clothing, rings and watches should be removed. C. Surgical intervention may be necessary for severe cases D. All o f the above

98. Which one of the following is WRONG? A. Salicylates have poor absorption when given by the oral route, so they should be given parentally. B. In overdoses situations, the half life o f salicylates may be prolonged to more than 20 hours. C. The half-life o f salicylates is 6-12 hours at lower doses.

102. Horse-derived antivenom that has been reported to produce allergic reaction is: A. Antivenin polyvalent B. Crotalidae polyvalent immune Fab C. Tetanus antitoxin D. None

103. In unstable theophylline poisoned patient who are in status epilepticus, the recommended technique of decontamination is: A. Activated charcoal B. Induction o f emesis with Syrup o f ipecac C. Charcoal hemoperfusion D. Alkaline diuresis

Answers

Clinical Toxicology

1. Answer: D. The effect o f industrial chemicals on the environment Explanation: Clinical toxicology focuses on the effects o f substances in patients by accidental or intentional overdoses o f medications, drugs o f abuse, household products, or various other chemicals.

2. Answer: C. Industrial chemicals Explanation: TOMES (toxicologic, occupational medicine and environmental series) provides information on Industrial chemicals

3. Answer: A. Poison index Explanation: Poison index is a computerized CD-ROM database that is updated regularly and is a primary source for poison control centers.

4. Answer: A. Evaluating and supporting vital functions

Explanation: Evaluating and supporting vital functions(airway, breathing and circulation) are the mandatory first steps in the initial management o f drug ingestions.

5. Answer: C. To treat the hypoglycemia associated with poisoning Explanation: The purpose of administering 50% dextrose (IV) in poisoning cases with depressed mental status is to treat the hypoglycemia associated with poisoning.

6. Answer: E. Interview with the patient Explanation: since the patient had a depressed mental status obtaining information through interview is impossible

7. Answer: A. AH possible intoxicating agents can be screened Explanation: All possible intoxicating agents cannot be screened by toxicology laboratory tests.

8. Answer: C. Naloxone

Explanation: Morphine, Methadone, Codeine are narcotics (opiod analgesics). Naloxone is an opiod antagonist which is used in the treatment o f opiod overdosage.

9. Answer: E. A and D

Explanation: For Acetaminophen and lithium the treatment depends up on their blood level, so the quantitative levels (in the blood) o f the drug important to guide therapy. Vitamins B and C are not harmful,if taken more than the prescribed.

10. Answer: C. Neutralization o f the acid bums with sodium bicarbonate Explanation: Neutralization o f the acid bums with sodium bicarbonate will produce an exothermic chemical reaction, thereby exacerbating the patients condition.

11 .Answer: E. By inducing diuresis Explanation: Inducing diuresis is not a GIT decontamination procedure. It is a procedure, which enhances removal the toxic substance through the kidneys.

12.Answer: E. All o f the above

Explanation: Induction o f emesis is contraindicated in Patients who have ingested a strong alkali or strong acid ;Patients with compromised airway protective (coma and convulsions); Patients with centra] nervous system depression ;and Patients who have ingested some type o f hydrocarbon or petroleum distillates.

13. Answer: C. There is evidence that syrup o f ipecac is beneficial even after delayed administration Explanation: Data suggest that there are no benefits following delayed administration after one hour o f poisoning.

14.Answer: E. A and B Explanation: Gastric lavage is used in patients who have ingested acids, alkalis, or hydrocarbons. It should not also be used in patients who are at risk o f GI perforation (the toxic substance may be absorbed through the perforation).

15. Answer: B. Protect the airways from the ingested poison. Explanation: In gastric lavage a cuffed endotracheal tube is in place to protect the airways from the ingested poison

16. Answer: A. Protection o f the airway-Aspiration o f GIT contents- instillation and aspiration o f 250 ml o f water or saline Explanation: Lavage is performed after a Cuffed endotracheal tube is in place to protect the airway. After aspiration o f the gastric contents. 250-300ml o f tap water or saline is instilled and then aspirated. The sequence is repeated until the return is continuously clear.

17.Answer: E. A and B Explanation: Activated charcoal is available as a colloidal dispersion with water or sorbitol.

18.Answer: A. Ethanol, iron, lithium, methanol, strong acids are strongly adsorbed on activated charcoal Explanation: Ethanol, iron, lithium, methanol, strong acids are not adsorbed onto activated charcoal.

19. Answer: A. Prevent reabsorption during recirculation Explanation: Toxic ingestions with drugs having an enterohepatic circulation generally require that charcoal be readministered every 6 hours in order to prevent reabsorption during recirculation.

20.Answer: C. Whole bowel irrigation Explanation: A procedure, which employs an isoosmotic cathartic solution and shown to be effective under certain conditions particularly when, activated charcoal lacks efficacy is whole bowel irrigation.

21 .Answer: C. They may cause electrolyte imbalance/and dehydration Explanation: Multiple doses o f any cathartics should be avoided because they may cause electrolyte imbalance/and dehydration.

22. Answer: D. Alkaline diuresis facilitates the excretion o f weak bases Explanation: Alkaline diuresis promotes the ionization o f the weak acids, thereby preventing reabsorption by the kidney, which facilitates the excretion o f these weak acids.

23.Answer: A. Metabolic acidosis

Explanation: Complications o f alkaline diuresis include metabolic alkalosis, Hypernatremia, Hyperosmolarity and Fluid overload.

24.Answer: A. Substances that are removed by hemodialysis generally are lipid soluble Explanation: Substances that are removed by hemodialysis generally are water-soluble, have a small volume o f distribution ( < 0.5 L/Kg ), have a low molecular weight (< 500 Daltons), and are not significantly bound to proteins. It is indicated for life threatening ingestions o f ethylene glycol, methanol or paraquat. 25.Answer: E. C and D Explanation: Hemoperfusion does not correct electrolyte abnormalities associated with poisoning. It is less effective in removing ethanol or methanol.

26.

Answer: A. Generation o f a toxic metabolite

Explanation: Acetaminophen can produce fatal hepatotoxicity in untreated patients through generation o f a toxic metabolite 27. Answer: A.GI decontamination with syrup o f ipecac or gastric lavage Explanation: Patients with levels greater than 150, 70, or 40mg/mL at 4, 8, 12 hours after ingestion require antidotal therapy with N-acetylcysteine. Adult patients who have ingested more than 7 grams or children more than 1OOmg/Kg require treatment. The recommended treatment is GI decontamination with syrup o f ipecac or gastric lavage for patients presenting within 2 hours o f ingestion.

28.Answer: B. Phase II Explanation: Phase I ( 12-24 hours post ingestion )-nausea, vomiting, anorexia, and, diaphoresis Phase II (1-4 days post ingestion) - asymptomatic Phase III (2-3 days in untreated patients)- nausea, abdominal pain, coma, death

29.Answer. A and B Explanation: During antidotal therapy in acetaminophen poisoning, the purpose o f including metaclopramide is to increase the rate o f N-acetylcysteine absorption and to counteract severe nausea secondary to N-acetylcysteine therapy.

30.Answer: C. Hypercalcemia Explanation: Calcium reacts with oxalic acid (metabolic product o f ethylene glycol) to form Calcium oxalate crystals. The calcium in our body gets depleted and this results in hypocalcaemia.

31 .Answer: A. Ethylene glycol -Glycoaldehyde-glycolic acid -Glycoxylic acid -O xalic acid Explanation: The correct sequence in the hepatic metabolism o f ethylene glycol is: Ethylene glycol -Glycoaldehyde-glycolic acid -G lyoxylic acid -O xalic acid

32.Answer: D. All except A Explanation: The symptoms which occur in 12-24 hours post ingestion include tachycardia, pulmonary edema, Pneumonitis.

33.Answer: A.Gastric lavage within 30 minutes Explanation: IV ethanol is indicated if the serum level o f ethylene glycol is greater than 20 mg/dl. Activated charcoal does not adsorb ethylene glycol.

34.Answer: B. It saturates alcohol dehydrogenase thus it inhibits the formation o f toxic metabolites from ethylene glycol. Explanation: Intravenous ethanol is used in the treatment o f ethylene glycol poisoning because it saturates alcohol dehydrogenase thus it inhibits the formation o f toxic metabolites from ethylene glycol.

35.Answer: C. Oxalic acid

Explanation: The most toxic metabolite o f glycolic acid is Oxalic acid. Carbonic acid, Sulphuric acid, and Glycoaldehyde are not metabolites o f glycolic acid.

36.Answer: C. Fomepizole Explanation: Fomepizole is a potent inhibitor o f alcohol dehydrogenase that can prevent the formation o f toxic metabolite from methanol or ethylene glycol.

37.Answer: A. They convert glyoxylic acid to nonoxalate metabolites Explanation: Pyridoxine and thiamine are used in the management o f ethylene glycol poisoning because they convert glyoxylic acid to nonoxalate metabolites 38. Answer: E. All o f the above

Explanation: Indications for hemodialysis include ethylene glycol levels are more than 50mg/dl, Congestive heart failure, renal failure or severe acidosis.

39.Answer: A. Metabolic alkalosis

Explanation: It is not Metabolic alkalosis but Metabolic acidosis. The formic acid is the cause of the metabolic acidosis.

40. Answer: A. It increases the metabolism o f formate Explanation: The possible mechanism o f folic acid in the management of methanol poisoning is by increasing the metabolism o f formate.

41.Answer: B. Hemodialysis Explanation: Hemodialysis is used for methanol levels o f greater than 50 mg/dL, severe resistant acidosis, renal failure, or visual symptoms.

42.Answer: A. Stopping heparin administration and restarting therapy at a reduced dose after 1-2 hours Explanation: The treatment recommended for mild over-anticoagulation is stopping heparin administration and restarting therapy at a reduced dose after 1-2 hours. Severe overdoses may require the administration o f protamine. The maximum dose o f protamine is 50 mg in any 10minute period.

43.Answer: B. Ill is correct Explanation: Warfarin is well absorbed when administered through the oral route 44. Answer: A.Protamine combines with heparin and neutralizes it

Explanation: The mechanism by which protamine counteracts the action o f heparin is protamine combines with heparin and neutralizes it.

45. Answer: D. Protamine is an acidic drug. Explanation: Protamine is a basic drug not an acidic drug.

46. Answer: D. All o f the above Explanation: Blood level monitoring o f tricyclic antidepressants does not correlate well with clinical sings and symptoms o f toxicity. Electrocardiographic monitoring is a better guide for assessing the severity o f ingestion in tricyclic antidepressants. They undergo enterohepatic recirculation.

47. Answer: A. Phenytoin has a hypotensive adverse effect when given in doses exceeding 25mg/min, but fosphenytoin has less hypotensive effect Explanation: Phenytoin has a hypotensive adverse effect when given in doses exceeding 25mg/min, but fosphenytoin has less hypotensive effect.

48.Answer: E. A and B Explanation: Phenytoin and Benzodiazepines are used to control seizures as part o f the management o f tricyclic antidepressants.

49.Answer: B.It may cause asystole as an adverse effect Explanation: Physostigmine may be used to reverse the severe anticholinergic toxicity due to tricyclic antidepressant poisoning, but the use o f this antidote is declining because it may cause asystole as an adverse effect.

50.

Answer: A .ECG monitoring

Explanation: The laboratory data recommended for selective serotonin reuptake inhibitors poisoning is ECG monitoring. Blood level monitoring is not recommended (the toxic effect o f the drug does not correlate with its blood level). WBC and Platelet counts are not recommended.

51 .Answer: E. C and D Explanation: Diazepam and Florazepam are not selective serotonin reuptake inhibitors. They are benzodiazepines.

52.Answer: A. Amitriptyline Explanation: Amitriptyline is a tricyclic antidepressant. The symptoms o f the patient are same with symptoms o f tricyclic antidepressant poisoning. 53. Answer: C. Patients may quickly become comatose and increase the risk o f aspiration.

Explanation: In the treatment o f tricyclic antidepressant poisoning ipecac syrup is not recommended because patients may quickly become comatose and increase the risk of aspiration.

54.Answer:A. It maintains an arterial pH of 7.45 to 7.55 and this decreases the fraction of absorbed toxins Explanation: It maintains an arterial pH o f 7.45 to 7.55 and this decreases the fraction o f absorbed toxins.

55. Answer: D. Seizure is one symptom of benzodiazepine poisonining Explanation: Seizure is not a symptom o f benzodiazepine poisonining.

56.Answer: E. C&D Explanation: Flumazenil is known for its short elimination half-life. It is contraindicated in mixed overdose patients (particularly involving tricyclic antidepressants) in whom seizures are likely.
i

57.Answer: A.Unopposed a-Receptor stimulation may lead to profound hypertension Explanation: Epinephrine should be used cautiously in [i-blocker Overdoses. Unopposed a-Receptor stimulation in the face o f complete (3-blocker may lead to profound hypertension.

58.Answer: B. Hypotension Explanation: Hypotension is a common clinical symptom that occurs in overdoses o f all classes o f calcium channel blockers.

59.

Answer: E. A and C

Explanation: Bradycardia and Atrioventricular block are commonly seen with ingestions o f Verapamil or Diltiazem.

60. Answer: D. All o f the above Explanation: In the treatment of calcium channel blocker poisoning calcium chloride is given for the management o f Hypotension, Bradycardia, or Heart block.

61 .Answer: C. Erthroxylon coca

62. Answer: C. Cocaine has poor absorption following inhalational administration Explanation: Cocaine is well absorbed following oral, inhalational, intranasal, and IV administration.

63.Answer: B. Labetolol Explanation: Labetolol is an antihypertensive drug.Diazepam is a benzodiazepine used in the management of pain. Fluoxetine is a non-selective serotonin reuptake inhibitor. 64. Answer: D. all o f he above

65. Answer: D. All o f the above Explanation: A cyanide antidote kit contains the following: Amyl nitrite- pearls are crushed and held under a patients nostrils. Sodium nitrite- converts hemoglobin to methemoglobin, which binds the cyanide ion. Sodium thiosulfate- 50ml o f a 25% solution IV push-may be repeated if there is no response. Oxygen, and sodium bicarbonate-as needed for severe acidosis.

66.Answer: A. Converts hemoglobin to methemoglobin Explanation: Sodium nitrite is included in a cyanide antidote kit because it converts hemoglobin to methemoglobin (the cyanide binds to methemoglobin and gets excreted from the poisoned patient).

67.Answer: C. 6-8 hrs Explanation: It takes 6-8 hrs before there is equilibrium between digoxin serum level and its myocardial binding.(i.e. its site o f action).

68.Answer: C. Cardiac dysrhythmias Explanation: In more severe cases of digoxin poisoning, cardiac dysrhythmias is a common symptom.

69.Answer: D. A and B Explanation: Removal by emesis is not a supportive therapy. It is a decontamination procedure (i.e. it is helpful in removal o f the poison only), but managing the hyperkalemia (high potassium level) or hypokalemia (low potassium level) and inotropic support are supportive therapies.

70.Answer: B. Dose= {ingested digoxin (mg) X 0.8 }/0.6

Explanation: Dose (vial) = {ingested digoxin (mg) X 0.8 }

0.6
Each vial contains 40 mg of digoxin antibodies (Digibind) and should be reconstituted with 4 mL of sterile water.

71 .Answer: D. Magnesium poisoning is classified as mild if the its plasma concentration is more than 1OmEq/L

Explanation: Magnesium poisoning is classified as mild if the concentration is more than 4mEq/L. and severe if more than 10 mEq/L.

72. Answer: B. temporarily antagonize the cardiac effects o f magnesium Explanation: In the treatment o f magnesium poisoning 10 % calcium chloride is given in order to temporarily antagonize the cardiac effects o f magnesium. It doesnt enhance the metabolism of magnesium.

73.Answer: B. Potassium Explanation: Potassium is an intracellular cation, whose serum values depends on the pH of serum and over dosage o f this cation may result in cardiac irritabilities, and peripheral weakness.

74. Answer: A. To increase serum pH and cause an intracellular shift o f potassium Explanation: The plasma concentration o f potassium depends up on the pH o f blood. The purpose o f using sodium carbonate in the treatment o f potassium over dosage is to increase serum pH and cause an intracellular shift o f potassium. Potassium is simply a cation so it is not metabolized.

75. Answer: B. It shifts potassium from the extra cellular fluids into cells Explanation: 50 ml o f 50 % dextrose and 5-10 units o f regular insulin are administered via IV push to shift potassium from the extra cellular fluids in to cells. The movement o f potassium from extra cellular fluids into cells decreases the amount o f potassium in the blood and the toxic effects o f potassium decrease accordingly. ;

76.Answer:A. They bind potassium in exchange for another cation Explanation: Cation exchange resins bind potassium in exchange for another cation (sodium).

77.Answer:

D. 23.5 % sorbitol

Explanation: Sodium polystyrene sulfonate (Kayexelate) is given in a dose o f 15 g/60 mL with 23.5 % sorbitol. Altematively.it can be given rectally in 200ml o f sodium polystyrene sulfonate.

78. Answer: B. Fumarate salt-13% elemental iron Explanation: Numerous OTC products o f iron products are available. Toxicity on the amount of elemental iron ingested: Sulfate salt 20 % elemental Fe; Fumarate salt 33% elemental Fe; and Gluconate salt 12% elemental Fe.

79.Answer: D. A and B Explanation: Iron is absorbed in the Duodenum and Jejunum.

80.Answer: A. Phase 1 Explanation: Phase 1 - nausea, vomiting, diarrhea, GI bleeding, hypotension. Phase II - clinical improvement seen 6-24 hours post ingestion Phase III - metabolic acidosis, renal and hepatic failure, sepsis, pulmonary edema, and death.

81.

Answer: C. Deferoxime

Explanation: Dimercaprol and Deferoxime are chelating agents i.e. they have the capacity to form complexes with metal ions. Deferoxime is a chelator used in the treatment o f iron poisoning. Pyridoxine and Sodium bicarbonate are not chelating agents.

82. Answer: E. All o f the above Explanation: Serum Fe levels, Liver function tests (because liver is involved in metabolism and storage o f iron), Hemoglobin, and Hematocrit (the red blood cell portion o f the blood cells).

83.Answer: B. Gastric lavage using sodium bicarbonate is very effective procedure Explanation: Gastric lavage using sodium bicarbonate has not been shown to be effective procedure.

84.Answ'er: A. 6 g/day

Explanation: Deferoxime is used to chelate iron. It is administered 25-50mg/Kg up to a dose of lg, and observe for a red color in the urine. Then administer at a rate o f 15mg/kg/hr up to a maximum dose of 6 g/day.

85.Answer: C. Pyridoxine Explanation: Pyridoxine is a coafator that reverses Isoniazid-induced seizures.

86. Answer: B. Patients at high risk o f developing seizures Explanation: Emesis should not be used in the treatment o f isoniazid poisoning because patients at high risk o f developing seizures (the poisoning may result in seizures). If emesis is induced in patients with seizure the GI contents will enter the airways (they will get aspirated).

87. Answer: A. Alkalosis Explanation: The laboratory data in isoniazid poisoning shows severe lactic acidosis, Hypoglycemia, Mild hyperkalemia, and Leukocytosis.

88.Answer: B. Lead Explanation: Lead is found in lead based paints and gasoline fume inhalation. The clinical presentation o f lead poisoning includes nausea, vomiting, abdominal pain, peripheral neuropathies, convulsions, and coma.

89.Answer: A. 2 months

Explanation: Lead has a half-life o f approximately 2 months in the human body.

90. Answer: E. A and B Explanation: The treatment for lead poisoning is Edetate calcium disodium or D im ercaprol.

91 .Answer: B. 1.5- 2.5 mEq/L Explanation: The following are concentration ranges o f lithium Therapeutic range: 0.6-1.2 mEq/L Mild toxicity toxicity: 1.5 mEq/L-2.5 mEq/L Moderate toxicity: 2.5-3 mEq/L ,and severe toxicity is more than 3 mEq/L.

92.Answer: E. AH except B Explanation: The plasma concentration o f lithium was 4 mEq/L, which is classified as severe toxicity.

Mild intoxication: polyuria, slurred speech, blurred vision, weakness, ataxia, tremor and myoclonic jerks. Severe intoxication: delirium, coma, seizures, and Hypertherima.

93.Answer: A. Rebound effect Explanation:In the treatment o f lithium poisoning by hemodialysis, lithium levels may rise after dialysis due to a rebound effect.

94.

Answer: D.A and B

Explanation: Naloxone (given as a treatment in opiod over dosage) has a very short half-life, and resedation is a problem in patients overdosing on long acting opiods or sustained release dosage forms.

95.Answer: D. A and B Explanation: Organophosphates are usually used as Pesticides or Chemical warfare agents. Theyare not used as drugs for humans.

96.Answer: B. Excessive cholinergic stimulation Explanation: The clinical presentation o f organophosphate poisoning includes excessive cholinergic stimulation. There is excessive action o f the neurotransmitter acetlycholine because organophosphates inhibit the enzyme, which metabolizes acetlycholine.

97.Answer: B. Atropine Explanation: Naloxone and nalmefene are narcotic analgesics. Dimercaprol is a chelator used in the treatment o f metal poisoning. Atropine reverses the peripheral muscarinic (cholinergic)effects o f organophosphates.

98. Answer: A. Salicylates have poor absorption when given by the oral route, so they should be given parentally Explanation: Salicylates have good absorption when given by the oral route. They are not given parentally probably due to their ability to disturb the pH o f blood.

99.Answer: A. Alkaline diuresis Explanation:Alkaline diuresis is given to enhance salicylate excretion. This is indicated for levels greater than 40mg/dL. Hemodialysis is indicated when the serum levels are greater than 100 mg/dL Induction oTEmesis with syrup o f ipecac is effective if given within 30 minutes o f exposure.

] 00.

Answer: C. Bradycardia is one o f the most common clinical symptoms

Explanation:Clinical presentation includes nausea, vomiting, syncope, tachycardia, and cold clammy skin. Bradycardia does not occur in cases o f snakebite. Onset o f symptomatolgy depends on the species o f snake (if the snake is very poisonous type the symptoms may occur rapidly) and the patients underlying medical conditions.

101.

Answer: D. all o f the above

Explanation: All o f the above are true about the supportive treatment o f snakebites.

102.

Answer: A. Antivenin polyvalent

Explanation: Antivenin polyvalent is horse-derived antivenom that has been reported to produce allergic reaction.Crotalidae polyvalent immune Fab is a polyvalent antivenin made from sheep sources.Tetanus antitoxin is given to protect from tetanus; it is not an antivenom. 103. Answer: C. Charcoal hemoperfusion

Explanation: Hemoperfusion is a technique in which anti coagulated blood is passed through (perfused) a column containing activated charcoal or resin particles. Charcoal hemoperfusion is utilized in patients who in status epilepticus (one type o f seizure).

Coronary Artery Disease

Your vision will become clear only when you can look into your own heart. Who looks outside, dreams; who looks inside, awakens. Carl Jung

1. The most common cause o f ischemic heart disease due to its ability to decrease coronary blood flow is: A. B. C. D. E. atherosclerosis coronary artery spasm traumatic injury embolic therapy none o f the above

6. In a cardiac muscle the phase o f contraction is known as: A. systole B. diastole C. asystole D. C and D E. none o f the above 7. The two phases o f systole are:

2. All o f the following may result in coronary artery spasm (sustained contraction o f one or more coronary arteries) EXCEPT: A. B. C. D. E. coronary catheterization intimal hemorrhage exposure to heat ergot -derivative drugs none o f the above

A. B. C. D. E.

contraction ejection relaxation retention A and B

8. Which o f the following result in increased oxygen demand? A. increased force o f myocardial contraction B. increases in systolic wall tension. C. shortening o f ejection time. D. decrease in heart rate E. A and B

3. AH o f the following factors result in increased heart rate EXCEPT: A. B. C. D. E. cold smoking p-blockers exercise nitroglycerin

9. Which o f the following statements is FALSE about angina pectoris A. it includes varying forms of transient chest discomfort that are attributable to insufficient myocardial oxygen. B. it is characterized by discomfort in the c h e st, jaw and shoulder. C. the discomfort associated with angina pectoris is usually aggravated by nitroglycerin. D. angina can occur in patients with valvular disease. E. none o f the above

4. Which o f the following may occur in ischemic heart disease? A. B. C. D. E. decreased blood flow increased blood flow increased oxygen demand decreased oxygen demand A and C

5. Which o f the following result in increased myocardial oxygen demand: A. B. C. D. E. exercise emotional stress shoveling snow Inotropic state o f the heart all o f the above

10. Which o f the following diseases cause oxygen imbalance?

A. B. C. D. E.

tachycardia anemia hypertension hypotension all o f the above

B. C. D. E.

unstable angina angina decubitis vasospastic angina none o f the above

15.Prinzmetal's angina occurs due to : 11 .Which o f the following statements is incorrect about stable angina? A. it is usually precipitated by exertion , emotional stress or a heavy meal. B. it usually lasts for hours. C. the anginal episode is usually substemal but has a tendency to radiate to the neck, jaw, epigastrium or arms. D. it is characteristically due to a fixed obstruction in a coronary artery. . none o f the above A. reduction o f coronary blood flow secondary to coronary artery spasm. B. vasodilatation o f coronary blood vessels. C. increased myocardial force o f contraction. D. an overdose o f calcium channels blockers. E. none o f the above

16. Which o f the following types o f angina respond well to nitroglycerin therapy? A. B. C. D. E. F. classic angina unstable angina angina decubitis vasospastic angina A and C B and D

12. Which o f the following statements are true about unstable angina ? A. it has decreased response to rest or nitroglycerin B. it is characterized by rest angina , which usually is prolonged greater 20 minutes occurring within a week o f presentation. C. it represents a progressive clinical entity. D. it may signal incipient myocardial infraction. E. all o f the above

17. Which o f the following statements is Incorrect? A. vasospastic angina usually occurs at rest ( i.e. pain may disrupt sleep ) rather than with exertion emotional stress B. an ECG taken during a vasospastic anginal attack characteristically shows an inverted T wave C. calcium channel blockers, rather than B- blockers are more effective for the treatment o f Prizementals angina D. diuretics alone or in combination effectively reduce left ventricular volume and thus, they may help relief pain in patients with angina decubitus E. none o f the above

13.Angina decubitus is also known as: A. B. C. D. E. acute coronary syndrome nocturnal angina acute coronary syndrome. Hyperlipidemia none o f the above

14. Which o f the following types o f angina occurs in the recumbent position ? A. stable angina

18. Which o f the following statements are incorrect about exercise stress? A. it is preferable to other variations of stress test such as pharmacological stress testing in patients who are able to exercise B. it is useful in diagnosis o f all patents with angina pectoris C. it aids in the diagnosis o f patients who have normal testing ECG D. it can be done with out ECG E. B and D

C. Flecainide D. Verapamile E. none o f the above

22. The goals o f treatment in angina pectoris are: A. to prevent myocardial infarction and death B. to reduce symptoms o f angina and occurrence o f ischemia C. to remove or reduce risk factors D. B & C only E. all o f the above

19. Which o f the following drugs are used in the phannacological stress testing (in the diagnosis o f angina pectoris) A. B. C. D. E. Dipyridamole Adenosine Furosemide Dobutamine A,B and D

23.In the management o f hyperlipidemia, the primary target treatment is to reduce: A. LDL cholesterol ( low density lipoprotein) B. HDL cholesterol ( high density lipoprotein) C. triglycerides D. A & C E. none of the above

20. Which o f the following radioactive elements are used as stress perfusion imaging agents that can diagnose multivessel diseases, localized ischemia, and may be able to determine myocardial viability? A. B. C. D. E. R ubidium 82 Technetium 99m Thallium 201 X en o n '33 B and C

24. Which of the following statements is False about the management of hyperlipedemia in order to reverse cardiac risk factors which may contribute to the development o f ischemic heart diseases? A. if LDL is less than 100 m g/dl, patients with IHD should be given instructions on diet and exercise and have levels monitored annually B. if the LDL cholesterol level is 101 129 mg/dl either at baseline or with LDL lowering therapy, initiate or intensify life style and /or therapies to lower LDL to less than 100 mg/dl C. if triglycerides are 200- 499 mg/dl ; only exercise is recommended with LDL lowering therapy D. if triglycerides are >_500mg, consider fibrate or niacin before LDL lowering therapy. E. None o f the above

21 .Various drugs can have an effect on the ECG and should be considered prior to, during, and after an exercise test is carried out. Which one o f the following drugs produces abnormal exercise induced ST depression in 25%-40% o f the apparently healthy normal subjects with ischemia? A. Digoxin B. Lidocain

25. Which o f the following indicate the presence o f metabolic syndrome ? A. abdominal obesity B. triglycerides > 150 mg/dL C. blood pressure readings > 135/85 mm Hg D. fasting serum glucose level morethan or equal to 11 Omg/dl E. All o f the above

A. B. C. D. E.

Simvastatin Pravastatin Atorvastatin Lovastatin none o f the above

30. Which o f the following drugs may increase the risk o f myopathy if they are given concurrently with Statins? A. B. C. D. E. cyclosporine macrolide antibiotics azole antifungals A & B only all o f the above

26. The mechanism o f action o f bile acid sequestrant resins against hyperlipidemia is that they A. bind to bile acids within the intestines. B. inhibit an enzyme involved in the synthesis o f fatty acids. C. inhibit the excretion o f lipids D. enhance elimination o f dietary fatty acids E. none o f the above

31 .When fibric acid derivatives are given concurrently with Statins , patients should be monitored to identify severe adverse effects such as: A. B. C. D. E. myopathy rhabdomyolysis constipation gastrointestinal distress A and B

27. Statins reduce cholesterol production by inhibiting the enzyme; A. B. C. D. E. Cholesterol synthetase HMG-CoA reducase Cholesterol esterase Cholesterol epoxidase none o f the above

32. All o f the following are actions o f niacin in the lowering o f cholesterol and triglycerides EXCEPT: A. decreases hepatic LDL and VLDL production B. inhibition o f adipose tissue lipolysis C. decreases lipoprotein lipase activity' D. deceases hepatic triglyceride esterification E. none o f the above

28.The biochemical effects o f HMG-CoA reducase inhibitors is to : A. B. C. D. E. lower LDL levels. increase HDL levels increased triglyceride levels. A and B only All o f the above

29. Which o f the following Statins results in long lasting inhibition o f HMG-CoA reducase?

33.Patients taking niacin may experience flushing and itching skin. This can be reduced by administration o f 325 mg o f : A. Acetaminophen

B. C. D. E.

Aspirin Naproxen Ibuprofen none o f the above

38. Which o f the following statements is FALSE about ezetimibe? A. it reduces total cholesterol. B. it is associated with elevation o f liver transaminases when given with HMG-CoA reductase inhibitors. C. it increases triglyceride levels. D. the normal recommended dose o f ezetimibe is lOmg given once daily. E. none o f the above

34. All of the following drugs are bile acid sequestrants EXCEPT: A. B. C. D. E. Cholestyramine Colestipol Colesevelam Cerivastatin none o f the above

39. All o f the following are transdermal nicotine containing patches EXCEPT: 35. Which one o f the following classes of anti-hyperlipidemia agents doesnt decrease the level o f triglycerides? A. B. C. D. E. HMG-CoA reducase inhibitors Fibric acids Nicotinic acid Bile acid sequestrants None o f the above A. B. C. D. E. Nicotrol Habitrol Nicoderm Nicorette none

40.A prescription antidepressant, marketed under the brand name zyban as an aid to smoking cessation is: A. B. C. D. E. Trazodone Bupropion Amoxapine Maprotiline none o f the above

36.The class o f anti-hyperlipidemia associated with unexplained non-coronary disease in a WHO study is : A. B. C. D. E. nicotinic acid derivatives bile acid sequestrants HMG-CoA reductase inhibitors fibric acid derivatives none o f the above

37.The mechanism of action of ezetimibe is A. it selectively inhibits the intestinal absorption of cholesterol . B. it decreases the elimination of cholesterol C. it inhibits HMG-CoA D. it induces the synthesis of cholesterol E. none of the above

41 .Which of the following represent a wrong match o f a class recommendation of drugs used in the treatment o f stable angina and the reason for their inclusion in that class ? A. Class Il-conflicting evidence or a divergence o f opinion about the usefulness/efficacy o f a treatment. B. Class I-evidence and /or general agreement that a treatment is ineffective. C. Class III- evidence and /or general agreement that a treatment is not useful/effective.

D. Class 11-evidence and/ general agreement that the treatment is harmful. E. B and D

A. B. C. D. E.

Felodipine Nicardipine Isradipine Verapamil none o f the above

42.All o f the following are true about the actions o f nitrates EXCEPT: A. they result in venous dilatation B. they increase left ventricular volume. C. they reduce arteriolar resistance. D. they decrease oxygen requirements E. reduce myocardial wall tension

46. Which o f the following statements are false about B-blockers in the treatment o f angina pectoris? A. they reduce the frequency and seventy o f exertional angina that is not controlled by nitrates B. they reduce oxygen demand both at rest and during exercise C. they decrease heart rate D. they increase myocardial contractility E. none o f the above

43.Which o f the following are WRONG about nitrates? A. acute attacks o f angina pectoris can be managed with intravenous nitrates only. B. sublingual nitrates should be taken after food or after sexual activity in order to be effective. C. they may not be effective as single agents for the treatment of Prinzm etal's angina. D. nitrates should be used in combination with p-adrenergic blockers have been shown to be effective than nitrates or padrenergic blockers alone. E. A and B

47.6-blockers should be avoided in vasospastic angina because: A. they do not relieve the anginal pain. B. they increase coronary resistance and may induce vasospasm. C. they dilate coronary blood vessels. D. they do not have any effect on coronary blood vessels. E. none o f the above

48. All o f the following nitrates are shortacting EXCEPT: A. isosorbide dinitrate oral tablets. B. pentaerythritol tetranitrate sublingual tablets. C. erythritol tetranitrate sublingual tablets D. nitroglycerin sublingual tablets E. none o f the above 49. Which o f the following statements is FALSE about calcium channel blockers?

The most common side effect o f nitrates

A. B. C. D. E.

an increase in blood pressure headache angina pectoris constipation none o f the above

45.All o f the following are dihydropyridine derivative calcium channel blockers EXCEPT:

A. they are used in stable or exertional angina that is not controlled by nitrates and P-blockers and in

B. C.

D.

E.

patients in which fi-blocker therapy is inadvisable. they decrease coronary vascular resistance they result in coronary spasm by inhibiting calcium influx into vascular smooth muscle. they reverse coronary spasm resulting in increased myocardial oxygen supply. none of the above

D. Isradipine E. Nisoldipine

53.The daily dose o f aspirin which should be used in all patients without acute or chronic ischemic heart disease is: A. B. C. D. E. 500-750 mg 450-550 mg 75-325 mg 500-1000mg none o f the above

50. Which one o f the following calcium channel blockers does not have a strong negative inotropic effect? A. B. C. D. E. diltiazem verapamil nifedpine bepridil none o f the above

54.Ticlopidine and clopidogrel are chemically: A. B. C. D. E. thienopyridine derivatives tetrazole derivatives thiazole derivatives pyrimidine derivatives None

51 .Which o f the following statements is FALSE about nifedipine? A. it decreases myocardial oxygen demand B. it can produce tachycardia C. its potent peripheral dilatory effects can increase coronary perfusion and produce excessive hypotension , which can aggravate myocardial ischemia. D. co-administration o f a p-blocker with nifedpine prevents the reflex tachycardia. E. none o f the above

55. Which o f the following statements is FALSE? A. ticlopidine inhibits platelet activation induced by adenosine diphosphate B. ticlopidine has been shown to decrease adverse cardiovascular events in patients with stable angina. C. clopidogrel possesses antithrombotic effects that are greater than that o f ticlopidine. D. clopidogrel is a therapeutic option in those patients who can not take aspirin due to contraindications. E. none o f the above

52. Which o f the following second generation dihydropyridine derivative calcium channel blockers, has been shown to have less negative inotropic potential in patients with CHF than other members of the class? A. Felodipine B. Nicardipine C. Amlodipine

56.Angiotensin converting enzyme inhibitors are recommended as whcih class o f agents for their use in patients with ischemic heart disease and other vascular disorders. A. class 1A B. class IB

C. class 11 a D. class 11 b E. none o f the above

E.

none o f the above

57.An ACE inhibitor studied in the heart outcomes prevention trail, and reduced cardiovascular death, myocardial infarction and stroke in patients who were at high risk for or had vascular disease in the absence of heart failure is: A. B. C. D. E. Ramipril Lisinopril Perindopril Trandopril none o f the above

60. Which o f the following statements is FALSE about creatnine kinase (CK-MB) in relation with acute coronary syndrome? A. it is first elevated 3-12 hours after the onset o f pain. B. its level peaks in 24 hours. C. its level may be elevated due to some other conditions (other than myocardial infarction). D. noncardiac causes o f change in levels o f creatnine kinase demonstrate the typical pattern o f rise and fall seen in a myocardial infarction. E. none o f the above

58.In acute coronary syndromes due to STEMI and NSTEMI, a portion of the cardiac muscle suffers a severe and prolonged restriction o f oxygenated coronary blood. In most patients the cause of this is: A. B. C. D. E. occlusive thrombus vasospasm vasodilatation B and C None o f the above

61 .Which o f the following statements is FALSE about cardiac troponins? A. cardiac troponin I and troponin T are even more sensitive than MBCK. B. they represent a powerful tool for risk stratification and have greater sensitivity than Creatnine kinase heart (CK-MB). C. they do provide a high sensitivity in the early phases o f myocardial infarction. D. they increase 3-12 hours after the onset o f pain E. none o f the above 62.Overall treatment goals in acute coronary syndrome include all o f the following EXCEPT: A. to relieve chest pain anxiety B. to reverse myocardial damage C. to prevent or arrest complications, such as lethal arrhythmias, CHF or sudden death. D. to reopen (or reperfuse) closed coronary vessels with thrombolytic drugs and /or percutaneous coronary intervention

59. Which of the following statements is FALSE? A. Reperfusion therapy routinely reverses the damage to myocardial tissues in patients with STEMI. B. Introduction o f thrombolysis or percutaneous coronary intervention for the management o f STEMI has demonstrated the ability to remove the offending thrombus from the affected coronary artery. C. Patients with NSTEMI do not benefit from reperfusion therapy. D. The development o f unstable angina carries a 10%-20% risk o f progression to an MI in untreated patients.

E. none o f the above

66.Patients taking morphine must be protected against aspiration o f stomach contents because: A. nausea and vomiting may occur. B. it results in brochospasm. C. it decreases myocardial oxygen consumption. D. it reduces pre-load. E. none o f the above

63. Which o f the following statements are true about class I recommendation therapeutic interventions against unstable angina/NSTEM I? A. bed rest with continuous ECG monitoring for ischemia and arrhythmia detection in patients with on going rest pain. B. supplemental oxygen for patients with cyanosis or respiratory distress and continued need for supplemental oxygen in the presence o f hypoxemia. C. in patients with continuing or frequently recurring ischemia when j3-adrenergic blockers are contraindicated, a non dihydropyridine calcium antagonists are recommended as an intial therapy in the absence of severe left ventricular dysfunciton D. morphine sulfate is useful in patients with severe agitation. E. All o f the above

67. All o f the following are gastrointestinal effects o f morphine EXCEPT: A. B. C. D. E. nausea vomiting diarrhea constipation none o f the above

68. Which o f the following is NOT TRUE about thrombolytic agents in the treatment o f acute coronary syndrome? A. they have not demonstrated beneficial clinical outcomes in the absence o f STEMI. B. they have failed to show benefit against UA versus standard therapy to prevent MI. C. they are recommended in the management o f acute coronary syndrome without ST elevation. D. they may increase the risk o f MI in some patients E. none o f the above

64.Morphine can produce orthostatic hypotension and fainting in patients with ACS because: A. it increases peripheral vasodilatation. B. It decreases peripheral resistance. C. It has vasospastic effect. D. A and B E. C and D 65.Morphine has a vagomimetic effect that can produce: A. B. C. D. E. brady arrhythmias tachy dysarrhythmi as dysarrhythmias tachycardia none o f the above

69.Clopidogrel should be administered to hospitalized patients (with ACS): A. who have gastrointestinal intolerance B. who have hypersensitivity reactions to aspirin C. all patients D. A & B E. All of the above

70. All o f the following are heparins used as antithrombotic agents in the treatment of ischemic heart disease EXCEPT: A. B. C. D. E. Dalteparin Enoxaparin Heparin Enalapril None

B. C. D.

E.

be lysed when administered early after symptom onset (<6-12 hours ). they do not help restore blood flow they may be helpful in patients as late as 12 hours after pain starts. they shoud be administred in less than 6 hours after after onset o f symptoms in order to be efeftive. none o f the above

71 .A drug which should be administered to patients already receiving heparin, aspirin and clopidogrel in whom catheterization and percutaneous coronary intervention are planned is: A. B. C. D. E. Dalteparin Glycoprotein llb/lla antagonist Ticlopidine Tirofiban none o f the above

75. Which o f the following thrombolytic agents may restore blood flow in an occluded artery if administred intravenously within 12 hours o f an acute MI? A. streptokinase B. recombinant tissue-type plasminogen activator alteplase C. anisoylated plasminogen streptokinase activator complex D. reteplase E. all o f the above

72. Atherosclerotic plaques are made up of: A. B. C. D. E. lipid ' fibrous proteins carbohydrates vitamin B A and B 76. Which one o f the fol lowing thrombolytic agents causes greater degree o f systemic bleeding as compared with the others? A. recombinant tissue-type plasminogen activator alteplase B. reteplase C. tenecteplase D. streptokinase E. none o f the above

73. Which o f the following is the substance released from injured blood vessels that initiates the clotting cascade? A. B. C. D. E. serotonin thromboxane A2 thromboplastin fibrin none o f the above

77.Recombinant t-PA is absolutely contraindicated in which o f the following conditions? A. B. C. D. E. internal bleeding recent cardiovascular accident intracranial surgery pregnancy all o f the above

74. Which o f the folllowing statements is FALSE about thrombolytic agents ? A. administration o f thrombolytic agents causes the thrombus clot to

78.Many patients develop arrhythmias, within 30-45 minutes o f streptokinase administration,which do not require treatment.These arrhythmias are called: A. B. C. D. E. ventricular arrhythmia reperfusion arrhythmias supraventricular arrhythmias torsades de pointes none o f the above

D. statins E. none o f the above

83. All o f the following drugs act by inhibiting glycoprotein Ilb/IIIa receptors EXCEPT: A. B. C. D. E. Abciximab Eptifibatide Enoxaparin Tirofiban none o f the above

79.As A. B. C. D.

compared to t-PA, tenecteplase has:

fewer bleeding complications. less fibrin specificity. slower rate o f administration. more effective in late-treated patients. E. A and D

84.p-blockers have all o f the following actions in STEMI patients EXCEPT: A. prevent reocclusion o f coronary artery. B. reduce ischemia C. decrease oxygen demand D. decrease cardiac work load E. none o f the above

80. Which of the following decreases mortality in patients with MI even if they have not received thrombolytic therapy? A. B. C. D. E. Aspirin Heparin Ticlopidine Clopidogrel none o f the above

81 .Unless chosen for a specific clinical indication, heparin use with which o f the following is not recommended because o f the risk o f hemorrhage. A. B. C. D. E. Reteplase Tenecteplase Streptokinase t-PA none o f the above

82. All o f the following prevent ischemia in patients with STEMI EXCEPT: A. antiplatelets B. p-blockers C. anticoagulants

ANSWERS

Coronary Artery Disease


1. Answer: A. Atherosclerosis Explanation:

Atherosclerosis is the most common cause o f ischemic heart disease. In Atherosclerosis the coronary arteries are progressively narrowed by smooth-muscle cell proliferation and the accumulation o f lipid deposits (plaque) along the inner lining (intima) o f the arteries.

2. Answer: C. Exposure to heat. Explanation: _ Coronary artery spasm is sustained contraction o f one or more coronary arteries. It can occur spontaneously or be induced by irritation {e.g Coronary catheterization,(for diagnostic purposes), or intimal hemorrhage (bleeding o f inner wall o f arteries), exposure to cold and ergot derivatives. Exposure to heat has not been shown to cause coronary artery spasm.

3. Answer: C. (3-blockers Explanation: Cold, smoking, and exercise result in increased heart rate, while p-blockers decrease heart rate.

4. Answer: E. A and C Explanation: In ischemic heart rate disease, there is imbalance between myocardial oxygen demand and coronary blood flow. There is increased oxygen demand, while there is decreased blood flow and there may be reduced blood oxygenation (as in various anemias) 5. Answer: E.all o f the above Explanation: Increased myocardial oxygen demand occurs with exertion suchas exercise, shoveling and emotional stress.lnotropic state of heart also causes the need for increased oxygen requirement by the myocardial tissue.

6. Answer: A. systole Explanation: In a normal heart beat, the two atria contract while the two ventricles relax. The term systole refers to the phase o f contraction whereas diastole refers to the phase o f relaxation.

7. Answer:E. A and B

Explanation: The two phases o f systole are contraction and ejection.

8. Answer: E. A and B Explanation: The contractile (inotropic) state o f the heart, increases in systolic wall tension and lengthening of ejection time and increases in heart rate demand oxygen supply.

9. Answer: C. The discomfort associated with angina pectoris is usually aggravated by nitroglycerin. Explanation; The term angina pectoris is applied to varying forms o f transient chest discomfort that are attributable to insufficient myocardial oxygen. Angina is a clinical syndrome characterized by discomfort in the chest, jaw and shoulder. Nitroglycerin relieves the discomfort associated with angina.

10. Answer: E. all o f the above Explanation: Atherosclerotic lesions that produce a narrowing o f the coronary arteries are the major cause of angina. However, tachycardia, anemia, hyperthyroidism, hypotension, and arterial hypoxemia can all cause an oxygen imbalance.

11 .Answer: B. It usually lasts for hours. Explanation: In stable angina, episode typically lasts for minutes. The angina is normally related to physical exertion, and the discomfort usually subsides quickly (i.e. in 3-5 minutes) with rest, if precipitated by emotional stress, the episode lasts longer(i.e. about 10 minutes ).

12. Answer: E. all o f the abeVe* Explanation: Unstable angina has decreased response to rest or nitroglycerin, it is characterized by rest angina, which usually is prolonged greater 20 minutes occurring within a week of presentation. It represents a progressive clinical entity. It may signal incipient myocardial infraction.

13.Answer: B. Nocturnal angina Explanation: Nocturnal angina is the second name o f angina decubitis. Unstable angina is referred to as acute coronary syndrome.

14.Answer: :C. Angina decubitis

Explanation: Angina decubitis occurs in the recumbent position and is not specifically related to either rest or exertion.

] 5. Answer: A. Reduction o f coronary blood flow secondary to coronary artery spasm. Explanation: Coronary artery spasm that reduces blood flow precipitates Prinzm etal's angina (it is also known as vasospastic or variant angina)

]6.Answer:!E. A and C Explanation: Stable (classic angina) angina and angina decubitis respond well to nitroglycerin therapy.

17. Answer: B. An ECG taken during a vasospastic anginal attack characteristically shows an inverted T wave Explanation: In vasospastic angina an ECG taken during an attack o f vasospastic angina reveals an ST segment elevation.All the other choices are correct.

18.Answer: E. B and D Explanation: It is a well established procedure, which aids the diagnosis in patients who have normal resting ECGs. Exercise stress testing is preferable to other variations o f stress tests (pharmacological) in patients who are able to exercise.

19.

Answer: E.A,B and D

Explanation: The pharmacological testing is useful in patients with suspected IHD who are unable to exercise. IV dipyridamole ( coronary vasodilator), adenosine ( coronary vasodilator),by inhibiting cellular uptake and degradation o f adenosine increase coronary blood flow, and high dose Dobutamine ( 20-40 (_ig/kg (m in )) which increases oxygen demand through increase in myocardial blood flow are all able to induce detectable cardiac ischemia in conjunction with ECG testing.

20.Answer: E. B and C Explanation:

Stress perfusion with Thallium 20L or Technetium 99mcan diagnose multivessel diseases, localized ischemia, and may be able to determine myocardial viability because these techniques are expensive, they are reserved for patients who have ECG abnormality at rest.

21 .Answer: A. Digoxin Explanation: Digoxin produces abnormal exercise induced ST depression in 25%- 40 % o f apparently healthy, normal subjects without ischemia.

22. Answer: E. All o f the above Explanation: The goals o f treatment in angina pectoris are to prevent myocardial infarction and death, to reduce symptoms o f angina and occurrence o f ischemia,and to remove or reduce risk factors.Treatment includes therapies aimed at reversing cardiac risk factors.

23.Answer: A. LDL cholesterol (low density lipoprotein) Explanation: Total cholesterol is no longer primary. Target o f treatment in patients with hyperlipidemia; LDL cholesterol is now the primary target. Lipids and cholesterols are transported through the blood stream as macromolecular complex o f lipid and protein known as lipoproteins. There are four main classes o f lipoproteins differing in the relative proportion of lipids and in the type o f apoprotein. They also differ in size and density,-and this later property, as measured by ultra configuration, is the basis for their classification into: a. High density lipoprotein ( HDL) b. Low density lipoprotein (LDL) c. Very low density lipoproteins(VLDL) d. Chylomicrons Cholesterol is esterified with long chain fatty acid in HDL particles, and the resulting cholestryl ester are subsequently transferred to VLDL or LDL, Lipoproteins is associated with atherosclerosis ( and localized in atherosclerosis ).

24. Answer: C. If triglycerides are 200- 499 m g /d l; only exercise is recommended with LDL lowering therapy Explanation: If triglycerides are 200-499 mg/dl; consider administration of fibrate or niacin before LDLlowering therapy.

25. Answer: E. All o f the above Explanation: The metabolic syndrome is closely linked to insulin resistance, where the normal actions o f insulin are impaired. Excess body fat and physical inactivity promote the development o f the syndrome, however; some individuals may be predisposed genetically. Patients with three

or more o f the following characteristics are referred to as having the metabolic syndrome, and should be treated accordingly ; abdominal obesity, triglycerides >150mg/dL , HDL levels o f < 40 mg/dL for men and 50mg/dL for women , blood pressure readings > J 30/85 mm Hg and a fasting serum glucose le v e ls 110 mg/dL .

26. Answer: : A. They bind to bile acids within the intestines Explanation: Bile acid sequestrant resins bind to bile acids within the intestines and the complex formed is eliminated via the feces. When taken by mouth, bile acid sequestrant resins sequester bile acids in the intestine and prevent their absorption and enterohepatic metabolism. The result is decreased absorption o f exogenous cholesterol and increased metabolism o f endogenous cholesterol into bile acids in the liver. This leads to increased expression o f LDL receptors on the liver cells and a reduced concentration o f LDL- cholesterol in plasma.

27. Answer: B. HMG-CoA reducase Explanation: Statins or HMG-CoA reducase inhibitors inhibit the enzyme which catalyzes the conversion of HMG-CoA to mevalonic acid. ( an important step in the synthesis o f cholesterol) and reduce cholesterol production. The resulting decrease in hepatic cholesterol synthesis leads to increased synthesis o f LDL receptors and increased clearance of LDL. The main biochemical effect of Statins is, therefore, to reduce plasma LDL- cholesterol concentration.

28.Answer: D. A and B only Explanation: Statins (HMG-CoA reducase inhibitors) are effective in lowering LDL levels, while increasing HDL levels and lowering triglyceride levels . They are primarily used to lower LDL levels.

29.

Answer: C. Atorvastatin

Explanation: Simvastatin, Pravastatin, and Lovastatin are competitive reversible inhibitors of HMG-CoA reducase. Atorvastatin causes long lasting inhibition o f HMG-CoA reducase.

30. Answer: E. All o f the above Explanation: Concurrent therapy o f Statins with other agents including cyclosporine, macrolide antibiotics, azole antifungals, niacin, or fibrates may increase the risk o f myopathy associated with Statins.

31 .Answer: E. A and B only Explanation:

Use o f Statins with fibric acid derivatives can lead to elevated creatinine kinase, and monitoring is necessary to identify Myopathy and Rhabdomyolysis.

32.Answer: C. decreases lipoprotein lipase activity Explanation: Niacin lowers o f cholesterol and triglycerides through various mechanisms such as participation in tissue respiration oxidation , reduction, which decreases hepatic HDL and very low density lipoprotein (VLDL) production ; inhibition o f adipose tissue lipolysis, decreased hepatic triglyceride esterification, and increases in lipoprotein lipase activity.

33.Answer: B. Aspirin Explanation: Patients taking niacin may experience flushing and itching skin. This can be reduced by administration o f 325 mg o f Aspirin about 30 minutes before the dose.

34.Answer: D. Cerivastatin Explanation: Cholestyramine, Colestipol, Colesevelam are bile acid sequestrants while Cerivastatin is an HMG-CoA reducase inhibitor..

35.Answer: D. Bile acid sequest rants Explanation: Bile acid sequestrants do not change the level o f triglycerides.

36.Answer: D. Fibric acid derivatives Explanation: Fibric acid derivatives (e.g. gemfibrozil, fenobirate and clofibrate) were associated with unexplained non-CHD deaths in WHO study.

37.Answer:A. It selectively inhibits the intestinal absorption o f cholesterol . Explanation: Ezetimibe works by selectively inhibiting the intestinal absorption of cholesterol and related phytosterols, with a resultant decrease in intestinal cholesterol delivered to the liver, decreased hepatic cholesterol stores and an increase in the clearance of cholesterol from the blood.

38.Answer: Explanation:

C. It increases triglyceride levels.

Ezetimibe has demonstrated the ability to reduce total cholesterol, LDL, apo-lipoprotein B, and triglyceride levels , while increasing HDL levels in patients with hypercholesterolemia.

39.Answer: D.nicorette Explanation: Nicorette is an oral nicotine polacrilex chewing gum, it is not transdermal nicotine containing patch.

40.Answer: B. Bupropion Explanation: Bupropion is a prescription antidepressant, marketed under the brand name zyban as an aid to smoking cessation.

41 .Answer: E. B and D Explanation: Recent evidence based guidelines have provided recommendations for the treatment o f patients with stable angina. Recommendations utilize 3 classes guidelines based on the levels o f evidence, class I { there is evidence or general agreement that a treatment is useful or effective}, class II {conflicting evidence or a divergence o f opinion about the usefulness/efficacy o f a treatment }, class III { there is evidence and/or general agreement that a treatment is not useful/effective and in some cases may be harmful}.

42.Answer: B. They increase left ventricular volume. Explanation: Organic nitrates relax vascular smooth muscles. They cause marked vasodilatation with a subsequent reduction in central venous pressure (reduced pre-load), and myocardial wall tension, decreasing oxygen requirements. Due to their effect on larger muscular arteries, there is reduction in central (aortic) pressure and coronary after load.

43.Answer: A and B Explanation: Acute attacks o f angina pectoris can be managed with sublingual nitrates, transmucosal (spray or buccal tablets), or intravenous delivery. Sublingual nitrates can be used before eating, sexual activity (since they are vasodilators they may interfere with erection), or any stressful event.

44.Answer: B. headache Explanation:

The most common side effect o f nitrates is headache. Patients should be warned o f the nature, suddenness, and potential strength o f these headaches to minimize the anxiety that might otherwise occur. Acetaminophen ingested 15-30 minutes before nitrate administration may prevent the headache.

45.Answer: D. Verapamil Explanation:

Felodipine, isradipine, and nicardipine are dihydropyridine derivatives. Verapamil is not a


dihydropyridine derivative.

46.Answer: D. They increase myocardial contractility Explanation: 6-blockers reduce oxygen demand, both at rest and during exercise by decreasing the heart rate and myocardial contractility, which also decrease arterial blood pressure.

47.Answer: B. They increase coronary resistance and may induce vasospasm Explanation: 6-blockers should be avoided in vasospastic angina because they increase coronary resistance and may induce vasospasm.

48.Answer: A. Isosorbide dinitrate oral tablets. Explanation: Isosorbide dinitrate oral tablets have long duration o f action (up to 8 hours).The others are short acting (the same as nitroglycerin sublingual tablets or spray which has short term effects o f 1-7 minutes)

49. muscle

Answer: C. They result in coronary spasm by inhibiting calcium influx into vascular smooth

Explanation: Calcium channel blockers prevent and reverse coronary spasm by inhibiting calcium influx into vascular smooth muscles and myocardial muscles. This results in increased blood flow, which enhances myocardial oxygen supply. Calcium channel blockers decrease coronary vascular resistance and increase blood flow, resulting in increased oxygen supply. Calcium channel blockers decrease systemic vascular resistance and arterial pressure; in addition, they decrease inotropic effects, resulting in decreased myocardial oxygen demand.

50.Answer: C. nifedpine Explanation:

Diltiazem, verapamil, and bepridil produce strong negative inotropic effect, and patients must be monitored closely for signs o f developing cardiac decompensation (i.e. fatigue, shortness of breath, edema), when co-administered with p-blockers or other agents that produce negative inotropic effects (e.g. disopyramide, quinidine, procainamide, flecainide), the negative chronotropic effects are additive. Nifedipine does not seem to have a strongly inotropic effect; therefore, it is preferred for combination therapy with agents that do.

51.Answer: A. It decreases myocardial oxygen demand Explanation: Because nifedipine increases heart rate, it can produce tachycardia, which would increase oxygen demand.

52. Answer: C. Amlodipine Explanation: Second generation dihydropyridine derivative calcium channel blockers should not be used in patients with CHF because they have potent negative inotropic potential. Amlodipine has less negative inotropic potential as compared to other members o f the class.

53.Answer: C. 75-325 mg Explanation: Aspirin in dose o f 75-325 mg daily should be routinely used in all patients with acute or chronic IHD with or with out symptoms in the absence o f any contraindications.

54.Answer: A. thienopyridine derivatives

55.Answer: B. Ticlopidine has been shown to decrease adverse cardiovascular events in patients with stable angina. Explanation: Ticlopidine has not been shown to decrease adverse cardiovascular events in patients with stable angina and is associated with thrombotic thrombolytic purpura.

56.Answer: C. class Ha Explanation: ACE inhibitors have attracted continued attention as additional therapy in patients with ischemic heart disease, as evidenced by the most recent guidelines, which provide a class Ila recommendation for their use in patients with IHD or other vascular disease.

57.Answer: A. Ramipril

Explanation: In the heart outcomes prevention trail (HOPE) trial, Ramipril reduced cardiovascular death, myocardial infarction and stroke in patients who were at high risk for or had vascular disease in the absence o f heart failure.

58.Answer: A. Occlusive thrombus Explanation: In acute coronary syndromes due to STEMI and NSTEMI, a portion o f the cardiac muscle suffers a severe and prolonged restriction of oxygenated coronary and in most patients it is due to occlusive thrombus.

59. Answer: A. Reperfusion therapy routinely reverses the damage to myocardial tissues in patients with STEMI. Explanation: Damage to myocardial tissues is not routinely reversible in patients with STEMI; due to the potential death o f myocardial tissue if perfusion does not take place early enough.

60.Answer: D. Noncardiac causes o f change in levels of creatnine kinase demonstrate the typical pattern o f rise and fall seen in a myocardial infarction. Explanation:

Creatnine kinase (CK-MB) is first elevated 3-12 hours after the onset o f pain, peaks in 24 hours and returns to baseline in 48-72 hours, other causes can result in elevated CK-MB levels but do not demonstrate the typical pattern o f rise and fall as seen in myocardial infarction. Until, recently, CK-MB had been the principal serum cardiac marker used in the evaluation o f acute coronary syndrome.

61 .Answer: C. They do provide a high sensitivity in the early phases o f myocardial infarction Explanation: Cardiac troponin I and T are even more sensitive than MB-CK, do provide a low sensitivity in the early phases o f MI (<6 hours after symptom on set) and require repeat requirements at 8-12 hours, if negative.

62.Answer: B. to reverse myocardial damage Explanation: Reversing myocardial damage is not the objective o f overall treatment goals in acute coronary syndrome, rather the treatment aims to prevent/reduce myocardial damage by limiting the area affected and preserving pump function.

63.

Answer: E. All o f the above

Explanation: All the given choices are true.

64.Answer: D.Aand B Explanation: Morphine can produce orthostatic hypotension in patients with ACS because it increases peripheral vasodilatation and decreases peripheral resistance.

65.Answer: A. Brady arrhythmias Explanation: Morphine has a vagomimetic effect (the same action as the vagus nerve, which has a slowing effect on the heart) that can produce Brady arrhythmias.

66.

Answer: A. "Nausea and vomiting may occur.

Explanation: Nausea and vomiting may occur, especially with initial doses, and patients must be protected against aspiration o f stomach contents.

67.Answer: C. Diarrhea Explanation: Diarrhea doesnt occur at therapeutic or toxic doses o f morphine.

68.Answer: C. They are recommended in the management o f acute coronary syndrome without ST elevation. Explanation: Thrombolytic agents have not demonstrated beneficial clinical outcomes in the absence of STEMI. Studies carried out to date have failed to show benefit with using thrombolytic agents against UA versus standard therapy to prevent ML In fact,thrombolytic agents increased the risk o f MI in such patients. Therefore, based on current evidence based guidelines, thrombolytic agents are not recommended in the management o f ACS without ST-segment elevation.

69.Answer: D. A and B Explanation: As part o f the anti-platelet and anticoagulant therapy in acute coronary syndrome clopidogrel should be administered to hospitalized patients who are unable to take aspirin because o f hypersensitivity or gastrointestinal intolerance.

70.Answer: D. Enalapril

Explanation: Enalapril is not a heparin but an ACE inhibitor.

71 .Answer: B. Glycoprotein Ilb/lla antagonist Explanation: A platelet glycoprotein llb/IIa antagonist should be administered to patients already receiving heparin, aspirin and clopidogrel in whom catheterization and percutaneous coronary intervention are planned.

72.Answer: E. A and B Explanation: Atherosclerotic plaques are made up o f Lipid and fibrous proteins.

73.Answer: C. thromboplastin Explanation: Atherosclerotic plaques are made up o f Lipid and fibrous proteins. When lesions rupture , the release o f adenosine diphosphate alteplase(ADP), serotonins, and thromboxane A2 is triggered , leading to platelet aggreagtion and the formation o f the primary clot. Thromboplastin relased from injured blood vessels initiates the clotting cascade. The resulting fibrin traps red blood cells (RBCs), platelets, and plasma protein to form an intraluminal thrombus.

74.

Answer: B. They do not help restore blood flow

Explanation: Administration o f thrombolytic agents causes the thrombus clot to be lysed when administered early after early symptom onset (<6-12 hours) and to restore blood flow.

75. Answer: E.all of the above Explanation: IV administration o f streptokinase, recombinant tissue-type plasminogen activator alteplase, anisoylated plasminogen streptokinase activator, reteplase and tenecteplase may restore blood flow in an occluded artery if adminisered within 12 hrs o f an acute MI.

76.Answer: D. streptokinase Explanation: SK activates the fibrinolytic system and has a greater likelihood o f causing systemic bleeding as compared with recombinant tissue-type plasminogen activator alteplase, reteplase, and tenecteplase.

77. Answer; E. All o f the above Explanation; Absolute contraindications to Recombinant t-PA include active internal bleeding, recent cardiovascular accident, intracranial surgery, spinal surgery, or trauma; severe uncontrolled hypertension etc. Recombinant t-PA is used in the management o f STEMI.

78.Answer: B. reperfusion arrhythmias Explanation: Patients taking streptokinase must be monitored for bleeding, arrhythmias, anaphylactoid reactions, and hypotension. Many patients develop arrhythmias, within 30-45 minutes o f streptokinase administration; these arrhythmias are called reperfusion arrhythmias.

79.Answer: E. A and D Explanation: Rapid rate o f administration, fibrin specificity, fewer bleeding complications, and superior activity in late treated patients as compared to t-PA, make tenecteplase a very likely candidate to replace t-PA as an agent o f choice in STEMI.

80.Answer: B. Heparin Explanation: Heparin has been administered along with the thrombolytics to prevent reocclusion once a coronary artery has been opened. It also appears to decrease mortality in patients with Ml even if they have not received thrombolytic therapy.

81 .Answer: C. Streptokinase Explanation: Unless chosen for a specific clinical indication, heparin use with streptokinase is not recommended because o f the risk o f hemorrhage.

82.Answer: D. Statins Explanation; Statins have not been shown to prevent ischemia in STEMI patients.

83.Answer: C. Enoxaparin Explanation:

Drug Information Resources

Knowing is not enough; we must apply. Willing is not enough; we must do. Johann von Goethe

]. Drug information should fulfill all of the following criteria EXCEPT: A. It should use the most recent, up-todate sources. B. It should be critically examined information. C. It should be relevant. D. It should only be information published in the USA. E. None 2. A Critically examined drug information should fulfill which o f the following criteria? A. More than one source should be used when appropriate. B. The extent o f agreement of sources should be determined; if sources dc not agree, good judgment should b used. C. The plausibility o f information, based on clinical circumstances should be determined. D. A,B&C E. A and B 3. Which of the following sources o f dru information are primary resources? A. British medical journal B. Journal o f pharmaceutical research C. International pharmaceutical abstracts. D. Iowa drug information system E. A and B 5. The main limitation o f primary drug information resources is: A. There is no guarantee that the articles are accurate. B. They do not provide any reliable information about drugs. C. They provide information limited to clinical application o f drugs only. D. The information published can be easily found in textbooks. E. None

6. The lag-time o f secondary drug information resources is: A. The interval of time between an article is submitted for publication and the time it is published. B. The interval o f time between publication o f an article and citation o f the article in an index. C. The interval of time between submission o f a journal to printing press and its distribution to readers. D. The time required for editing a journal. E. None

7. Which o f the following statements is WRONG about secondary drug information resources? A. They are valuable tools for quick and selective screening of the primary literature for specific information, data, citation, and articles. B. In some cases, the sources provide sufficient information to serve as references for answering drug information requests. C. The lag time for all indexing /abstracting services is the same. D. Each indexing or abstracting service reviews a finite number o f journals; therefore relying on only one

4. Primary drug information resources enable the pharmacist to: A. Keep abreast of professional news;. B. Learn how a second clinician handles a particular problem. C. To keep up with new developments in pathophysiology, diagnostic agents, and therapeutic regimens. D. To decide the medical intervention required for a particular patient.

service can greatly hinder the thoroughness o f a literature search. E. None

11 .Which of the following statements is TRUE about internet information resources? A. Information obtained from the internet may not be peer reviewed or edited prior to release. B. A website should be evaluated by its source (author) o f information. C. Pharmacists should use traditional literature evaluation skills to determine whether the information given in the internet is clear, concise, unbiased, relevant and referenced. D. Disclosing name, location, and sponsorship o f the internet resource is an important in assessing the credibility o f the information. E. All o f the above

8. In general abstracts should not be used as primary sources of information because: A. They are not easily available. B. They are generally interpretations o f a study and may be a misinterpretation o f important information. C. They do not have any drug related information. D. They are detailed, thus they may contain irrelevant information. E. None 9. Which o f the following statements is WRONG about tertiary information resources? A. They can provide easy and convenient access to a broad spectrum of related topics. B. The Information might not include the most recent developments in the field. C. They may be misinterpretations o f a primary or secondary literature. D. They are most reliable o f all information resources. E. None

12. All o f the following drug information resources are updated annually EXCEPT: A. B. C. D. The American drug index Drug facts and comparisons The physician5s Desk Reference Martindale: The complete drug reference E. None

13. All of the following provide information about investigational drugs EXCEPT: A. Martindale: The complete reference. B. Drug facts and comparisons. C. Unlisted drugs D. United states pharmacopoeia E. The NDA pipeline drug

10. Once should consider all o f the following when examining and using textbooks as sources o f drug information EXCEPT: A. The year o f publication. B. The country where the book was published. C. The edition o f the text book. D. What are the authors and publishers track records? E. None

14.Orphan drugs are: A. Drugs that are used to prevent or treat a rare disease B. Drugs that are used to prevent or treat a disease common in orphan children.

C. Drugs are that are imported from foreign countries. D. Drugs that do not have adverse effects. E. None 15. Which o f the following provide information regarding orphan drugs? A. Drug facts and comparisons B. The national information center for orphan drugs and rare diseases. C. The physicians desk reference D. British pharmacopoeia E. A and B 16. Which o f the following abstracting/indexing services is known for the information it provides about orphan drugs? A. Pharmaceutical news index B. International pharmaceutical abstracts C. Science citation index D. Drugdex E. None 17. Which o f the following sources are helpful for identification o f an unknown drug (i.e. one that is in hand but not identified)? A. B. C. D. E. Identidex The manufacturer Ident-A-Drug reference A, B and C A and B

19. Which o f the following questions are important to be asked if a patient experiences any signs or symptoms o f a possible adverse reaction? A. How severe was the reaction. B. When did the reaction appear? C. Has the patient (or any member o f the patients family) experienced any allergic or adverse reactions to medications in the past? D. A, B and C E. None 20. All o f the following references provide information about stability o f a drug and its compatibility with other drugs Except: A. Trissels Stability o f compounded formulations. B. Kings Guide to parenteral admixtures. C. Trissels handbook on injectable drugs. D. Medline E. None 21 .After identification o f a drug information resource the step which follows is: A. Giving the final appropriate response to the information inquirer. B. Critical assessment o f the available information. C. To check whether the information included in the source is also found in other information resources. D. To check the background o f the author. E. None

18. All o f the following resources provide information both on approved and unapproved uses o f drugs EXCEPT: A. B. C. D. E. Drugs facts and comparisons AFHS drug information Drugdex Clinical pharmacology None

22. When evaluating a clinical study involving patients which o f the following questions help determine the profile o f the study population? A. Were healthy subjects or affected patients used in the study? B. Were the subjects volunteers?

C. What were the criteria for selecting the subjects? D. How many subjects were included, and what is the breakdown o f age, sex, and race? E. All o f the above 23.If studying a group o f patients that exhibits significant intrapatient variability, researchers may divide the patients into groups according to the variables likely to be associated with responsiveness to therapy. This is known as: A. B. C. D. E. Stratification Segregation Selection Aggregation None

26. All o f the following statements are true about the characteristics o f retrospective studies? A. They look at events that have already occurred to find some common link between them. B. They require reliance on patient memories and require accurate medical record. C. They are useful for studying rare diseases. D. They are able to show cause and effect. E. None

27. Which o f the following are true about prospective studies? A. they look forward in time at a question the study seeks to Answer: choice B. they can be observational C. they can be experimental D. A, B and C E. B and C only

24. Which o f the following statements is FALSE about patient selection o f a clinical study being evaluated? A. Patient selection does not affect the outcomes o f a clinical study. B. If a disease state is being studied in a clinical study, patients should exhibit similar severity o f symptoms. C. By selecting patients with similar characteristics, researchers can avoid results that are caused by individual differences among patients. D. Strong inter-individual differences can obscure the results of the experiment. E. None

28. Which o f the following statements is WRONG about crossover study design? A. It may be used as an additional control for interpatient and intrapatient variability. B. In this study a patient undergoes each type o f treatment, and the sequence in which the subjects undergo treatment is reversed for one group. C. It reduces the possibility that the results were strongly influenced by the order in which therapy was given. D. It is not helpful in uncovering any differences in responsiveness between the groups due to patient selection. E. None

25. Details o f treatment for a drug used in a clinical study may include which o f the following: A. B. C. D. E. Daily dose Frequency o f administration. Route o f administration. Dosage form. All o f the above

29. Which o f the following best describes double blind study? A. It means that the patients do not know whether they received the substance being studied or a placebo and the people observing the patients do not know who is a subject and who is a control. B. Only the people observing the patients do not know who is a subject and who is a control. C. The publisher and the editor o f the journal do not know who was a subject and who was a control in a clinical study. D. Only the patients do not know whether they received the substance being examined or a placebo. E. None

32. If statistical tests show no significant difference between test groups, which o f the following should be checked? A. The number o f patients involved in the study. B. Conclusion o f the study. C. Reputation o f members o f the research team. D. The aim o f the study. E. None 33. In which o f the following situations should a pharmacist be careful in giving information to an information inquirer? A. If a patient asks a pharmacist to identify a tablet that is prescription product known for a high rate o f abuse. B. If a patient asks a pharmacist to how much dose o f the drug can be increased. C. If a patient asks a pharmacist about the cost o f an OTC drug. D. All o f the above E. A and B only

30. Placebos are:


i

A. Products containing less amount df the active ingredient as compared tj> the product under study. B. products that are physically identical to the active dosage form bein^ studied, but does not contain the drug I C. Products containing more amount o f the active ingredient as compared to the product under study. D. Products containing less amount o f the active ingredient as compared tc the product under study. E. None

34. Which o f the following statements is INCORRECT? A. Abstracts can give answers to all drug related questions. B. The inquirer o f drug related information should be alerted o f a possible delay when it takes longer than anticipated to answer the question. C. Drug related information should be organized before attempting to communicate the response to the inquirer. D. When evaluating a clinical study, description o f the physical setting in which the study was conducted is important. E. None

31 .Which o f the following measures helps eliminate carry over effects when comparing between drug therapies? A. B. C. D. E. Use o f parallel study design Use o f controls. Scheduling a run in period Use o f more efficient instruments. None

Answers Drug Information Resources


1. Answer: D. It should only be an information published in the USA. Explanation: Drug information is current, critically examined, relevant data, about drugs and drug use in a given patient or situation. 2. Answer: D. A, B &C Explanation: Critically examined information should meet the following criteria: -more than one source should be used when appropriate. -the extent o f agreement o f sources should be determined -the plausibility o f information, based on clinical circumstances should be determined. 3. Answer: E. A and B Explanation: There are three sources o f drug information: journals, (primary sources), indexing and abstracting services (secondary sources), and textbooks (tertiary sources). British medical journal and Journal o f pharmaceutical research are primary resources. International Pharmaceutical abstracts and Iowa drug information system belong to the indexing and abstracting services which are categorized under secondary sources. 4. Answer: E. A, B, and C Explanation: Primary drug information resources do not help the pharmacist decide the medical intervention required for a particular patient (in fact this is not the job o f a pharmacist). Journals enable the pharmacist to: -keep up with new developments in pathophysiology, diagnostic agents, and therapeutic regimens. - Distinguish useful from useless or even harmful therapy. -Enhance communication with other health-care professionals and consumers. -Obtain continuing education credits. - Keep abreast of professional news. - prepare for board certification examination in pharmacotherapy, nutrition support etc. 5. Answer: A. There is no guarantee that the articles are accurate. Explanation: Although publication o f an article in a well-known, respected journal enhances the credibility o f information contained in an article, this does not guarantee that the articles are accurate.

6. Answer: B. The interval o f time between publication o f an article and citation o f the article 'in an index.

Explanation: Lag-time is the interval o f time between publication o f an article and citation o f that article in an index.

7. Answer: C. The lag time for all indexirg /abstracting services is the same. Explanation: There is substantial difference in lag time anliong various indexing /abstracting services.

8. Answer: B. They are generally interpretations o f a study and may be a misinterpretation of important information. Explanation: Indexing and abstracting services are primari ly used to locate journal articles. In general, abstracts should not be used as primary sourc es o f information because they are generally interpretations o f a study and may be a misi:rtterpretation o f important information. Pharmacists should obtain and evaluate the original articl s because abstracts might not tell the whole story.

9. Answer: D. They are most reliable o f all information resources. Explanation: General reference textbooks can provide e asy and convenient access to a broad spectrum of related topics. Background information on drugs and diseases is often available. Although a textbook might answer many drug-related questions, the limitations o f these resources should not be overlooked. It could take several years to publish a text, so information available in textbooks might not include the most recent developments in fhe field. Other resources should be to update or supplement information obtained from textbooks. The author o f a textbook might not have done a thorough search o f the literature, so pertinent data could have been omitted. An author also rhight have misinterpreted the primary or secondary literature. Reference citations should be available to verify the validity and accuracy o f the data. 10. Answer: B. The country where the book was published. Explanation: General considerations when examining ar d using textbooks as sources o f drug information include: - The year of publication (copyright date) - The edition o f the text: is it the most current edition? - The author, publisher, or both: what are the authors and publishers track records? - The presence or absence o f a bibliography: if a bibliography is included, are important statements accurately referenced? When were the references published? - The scope o f the textbook: how accessible is the information? - Alternative resources that are available (e.g. primary and secondary sources, other relevant texts). The country o f publication o f the book is not important. (Examining the authors and publishers track records is more than enough)

]] . Answer: E. all o f the above j Explanation: I Information received from the internet may be as reliable as the person who posted it and the users who read and comment on its content. A web site should be evaluated by its source (author) o f information. The name, location, and sponsorship should be disclosed. Also, a reputable site will provide an ease o f access to information and the ability to give feed back. Pharmacists should use traditional literature evaluation skills to determine whether the information given in the internet is clear, concise, unbiased, relevant and referenced. 12.Answer: D. Martindale: The complete drug reference Explanation: Martindale: The complete drug reference is updated every 3 years.

13.Answer: D. United states pharmacopoeia Explanation: j For investigational drugs the resources available are: - Martindale: the complete Drug reference - Drug facts and comparisons ; - Unlisted drugs | - The NDA(new drug application) pipeline The United States pharmacopoeia doe^ not provide information about new investigational drugs.

14.Answer: A. Drugs that are used t6 prevent or treat a rare disease Explanation: Orphan drugs are drugs used to prevent or treat a rare disease.

15.Answer: E. A and B

i j

Explanation: j For orphan drugs the resources available are: -Drug facts and comparisons J -The national information center for orphan drugs and rare diseases. -Drugdex The physicians desk reference and the British pharmacopoeia do not exclusively provide information regarding orphan drugs. |

16.Answer: D. Drugdex Explanation: j Drugdex provides information aboilt orphan drugs. 17.Answer: D. A, B and C

Explanation: For an unknown drug (i.e. one that is in hand but not identified),the following sources can be consulted for help: - The PDR, drug facts and comparisons! Drug topics Red book, Ident-A-Drug reference - Identidex - The manufacturer Lexi-Comps clinical reference library-dru; y identification. ] 8.Answer: D. Clinical pharmacology Explanation: Clinical pharmacology studies the clinical use o f drugs. It is not concerned with the unapproved uses o f drugs. 19. Answer: D. A, B and C Explanation: All o f the above are important questions if a patient experiences any signs or symptoms o f a possible adverse reaction. j

20.Answer: D. Medline Explanation: Medline is an abstracting/abstracting service which provides health related information. It does not specifically provide information about stability and compatibility o f drugs. I f the stability o f a drug, compatibility With other drugs, the administration technique, and the equipment that holds it is required, the resources which might be referred to are: -T rissels Stability o f compounded formulations. - Kings Guide to parenteral admixtures. - Trissels handbook on injectable drugs.

21 .Answer: B. Critical assessment o f th i available information. Explanation: After an information resource has been identified for required information; it is followed by Critical assessment o f the available information. This step is critical in developing an appropriate response.

22. Answer: E. All o f the above Explanation: When evaluating the subjects o f the study determining the profile o f the study population is by looking for the following information: - Were healthy subjects or affected patients used in the study? - Were the subjects volunteers? - What were criteria for selecting the subjects? - How many subjects were included and kvhat is the breakdown o f age, sex, and race?

-What was the patient selection method, and who was excluded from the study?

23.Answer: A. Stratification Explanation: If studying a group o f patients that exhibits significant intrapatient variability, researchers may divide the patients into groups according to the variables likely to be associated with responsiveness to therapy. This is known as stratification.

24.

Answer: A. Patient selection does not affect the outcomes o f a clinical study.

Explanation: Patient selection is one o f the important factors which affect the outcomes o f a clinical study. 25. Answer: E. All o f the above Explanation: For each drug being investigated, determine the following information: 1. Details o f treatment with the drug being studied - Daily dose, Frequency o f administration, route o f administration, hours o f a day when administered, source o f drug (i.e. supplier), dosage form, total duration o f treatment. 2. Other therapeutic measures in addition to the agent being studied 26. Answer: D. They are able to show cause and effect. Explanation: Retrospective studies look at events that have already occurred to find some common link between, require reliance on patient memories and accurate medical records , and are unable to show cause and effect. Retrospective studies are useful for studying rare diseases (or effects) and can help to decide if enough information exists to warrant prospective examination o f a problem. 27. Answer: D. A, B and C Explanation: Prospective studies look forward in time at a question the study seeks to answer. They can be observational or experimental (i.e. clinical trials).

28. Answer: D. It is not helpful in uncovering any differences in responsiveness between the groups due to patient selection. Explanation: Crossover design may be used as an additional control for interpatient and intrapatient variability. In this type o f study design, each patient group undergoes each type o f treatment. However, the sequence in which the subjects undergo treatment is reversed for one group. Crossover design reduces the possibility that the results were strongly influenced by the order in which therapy was given. And because both groups o f patients receive both types o f treatment, any difference in responsiveness between the groups due to patient selection will be uncovered.

29. Answer: A. It means that the patients do not know whether they received the substance being studied or a placebo and the people Observing the patients do not know who is a subject and who is a control. Explanation: In a double blinded clinical study both t le patients (the patients do not know whether they received the substance being studied or i placebo) and the people are blinded (the people observing the patients do not know who is a subject and who is a control).

30.Answer: B. products that are physical y identical to the active dosage form being studied, but does not contain the drug. Explanation: Placebos are products that are physically idfentical to the active agent being studied. They do not contain any therapeutic substance. (A drug plroduct minus the active ingredient).

31 .Answer: C. Scheduling a run in period

Explanation: A run in period (wash out) is a period where the effects o f previous drug therapy are minimized, so that its effects are not carried over to and nterfere with effects o f next drug given.

32.Answer: A. The number o f patients inv jived in the study. Explanation: I f statistical test results do not show signific ant difference between test groups, it is advisable to check the whether there were enough patients or not. ( i.e statistical power).

33.Answer: E. A and B only Explanation: Response is not necessary if the inquirer intends to misuse or abuse information that is provided. The inquirer often admits intent or offers clues to potential abuse, such as in the following examples: - A patient asks how a certain drug is dosed (i.e. how much the drug can be increased, when it can be increased, what the maximum daily dose is). This kind o f inquiry signals that the patient might be adjusting his or her owni therapy. A patient asks a pharmacist to identify a tablet that is a prescription product known for a high rate o f abuse. 34.Answer: A. Abstracts can give Answer bhoices to all drug related questions. Explanation: j The pharmacist should use more than abstracts to answer drug information questions because they might be taken out o f context and do not include all of the data available in the original article. ~

Drug Interactions

Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.

Dale Carnegie

1. Which o f the following is/are true about drug interaction? A. It refers to the altered response o f a drug as a result o f administration o f another substance B. It may be employed to improve therapeutic response C. it may be used to decrease adverse drug effects D. It may be harmful to the patient E. all o f the above

A. B. C. D. E.

Pharmacodynamic interaction Pharmacokinetic interaction Pharmaceutical interaction Pharmacodynamic interaction B and D

6. Which o f the following is not true about the effect o f drug-interaction up on the absorption o f drugs? A. Drug interaction always results in decreased rate o f absorption B. Drug interaction always decreases bioavailability o f drugs C. The extent o f drug absorption is not affected by drug-interaction D. Only drug absorption from the GIT is affected by drug-interaction E. All o f the above

2. A precipitant drug is A. The drug affected by the B. The substance which interaction negatively C. The substance which interaction positively D. The substance which interaction E. A and C interaction affects the affects the causes the

7. Which o f the following is a wrong match between a precipitant drug and the kind o f drug interaction it is involved? A. Cholestyramine; adsorption B. Anticholinergic drugs; decreased GI motility C. Antacids; alteration o f gastric pH D. Antibiotics; alteration o f intestinal flora E. None o f the above

3. Drug interaction includes all o f the following except A. B. C. D. E. Drug-blood protein interaction Food-drug interaction Chemical-drug interaction Drug-laboratory interaction Drug-drug interaction

4. The interaction caused by a chemical or physical incompatibility when two or more drugs are mixed together is called A. B. C. D. E. Pharmacokinetic interaction Biopharmaceutical interaction Pharmacodynamic interaction Pharmaceutical interaction Chemical- drug interaction

8. Activated charcoal decreases the bioavailability o f many drugs because A. B. C. D. It increases the intestinal motility It decreases the pH o f the GI tract It has the ability to adsorb drugs It has the ability to form chelation with drugs E. All o f the above

5. The precipitation o f phenytoin sodium from a solution that has an acidic pH, such as dextrose 5% is classified as

9. The type o f drugs that are more likely to be affected by laxatives and cathartics include

A. Drugs that are absorbed slowly B. Controlled release drugs C. Drugs that are metabolized in the small intestine D. Drugs that are degraded in the stomach E. A and B

13.Digoxin toxicity can be enhanced by concurrent administration o f quinidine. This is because A. Quinidine inhibits the metabolism o f digoxin B. Quinidine displaces digoxin from plasma protein binding site C. Quinidine displaces digoxin from tissue binding site D. Quinidine binds with digoxin inhibiting protein binding o f digoxin E. A and C

10.Digoxin has better bioavailability if administered after erythromycin. This is because, A. Erythromycin decreases the gastric pH B. Erythromycin decreases the GI motility C. Erythromycin reduces the bacterial inactivation o f digoxin D. Erythromycin decreases the stomach degradation o f digoxin E. All o f the above

14. Which o f the following affect hepatic drug metabolism, A. Enzyme induction B. Enzyme inhibition C. Substrates competition for the same metabolizing enzymes D. Change in hepatic blood flow E. All o f the above

11 .Digoxin administration often increases the bioavailability o f many object drugs in case o f CHF. This is because A. Digoxin increases blood flow into GI B. Digoxin decreases the rate renal excretion o C. Digoxin decreases hepatic metabolism D. Digoxin decreases acid secretion from stomach E. All o f the above

15. A patient taking the drug cyclosporine is advised not to take St.Johns wort since A. St. Johns wort induces the enzyme that metabolize cyclosporine so that there is accumulation o f the toxic metabolite o f the drug B. St. Johns wort inhibits the enzyme responsible for the metabolism o f cyclosporine thus leading to toxic accumulation o f the drug C. St. Johns wort induces the enzyme that metabolizes cyclosporine resulting in sub-therapeutic level o f the drug D. St.Johns wort inhibits the clearance o f cyclosporine as a result o f which there increased level o f the drug E. B and D ,

12.Calcium, magnesium or aluminum and iron salts are known to cause the following that can lead to drug interaction. A. B. C. D. Inhibition o f drug metabolism Alteration of gastric pH Complexation/chelation Competition for carrier mediated drug absorption E. B and C

16.Grape juice should be avoided when taking one o f the following drugs

A. B. C. D. E.

Cimetidine Cyclosporine Isoniazid Saquinavir All o f the above

C. feverfew D. garlic E. all the above

21 .The type and extent o f interaction between herbs and drugs is directly influenced by A. The stage o f growth during which the herb was harvested B. The solvents used in extraction o f the herb C. The shelf life o f the herbal extract D. The relative potency o f each constituents in the herb E. All o f the above

17.The effect o f methylxanthines upon many drugs is A. B. C. D. E. To increase the blood level To increase the metabolism To increase renal excretion To increase extrarenal excretion All o f the above

18. Which o f the following is/are the effect(s) o f antacids up on salicylates A. They increase the ionization o f salicylates B. They decrease the tubular reabsorption o f salicylates C. They increase the clearance o f salicylates D. B and C E. A, B and C

22. Which o f the following is not true about food-drug interaction? A. Food can increase, decrease or not affect the absorption o f drugs B. The effect o f food upon the bioavailability o f drugs is more pronounced for modified release dosage forms than for immediate release ones C. Foods do not antagonize drugs pharmacologically. D. Food can compete for metabolizing enzyme with other drugs E. None o f the above

19.The fact that probenecid can increase the blood levels o f penicillin and some cephalosporin antibiotics is attributed to A. B. Its ability to increase renal perfusion Its ability to decrease glomerular filtration rate C. Its ability to increase the urine pH D. Its ability to increase tubular reabsorption o f these drugs E. Its ability to block active tubular secretion o f these drugs

23. The metabolism o f one o f the following drugs is not affected by smoking. A. B. C. D. E. Theophylline Penicillin Diazepam Amitriptlylin None o f the above

20. Which o f the following herbal preparations should be avoided in patients taking warfarin? A. ginger B. wheat grass

24. Which o f the following is not true about the effect o f alcohol upon the metabolism o f drugs?

I .Alcohol increases the activity of hepatic drug metabolizing enzymes II Alcohol decreases the activity of hepatic drug metabolizing enzymes III Acute alcohol intoxication can inhibit hepatic enzymes in nonalcoholic individuals A. B. C. D. E. I only I and III II and III II only I, II and III

28. Which o f the following combination o f drugs does not have beneficial effects? A. Trimethoprim and sulfamethoxazole B. Amoxicillin and clavulanate potassium C. Phenobarbital and Warfarin D. Hydrochlorothiazide and triamterene E. None

25. Which o f the following are examples of pharmacodynamic type o f drug-drug interactions? A. B. C. D. E. Alcohol and antihistamines Thiazide derivatives and digoxin Aspirin and warfarin Promethazine All o f the above

29. Which o f the following is a wrong match between a class o f the likelihood o f a drug interaction and its definition? A. Established - a drug interaction supported by well-proven clinical studies B. Probable - a drug interaction that could occur; limited date available C. Suspected - a drug interaction that might occur; some date might be available D. Unlikely - a drug interaction that is doubtful; no good evidence o f an altered clinical effect is available. E. None o f the above

26.One o f the following would be expected to trigger drug interaction A. B. C. D. E. Multiple-drug therapy Multiple prescribers Patient compliance Patient age all o f the above

30. One o f the following is not needed to be considered in the clinical relevance o f a potential drug interaction. A. B. C. D. E. Size o f the dose Dosage form Extrapolation to related drugs Onset o f the potential interaction Duration o f the therapy.

27. Which o f the following is not true about the clinical significance o f drug-drug interaction? A. All drug interactions are clinically significant B. Not all drug interactions cause adverse effects C. Sometimes it is possible to prescribe interacting drugs D. Drug interactions could be exploited to reduce adverse effects E. Therapeutic efficiency could be improved by administrating interacting drugs

ANSWERS Drug interactions


1. Answer: E.all of the above Explanation: Drug interaction refers to an altered drug response produced by the administration o f a drug or co-exposure of the drug with another substance, which modifies the patients response to the drug. Some drug interactions are intentional in order to provide improved therapeutic response or to decrease adverse drug effects.

2. Answer: D. The substance which causes the interaction. Explanation: A precipitant drug is the drug, chemical, or food element causing the interaction. The drug affected by the interaction is known as an object drug.

3. Answer: A. Drug-blood protein interaction. Explanation: Drug interactions include drug-drug interaction, drug-herbal interaction, food-drug interaction, chemical drug interaction, and drug-laboratory interaction. The interaction between drugs and blood proteins is not considered as a type o f drug interaction since by definition drug-interaction is between drugs and other drugs or substances and not with body components/molecules.

4. Answer: D. Pharmaceutical interaction. Explanation: The interaction which occurs when the absorption, distribution, (protein and tissue binding), or elimination (excretion and/or metabolism) o f the drug us affected by another drug, chemical or food element is called pharmacokinetic or biopharmaceutical interaction. Pharmacodynamic interactions occur when the pharmacodynamic effect o f the drug is altered by another drug, chemical or food element producing an antagonistic, synergistic, or additive effect. Pharmaceutical interactions are those caused by a chemical or physical incompatibility when two or more drugs are mixed together.

5. Answer: C. Pharmaceutical interaction. Explanation: Pharmaceutical interactions can occur during the extemporaneous preparation o f drugs, including preparation o f IV solutions. For example, the interaction between phenytoin sodium and the acidic dextrose 5% solution can lead to the precipitation o f the former. This is typical example of pharmaceutical interaction.

6. Answer: E. All o f the above. Explanation: Drug-interactions can affect the rate and the extent o f drug absorption (bioavailability) from the absorption site, resulting in increased or decreased drug bioavailability. The most common drug absorption site is in the GI tract. However, drug bioavailability from other absorption sites, such as the skin, can be affected by drug interactions. For example, epinephrine, a vasoconstrictor, will decrease the percutaneous absorption o f lidocaine, a local anesthetic agent.

7. Answer: E. None o f the above Explanation: All the given choices are correct.

8. Answer; C. It has the ability to adsorb drugs. Explanation: Activated charcoal has the ability to adsorb many drugs thus decreasing the amount o f drugs available for absorption and therefore, decrease their bioavailability. Other precipitant drugs with similar properties are cholestyramine and kaolin.

9. Answer: E. A and B. Explanation: The effect o f laxatives and cathartics is to increase the GI motility. GI motility decreases the bioavailability o f drugs that are absorbed slowly. It may also affect the bioavailability o f drugs from controlled-release drugs.

10. Answer: C. Erythromycin reduces the bacterial inactivation o f digoxin Explanation: Antibiotics like erythromycin have the ability to decrease the microbial flora o f the GI tract. Since digoxin is one o f the drugs that are degraded by the intestinal bacteria, its bioavailability will be increased if these bacteria are reduced by administering drugs like erythromycin.

11 .Answer: A. Digoxin increases blood flow into GI. Explanation: In congestive heart failure, the blood flow to the GJ tract is poor and an orally administered drug can have a slower rate o f bioavailability. After digoxin therapy, the perfusion o f the GI tract is improved along with bioavailability o f the object drug.

12.Answer: E. B and C.

Explanation: Levofloxacin complexes with divalent cations (Ca, Mg, Al, Fe) causing a decreased bioavailability. Antacids increase gastric pH, which can lead to reduced dissolution o f drugs like ketoconazole and omeprazole.

13.Answer: C. Quinidine displaces digoxin from tissue binding site. Explanation: The distribution o f the drug may be affected by plasma protein binding and displacement interactions or tissue and cellular interactions. For example, Valproic acid displaces phenytoin from plasma protein-binding sites and reduces hepatic phenytoin clearances by inhibiting the livers metabolism of phenytoin. Aspirin decreases protein binding and inhibits the metabolism of valproate. Quinidine reduces digoxin clearance and displaces digoxin from tissue-binding sites, leading to a higher plasma digoxin concentration and reduces distribution volume. This can result in enhanced digoxin toxicity by concurrent administration o f quinidine.

14.

Answer: E. All o f the above

Explanation: The metabolism o f drugs by liver is affected by such factors as the induction or inhibition of enzymes involved. Many drugs that share the same drug-metabolizing enzymes have also the potential for a drug interaction. A decrease in the hepatic blood flow can decrease the hepatic clearance for high extraction drugs, such as propranolol and morphine.

15.Answer: C. St. Johns wort induces the enzyme that metabolizes cyclosporine resulting in sub-therapeutic level o f the drug Explanation: Over the counter (OTC) drugs and herbal preparations can also be involved in CYP450 isoenzyme metabolism and can cause serious drug-herbal interactions. For example, St. Johns wort may induce CYP3A4 isoenzymes and decrease cyclosporine to sub-therapeutic levels.

16.Answer: D. Saquinavir. Explanation: Foods may interfere with hepatic drug metabolism. For example, grape juice is a powerful inhibitor of the CYP3A4 isoenzyme, and will increase blood levels o f saquinavir if taken together.

17.Answer: C. To increase renal excretion. Explanation: Renal drug clearance can be affected by changes in glomerular filtration, tubular reabsorption, active drug secretion, and renal blood flow and nephrotoxicity. For example, methylxanthines

(e.g., caffeine, theobromine) increase renal blood flow and GRF will decrease time for absorption o f various drugs, leading to more rapid urinary drug excretion.

18.Answer: E. A,B and C Explanation: Antacids (and sodium bicarbonate) increase the pH of urine. This alkalization o f urine pH results in increased ionization o f the salicylates, decreased reabsorption, and thus increases the clearance o f salicylates. Other drug affected by antacids and sodium bicarbonate is amphetamine. Alkalization o f the urine due to the antacids/sodium bicarbonate increases the reabsorption o f amphetamine and decreases its clearance.

19.

Answer: E. Its ability to block active tubular secretion of these drugs.

Explanation: Probenecid has the ability to block the active tubular secretion o f these drugs, thus decreasing their renal clearance and thereby increase the blood levels of these drugs.

20. Answer: E. all the above. Explanation:

Ginger, wheat grass, feverfew, and garlic are known to increase the bleeding time in patients taking warfarin. Therefore, patients on warfarin treatment should avoid these herbal preparations.

21 .Answer: D. The relative potency o f each constituents in the herb. Explanation: In herbal-drug interactions, the predominant effect or interaction depends upon the relative potency o f each constituent in the herb. Potency is affected by a variety o f factors which include, the stage o f growth during which the herb was harvested, the solvents used in extraction o f the herb, the shelf life and storage condition o f the herbal extract, and drying time.

22. Answer: C. foods do not antagonize drugs pharmacologically Explanation: There are examples in which food pharmacologically antagonize the effect of drugs. Spinach and broccoli provide dietary sources o f vitamin K, which antagonize the effect o f warfarin.

23.Answer: B. Penicillin. Explanation: Smoking by inhaling aromatic polycyclic hydrocarbons can increase the intrinsic clearance (enzyme induction) o f drugs such as theophylline, diazepam, and tricyclic antidepressants (e.g., amitriptlyn).

24.Answer: E. I, II and III. Explanation: Alcohol can increase or decrease the activity o f hepatic drug metabolizing enzymes. Chronic alcoholism can increase the rate o f metabolism o f tolbutamide, warfarin, and phenytoin. Acute alcohol intoxication can inhibit hepatic enzymes in nonalcoholic individuals.

25.

Answer: E. All o f the above

Explanation: Drugs that have similar pharmacodynamic actions may produce an excessive pharmacological or toxic responses. For example, central nervous system depressants, such as the combination o f alcohol and anthistamines (e.g., chlorpheniramine) can produce increased drowsiness in the patient. The alteration o f electrolyte concentrations produced by a diuretic, such as a thiazide derivative, will deplete potassium, resulting in sensitization o f the heart to digoxin therapy. By inhibiting platelet aggregation, aspirin increases the risk o f bleeding in patients on anticoagulant (e.g., warfarin, dicoumarol, clopidogrel) therapy.

26. Answer: E. All of the following Explanation: Multiple drug therapy, including both prescription and nonprescription (OTC) medication, can potentially lead to drug interaction. The more drugs used by a patient, the greater the potential for a drug interaction in the patient. Patients can be seen by different prescribes who prescribe interacting medication. Patients need to follow proper instruction for taking medications. For example, a patient might take tetracycline with food rather than before meals. Older patients are at more risk for drug interactions than younger patients. Older patients might have changes in their physiological and pathophysiological condition that lead to altered body composition, altered GI transit time and drug absorption, decreased protein binding, altered distribution, and decreased drug clearance. Patients with predisposing illness (diabetes, AIDS, asthma and alcoholism) and patients who are clinically hypersensitive (atopic) are more at risk for drug interaction than non-atopic patients. 27. Answer: A. All drug interactions are clinically significant. Explanation: Not all drug interactions are clinically significant and not all drug interactions could cause adverse effects. In some cases, interacting drugs can be prescribed for patients as long as the patient is given proper instructions and is complaint. For example, cimetidine and antacid might be prescribed to the patient, but the patient should be instructed not to take both medications at the same time. Combination o f interacting drugs may be used to improve the therapeutic objective or to decrease adverse effects.

28.Answer: C. Phenobarbital and Warfarin. Explanation:

Phenobarbital and Warfarin should not be administered simultaneously, since phenobarbital increases the metabolism o f Warfarin making its blood concentration below the therapeutic level. Trimethoprim and sulfamethoxazole are combination antibiotics that may be used for increased efficacy in urinary tract infection. The combination o f amoxicillin and clavulanate potassium is a combination in which a P-lactamase inhibitor (clavulanate) is used to inhibit the break down of amoxicillin. Hydrochlorothiazide and triamterene constitute a combination o f a diuretic and antihypertensive to minimize potassium excretion.

29. Answer: B. Probable - a drug interaction that could occur; limited date available. Explanation: A probable likelihood o f drug interaction is one in which a drug interactions is very likely but might not be proven clinically. If the situation is such that, a drug interaction could occur but only limited data is available, the likelihood is called possible.

30.Answer: B. Dosage form Explanation: The clinical relevance o f a potential drug interaction should also consider size o f the dose and the duration o f therapy; onset (rapid, delayed) and severity (major, moderate, minor) o f the potential interaction; and extrapolation to related drugs. The dosage form is less important in drug interaction.

Endocrinology & Related Drugs

pv

The minute you settle for less than you deserve, you get even less than you settled for. Maureen Dowd

1. Which one o f the following is posterior pituitary hormone? A. growth hormone B. human chorionic gonadotropin C. vasopressin D. thyrotropin E. none o f the above

6. A hormone that plays an important role in the induction o f labor is A. B. C. D. E. vasopressin oxytocin menotropin corticotropin urofollitropin

2. Which one o f the following anterior pituitary hormones is used therapeutically? A. B. C. D. E. thyrotropin menotropin human chorionic gonadotropin leuteinizing hormone all

7. Which one o f the following hormones is present in the urine o f pregnant woman? A. B. C. D. urofollitropin corticotropin thyroid-stimulating hormone human chorionic gonadotropin(HCG) E. all o f the above

3. Thyrotropin is A. adrenocorticotropic hormone B. somatotropin C. thyroid-stimulating hormone D. follicle-stimulating hormone E. none o f the above 8. Corticotropin is used A. to treat post operative abdominal distention B. to control postpartum bleeding and hemorrhage C. to induce spermatogenesis D. for the diagnosis and differentiation o f primary and secondary adrenal insufficiency E. none o f the above

4. One o f the following hormones has high FSH-like activity menotropin urofollitropin human chorionic gonadotropin human menopausal gonadotropin E. luteneinizing hormone A. B. C. D.

9. One o f the following hormones is used to treat neurogenic diabetes insipidus A. B. C. D. E. vasopressin menotropins oxytocin corticotropin none o f the above

5. All o f the following are therapeutically important pituitary hormones .EXCEPT A. growth hormones B. corticotropin C. urofollitropin D. oxytocin E. none o f the above

10.All are adverse effects associated with the use of oxytocin, EXCEPT

A. B. C. D. E.

Gynecomastia uterine hypertonicity water intoxication neonatal jaundice post partum haemorrhage

A. clomiphene B. chlorotrianisene C. tamoxifen citrate D. toremifene citrate E. fulvestrant

11 .Most o f the natural and synthetic gonadal hormones are derivatives of A. cyclopentanoperhydrophenanthr ene B. bipyridine C. sulfamoylbenzamide D. phenylcyclopropylamine E. aromatic amino acids

16.Estrogen receptors are found in A. hypothalamus B. mammary glands C. anterior pituitary D. uterus E. all o f the above

17. All are therapeutic uses o f estrogens, EXCEPT 12. Steroid hormones that have aromatic A ring is A. B. C. D. E. progestin estrogen androgen gonadotropin none o f the above A .acne B. osteoporosis C. anemia D. urogenital atrophy E. vasomotor disorders

13.The two estradiol derivatives that are used as oral contraceptives are A. ethinyl estradiol and mestranol B. estradiol cypionate and estradiol valerate C. estrone and estriol D. diethylstilbestrol and quinestrol E. estrone and quinestrol

18. One o f the following is estrogen antagonist that is used to treat estrogen dependent breast cancer A. clomiphene B. tamoxifen C. quinestrol D. none

19. Which one o f the following is steroidal irreversible inhibitor of aromatase? A. anastrozole B. exemestane C. letrozole D. raloxifene E. none o f the above

14.All are nonsteroidal synthetic estrogens EXCEPT A. dienestrol B. chlorotrianisene C. quinestrol D. diethylstilbestrol E. none o f the above 15.One o f the following is not estrogen antagonist

20. Which one o f the following is selective estrogen receptor modulator?

A. raloxifene B. anastrozole C. clomiphene D. fulvestrant E. letrozole

25. One o f the following is structurally classified as androgen but contains progestational activity A. norethindrone B. fluoxymesterone C. dromostanolone D. oxandrolone E. none o f the above

21 .Selective estrogen receptor modulators( SERMs) are used for the prevention of A. breast cancer B. hepatic adenomas C. osteoporosis D. endometrial cancer E. all o f the above

26.Progestins are used therapeutically for all, EXCEPT A. oral contraceptives B. breast cancer C. endometriosis D. uterine bleeding E. none o f the above

22. Which class o f drugs is used to treat advanced breast cancer? A. estrogens B. selective estrogen receptor modulator C. antiestrogens D. aromatase inhibitors E. progestins

27. Which o f the following is the adverse effect o f progestin? A. irregular menses B. amenorrhea C. exacerbation o f breast carcinoma D. weight gain and oedema E. all o f the above

23. Which one o f the following is a naturally occurring progestin? A. megestrol B. progesterone C. medroxyprogesterone D. norethindrone E. norethynodrel 28.One o f the following is a naturally occurring androgen A. fluoxymesterone B. oxandrolone C. testosterone D. progesterone E. A and C

24. Which one o f the following is a 17 ahydroxyprogesterone derivative? A. B. C. D. E. norethindrone ethynodiol diacetate norgestrel megestrol acetate mestranol 29.Drug that have enhanced anabolic effect than androgenic effect is A. testosterone B. fluoxymesterone C. dromostanolone D. nilutamide E. none o f the above

30.The enzyme that converts testosterone to dihydrotestosterone is A. 5 a-reductase B. aromatase C. esterase D. 5-p-reductase E. none o f the above

B. flutamide - antiandrogens C. nilutamide - inhibit the action o f androgens by competitively binding to androgen receptors in the target tissue D. bicalutamide - inhibits the conversion o f testosterone to 5 a-dihydrotestosterone E. none o f the above

31. Which one o f the following compounds is incorrectly matched with its therapeutic use? A. flutamide - treatment o f prostate cancer B. oxandrolone - anemia C. dromostanolone - oral contraceptive D. finasteride - benign prostatic hyperplasia E. finasteride androgenic alopecia

35.The therapeutic use o f 5 a-reductase inhibitors is A. androgenic alopecia B. anabolic therapy C. breast cancer D. endometriosis E. oral contraception

36.Antiandrogens are therapeutically used for A. anabolic therapy B. treatment o f prostate cancer C. menstrual disorder D. oral contraceptive E. none of the above

32. Which o f the following is the adverse effect o f androgens A. B. C. D. psychological changes liver disorders decreased fertility in male development o f masculine features in females E. all o f the above

37. A drug which has increased glucocorticoid activity without an increase in the mineralocorticoid activity is A. hydrocortisone B. prednisolone C. dexamethasone D. fludrocortisone E. cortisone

33. All are antiandrogens, EXCEPT A. flutamide B. bicalutamide C. finasteride D. nilutamide E. none o f the above

38.Fludrocortisone has 34.All the following compounds are matched to the correct mechanism of action, EXCEPT A. finasteride - 5 a-reductase inhibitor A. increased glucocorticoid and decreased mineralocorticoid activity B. increased mineralocorticoid and decreased glucocorticoid activity

C. increased mineralocorticoid and glucocorticoid activity D. decreased mineralocorticoid and glucocorticoid activity E. none o f the above

42. Which one o f the following drugs has enhanced topical absorption? A. fluprednisolone B. fluocinonide C. prednisolone D. dexamethasone E. none o f the above

39.Fluorination o f hydrocortisone and cortisone at position C-6 A. increases both mineralocorticoid and glucocorticoid activity B. increases mineralocorticoid and decreases glucocorticoid activity C. increases glucocorticoid activity and decreases mineralocorticoid activity D. increases glucocorticoid activity with less effect on mineralocorticoid activity E. decreases both glucocorticoid and mineralocorticoid activity

43.Aldosterone is formed in A. middle layer o f the adrenal cortex B. outer layer o f the adrenal cortex C. fascicular o f the adrenal cortex D. B and C E. none o f the above

44. Which one of the following drugs are clinically useful mineralocorticoids? A. triamcinolone and fluocinonide B. desoxycorticosterone acetate and dexamethasone C. fludrocortisone acetate and fluprednisolone D. desoxycorticosterone acetate and fludrocortisone acetate E. desoxycorticosterone acetate and fluprednisolone

40. Which one o f the following is prototypical glucocorticoid? A. hydrocortisone B. prednisolone C. aldosterone D. fludrocortisone E. prednisone

41 .The prototypes cortisone and hydrocortisone are modified to A. increase the glucocorticoid activity only B. increase both glucocorticoid and mineralocorticoid activity C. increase the glucocorticoid activity and decrease the mineralocorticoid activity D. decrease both glucocorticoid and mineralocorticoid activity E. decrease glucocorticoid and increase mineralocorticoid activity

45. Which o f the following glucocorticoid has the least mineralocorticoid activity? A. B. C. D. E. cortisone dexamethasone fludrocortisone prednisolone hydrocortisone

46.Adrenocorticosteroids are therapeutically used for A. treatment o f collagen vascular diseases

B. inflammatory ocular disorders C. treatment o f rheumatic carditis D. nephritic syndrome E. all o f the above

B. C. D. E.

liotrix thyroglobulin thyrotropin none o f the above

47.All are adverse effects associated with the use o f adrenocorticosteroid , EXCEPT A. suppression o f pituitary-adrenal integrity B. cholestatic jaundice C. increased intraocular and intracranial pressures D. cushingoid moon face and buffalo hump E. ulcerative esophagitis

51 .One o f the following thyroid hormones is less potent but has a longer duration o f action A. B. C. D. E. thyrotropin levothyroxine thyroglobulin liothyronine none o f the above

52.The administration o f levothyroxine sodium can produce the natural ratio o f A. B. C. D. E. 4 to 4 to 3 to 3 to 2 to 1 o f T4 to T3 I o f T3 to T4 1 o f T3 to T4 1 o f T4 to T3 1 o f T4 to T3

4 8.The enzyme that converts levothyroxine T4 to liothyronine T3 is A. B. C. D. E. 5 a-reductase iodoperoxidase 5'-deiodinase 5-iodinase none

53. Which one of the following is NOT a true statement? A. levothyroxine and liothyronine are naturally occurring thyroid hormones B. levothyroxine can be converted to liothyronine in the peripheral circulation C. levothyroxine is more potent than liothyronine D. the plasma concentration of liothyronine is less than that of levothyroxine E. levothyroxine is less potent than liothyronine

49. Which one o f the following is the hormone that stimulates the production o f T4 and T3 by the thyroid gland? I. thyroid stimulating hormone II. thyrotropin - releasing hormone III. thyrotropin A. B. C. D. E. I only II only I & II II and III I & III

50.A thyroid preparation which is highly purified and lyophilized thyrotropic hormone isolated from bovine anterior pituitary gland is A. thyroid

54.All are thyroid function inhibitors, EXCEPT A. propylthiouracil B. liotrix C. methimazole

D. lugols solution E. none o f the above

B. C. D. E.

radio active iodine ionic inhibitors lugols solution methimazole

55.A drug that inhibits the conversion o f T4 to T3 is A. lugols solution B. radioactive iodine C. methimazole D. propylthiouracil E. none o f the above 60. One o f the following drugs decreases the absorption o f thyroid hormones? A. B. C. D. E. phenytoin carbamazepine ferrous sulfate rifampin isoniazid

56. A thyroid inhibitor that interferes with the concentration o f iodide ion by the thyroid gland is A. B. C. D. E. thiourylenes radioactive iodine ionic inhibitors iodides in high concentrations all o f the above

61 .Over dosage o f thyroid hormones can cause A. B. C. D. E. hypothyroidism palpitation agranulocytosis Bradycardia all

57.Thyroid hormone preparations are therapeutically indicated for A. B. C. D. E. hypothyroidism myxedema coma cretinism simple goiter all '

62.A thyroid inhibitor with possible effects on the future offspring o f young adults is A. B. C. D. E. ionic inhibitor iodides radioactive iodine methimazole none

58.A drug that is used in the detection and treatment o f thyroid cancer is A. B. C. D. E. levothyroxine liothyronine thyrotropin methimazole all o f the above 63.A drug which accelerates thyroid metabolism is A. B. C. D. E. carbamazepine iron sucralfate calcium none o f the above

59.A thyroid inhibitor that is particularly used in treating hyperthyroidism in older patients and in patients with heart disease is A. thiourylenes

64. A class o f thyroid inhibitors that has the following adverse effect- urticarial papular rash, dermatitis, agranulocytosis, thrombocytopcnia,

granulocytopenia, pain, stiffness in the joints, headache and paresthesias is A. B. C. D. E. thyrotropin thiourylenes iodides ionic inhibitors propylthiouracil

D. regular insulin E. all o f the above

69.Regular insulin can be mixed with all other insulin, EXCEPT with A. PZI (protamine zinc insulin) B. semilente insulin C. insulin glargine D. ultralente insulin E. none o f the above

65.How many polypeptide chains are present in insulin? A. B. C. D. E. 3 2 4 1 5

70. Which one o f the following is long acting insulin? A. B. C. D. E. lispro insulin insulin glargine insulin aspart lente insulin all o f the above

66.Human insulin are prepared by ] - mixing both bovine and porcine insulin II- enzymatic conversion o f the terminal amino acid o f porcine insulin III- recombinant DNA technology A. B. C. D. E. I & II 1 & III II & III III only II only

71 .Which insulin is a mixture o f 70% ultralente crystals and 30% semilente powder? A. B. C. D. E. NPH( isophane insulin) PZI(protamine zinc insulin) Insulin aspart insulin zinc suspension none o f the above

67.The solubility o f insulin at the injection site depends on A. B. C. D. E. the zinc content the nature o f the buffer the physical state protein content all

72.Which one o f the following is a second generation sulfonylurea oral hypoglycemic agent? A. B. C. D. E. tolazamide glimepride chlorpropamide tolbutamide none

68.Insulin that can be given intravenously is A. insulin aspart B. lispro insulin


C. semilente insulin

73.Lente insulin cannot be mixed with A. insulin aspart B. insulin glargine


C. protamine zinc insulin

D. lispro insulin E. al o f the above

C. sulfonylureas D. inhibitors o f a-glucosidase E. biguanides

74.Which is a biguanide oral hypoglycemic agent that is still available in the market? A. B. C. D. E. metformin phenformin nateglinide precose none o f the above

79. Which one o f the following is a tetrasaccharide inhibitor of aglucosidase? A. B. C. D. E. miglitol metformin acarbose glibenclamide all

75.Oral hypoglycemic agent that is a basic compound is A. B. C. D. E. sulfonylureas biguanide thiazolidinediones meglitinide none o f the above 80. A class o f oral hypoglycemic agent that is also classified as potassium channel blocker is A. B. C. D. E. biguanide sulfonylureas meglitinides a-glucosidase inhibitors thiazolidinediones

76.Repaglinide and nateglinide belong to which class o f oral hypoglycemic agent? A. B. C. D. E. biguanide sulfonylurea meglitinides thiazolidinediones none

81 .Which one o f the following interacts with a specific cell surface receptor to facilitate the transport o f glucose and amino acids? A. B. C. D. E. metformin insulin glyburide tolbutamide glipizide

77. An oral hypoglycemic agent that is withdrawn form the market because of rare but severe hepatic toxicity is A. B. C. D. E. rosiglitazone troglitizone pioglitazone repaglinide phenformin

82. Which one o f the following hypoglycemic agent is best described as antihyperglycemic agent? A. B. C. D. E. metformin glyburide insulin acarbose glibenclamide

78.Repaglinide belongs to which class o f oral hypoglycemic agent? A. meglitinides B. biguanides

83. Which one o f the following compounds is incorrectly matched with its mechanism o f action? A. sulfonylureas - block ATP sensitive potassium channels B. acarbose - inhibits the digestion o f carbohydrates C. rosiglitazone - inhibits gluconeogenesis D. metformin - increases insulin action in peripheral tissue E. meglitinides- stimulate insulin release

D. local irritation E. none o f the above

87. Which sulfonylurea antidiabetic agent primarily causes hyponatremia? A. B. C. D. E. tolbutamide chlorpropamide tolazamide glipizide metformin

84. One o f the following drugs stimulates the release o f insulin from pancreatic p cell? A. B. C. D. E. metformin miglitol tolazamide pioglitazone phenformin

88. Which one o f the following classes o f compounds does NOT cause hypoglycemia? A. B. C. D. E. biguanides sulfonylureas insulin preparation meglitinides none o f the above

89.All are adverse effects associated with the use o f biguanides , EXCEPT 85.Insulin preparations can be used to treat I. insulin dependent diabetes mellitus II. non-insulin dependent diabetes mellitus III. patients w'hose glucose is not adequately controlled by diet or oral antidiabetic agent A. B. C. D. E. 1 only 11 only II and III I and III 1 and II A. B. C. D. E. fatal lactic acidosis metallic taste GI effect hypoglycemia none o f the above

90. The use o f thiazides with an oral antidiabetic agent can A. increase the blood glucose level B. has no effect on blood glucose level C. can decrease the blood glucose level D. decreases the blood glucose level in some patients and increases the blood glucose level in others E. none o f the above

86. All are the adverse effect of insulin preparation, EXCEPT A. cholestatic jaundice B. hypoglycemia C. hypersensitivity

91 .Varying effects on glucose levels is observed when oral antidiabetic agents interact with A. monoamine oxidase inhibitors B. p-blockers C. thiazide diuretics D. oral contraceptives E. ACE-inhibitors

96.A drug that has no drug interaction involving CYP450 enzyme is A. B. C. D. E. pioglitazone nateglinide metformin rosiglitazone glibenclamide

92. Sulfonylureas interact with A. B. C. D. E. digoxin ranitidine quinine minoxidil none o f the abovel

97.An antidiabetic drug that decreases the bioavailability o f oral contraceptives is A. B. C. D. E. metformin pioglitazone nateglinide repaglinide none o f the above

93.A drug metabolized by CYP2C9 is A. B. C. D. E. pioglitazone repaglinide glimepride rosiglitazone tolbutamide 98. Which o f the following is not correctly paired with the correct isozyme? A. glimepride - CYP2C9 B. nateglinide-C Y P2C 8 C. pioglitazone - CYP3A4 D. rosiglitazone - CYP2C8 E. repaglinide - CYP3A4

94. Which o f the following drugs can interfere with the renal tubular secretion o f metformin? A. B. C. D. E. amiloride morphine ranitidine quinidine all

95.Which class o f antidiabetic agent impairs the oral absorption o f digoxin? A. sulfonylureas B. a-glucosidase inhibitors
C . biguanides

D. meglitinides E. none o f the above

ANSW ERS

Endocrinology & Related Drugs


1. Answer: C. vasopressin Explanation: Oxytocin and vasopressin are posterior pituitary hormones. Corticotrophin, thyrotropin, thyrotropin-releasing hormone, growth hormone, menotropins, urofollitropin and human chorionic gonadotropin are anterior pituitary hormones. 2. Answer: A. thyrotropin Explanation: Corticotrophin, thyrotropin, thyrotropin-releasing hormone and growth hormone are the anterior pituitary hormones that are used therapeutically. 3. Answer: C. thyroid-stimulating hormone Explanation: Thyrotropin is a glycoprotein with a molecular weight o f 28000, known as thyroid stimulating hormone. 4. Answer: B. urofollitropin Explanation:. Urofollitropin has high FSH-like activity. Menotropins also known as human menopausal gonadotropin have a high FSH-like and LH-activity. Human chorionic gonadotropin has LH-like activity. 5. Answer: C. urofollitropin Explanation: The therapeutically important anterior pituitary hormones are corticotrophin, growth hormone (somatotropin) and menotropins (gonadotropin) and the posterior pituitary agents (vasopressin and oxytocin). 6. Answer: B. oxytocin Explanation: Oxytocin plays an important role in the induction o f labor.

7. Answer: D. human chorionic gonadotropin(HCG) Explanation: HCG is secreted by chorionic tissue and is present in the urine only after conception has occurred.

8. Answer: D. for the diagnosis and differentiation o f primary and secondary adrenal insufficiency Explanation: Corticotropin is used mainly for the diagnosis and differentiation o f primary and secondary adrenal insufficiency. 9. Answer: A. vasopressin
Explanation:

Since vasopressin has vasopressor and antidiuretic hormone activity which promotes the reabsorption o f water from the distal renal tubular epithelium, it can be used to treat neurogenic diabetes insipidus. 10. Answer: A.gynecomastia Explanation: The use o f oxytocin is associated with severe water intoxication with convulsions and coma, uterine hypertonicity with spasm, tetanic contraction or uterine rupture, postpartum hemorrhage and fetal effects such as bradycardia, neonatal jaundice, cardiac dysrhythmias and premature ventricular contractions. 11 .Answer: A. cyclopentanoperhydrophenanthrene Explanation: Most natural and synthetic gonadal hormones are derived from cyclopentanoperhydrophenanthrene, the parent structure o f a steroid..

12.Answer: B. estrogen Explanation: Unlike other steroid hormones, all estrogens have an aromatic A ring. 0
'O H

HO

Estriol.
Note the two hydroxyl (-OH) groups attached to the D ring (rightmost ring).

H Q -

- c - '

'v .-'

Estradiol. Note one hydroxyl


group attached to the D ring. The 'di' refers both to this hydroxyl and the one on the A ring (leftmost).

Estrone. Note the ketone (= 0 )


group attached to the D ring.

Al
13.Answer: A. ethinyl estradiol and mestranol Explanation: The two estradiol derivatives, ethinyl estradiol and its 3-methyl ether mestranol are 17 asubstituted estradiols which have increased resistance to first pass metabolism and are effective for oral contraceptive.

Ethinyl estradiol

Mestranol

14.Answer: C. quinestrol Explanation: Dienestrol, chlorotrianisene and diethylstilbestrol are nonsteroidal stilbene derivatives that appear to assume and estradiol-like conformation in vivo. Quinestrol is estrogen derivative that is used principally for estrogen-replacement therapy.

15.Answer: B. chlorotrianisene Explanation: The antiestrogens clomiphene, tamoxifen citrate and toremifen are stilbene derivativesthat are structurally related to chlorotrianesene. Fulvestrant is the newest potent steroidal antiestrgen.

16.

Answer: E. all o f the above

Explanation: Estrogen receptors are found in estrogen responsive tissues such as vagina, uterus, mammary glands, anterior pituitary and hypothalamus.

17.Answer: C. anemia Explanation: Estrogens are used as oral contraceptives, treatment o f menopausal symptoms such as vasomotor disorders, urogenital atrophy, psychological disorder, acne, osteoporosis and prostate cancer.

18.Answer: B. tamoxifen

Explanation:

Tamoxifen, toremifene and fulvestrant are estrogen antagonists that are used to treat estrogen
dependent breast cancer.

19. Answer: B. exemestane Explanation: Anastrozol and letrozol are potent and selective nonsteroidal inhibitors o f aromatase. Exemestane is the only steroidal irreversible inhibitor o f aromatase an enzyme responsible for the conversion o f androgens to estrogens.

20.Answer: A. raloxifene Explanation: Raloxifene is a selective estrogen receptor modulator with biological action similar to that of estrogens but exhibits estrogen antagonist effects on uterine and breast tissue.

21.Answer: C. osteoporosis Explanation: SERMs are used for the prevention o f osteoporosis.

22.Answer: D. aromatase inhibitors Explanation: Aromatase inhibitors (anastrozole, letrozole and exemestane) are used to treat advanced breast cancer.

23 .Answer: B. progesterone Explanation: Progesterone is a naturally occurring progestin with a C-21 steroidal skeleton.

24.Answer: D. megestrol acetate Explanation:

Medroxyprogesterone acetate and megestrol acetate are examples o f 17 a-hydroxyprogesterone derivatives, which have a methyl group at position C-6 o f progesterone and an acetoxyl group at position C-17.

25.Answer: A. norethindrone Explanation: The 17 a-ethinylandrogens such as norethindrone, norethynodrel, and norgestrel and ethynodiol diacetate are structurally classified as androgens but contain progestational activities.

26. Answer: B. breast cancer Explanation: Progestins are used as oral contraceptives alone or in combination with estrogens, menstrual disorder such as dysfunctional uterine bleeding and dysmenorrhea and endometriosis.

27. Answer: E. all o f the above Explanation: Gynecological effects such as irregular menses, breakthrough bleeding and amenorrhea, weight gain and edema, exacerbation o f breast carcinoma are the adverse effects o f progestins.

28.Answer: C. testosterone Explanation: Testosterone is the primary natural androgen which has androgenic and anabolic effect.

Testosterone
29.Answer: C. dromostanolone

Explanation: Oxandrolone and dromostanolone are drugs that have more anabolic effect than androgenic effect.

30. Answer: A. 5 a-reductase Explanation: Since testosterone can not bind to the androgen receptor, the enzyme 5 a-reductase converts testosterone to dihydrotestosterone m the cytoplasm o f androgen-responsive tissue which then binds to an androgen receptor in the nucleus.

31 .Answer: C. dromostanolone - oral contraceptive Explanation; Dromostanolone is an androgen with more anabolic effect and the therapeutic use o f androgens are androgen-replacement therapy, breast cancer and endometriosis, female hypopituitarism, anabolic therapy and anemia.

32.Answer: E. all the above Explanation: The adverse effect o f androgens are fluid retention, increased low density lipoprotein and decreased high density lipoprotein cholesterol levels, psychological changes, liver disorders, development o f masculine features in female and decreased fertility in male.

33.Answer: C. finasteride Explanation: Finasteride is a 5 a-reductase inhibitor, an enzyme that converts testosterone to 5 a-

dihydrotestosterone.

34.

Answer: D. bicalutamide - inhibits the conversion o f testosterone to 5 a-dihydrotestosterone

Explanation: Bicalutamide is an antiandrogen that inhibits the action o f androgens by competitively binding to androgen receptors in the target tissue.

35.Answer: A. androgenic alopecia Explanation: 5 a-reductase inhibitors are therapeutically used for benign prostatic hyperplasia and

androgenic alopecia.

36. Answer: B. treatment o f prostate cancer Explanation: Antiandrogens are used in the treatment o f prostate cancer, in combination with luteinizing hormone-releasing hormone (LH-RH) antagonists.

37.Answer: B. prednisolone Explanation: In prednisolone, there is a double bond between positions C -l and C-2. This double bond increases glucocorticoid activity without increasing mineralocorticoid activity.
iC H ,O H

38.Answer: C. increased mineralocorticoid and glucocorticoid activity Explanation: Fludrocortisone has a fluorine at position C-9 which greatly increases both mineralocorticoid and glucocorticoid activity.

CHgOCOCH, CO

OH

39.Answer: D. increases glucocorticoid activity with less effect on mineralocorticoid activity Explanation: Unlike fluorination at C-9, this increases mineralocorticoid and glucocorticoid activity, fluorination at C-6 increases glucocorticoid activity with less effect mineralocorticoid activity.

40.Answer: A. hydrocortisone Explanation:

The two prototypical glucocorticoids that are formed in the middle layer o f the adrenal cortex are cortisone and hydrocortisone.

41 .Answer: C. increase the glucocorticoid activity and decrease the mineralocorticoid activity Explanation: Cortisone and hydrocortisone are modified to increase glucocorticoid activity while decreasing the mineralocorticoid activity.

42.Answer: B. fluocinonide O
c h 2o c c h 3

F Explanation: Fluocinonide has an acetate ester at position C-21 that enhances its topical absorption.

43.Answer: B. outer layer o f the adrenal cortex Explanation: Aldosterone is formed in the outer (glomerular) layer o f the adrenal cortex.

44.Answer: D. desoxycorticosterone acetate and fludrocortisone acetate Explanation: Desoxycorticosterone acetate and fludrocortisone acetate are the two clinically useful mineralocorticoids.

45.Answer: B. dexamethasone

ch2 oh

CO

Explanation; Dexamethasone has a methyl group at position C-16 that enhances glucocorticoid activity and abolishes mineralocorticoid activity.

46. Answer: E. all o f the above Explanation: Adrenocorticosteroids are used as replacement therapy to treat acute and chronic adrenal insufficiency, for the treatment o f severe allergic reactions, chronic ulcerative colitis, rheumatic carditis, renal diseases including nephritic syndrome collagen vascular disease and cerebral edema. It is also used as therapy at last resort, to treat severe, disabling arthritis. The topical agents are used to treat skin disorders and inflammatory.

47. Answer: B. cholestatic jaundice Explanation: The adverse effects associated with the use o f adrenocorticosteroids are suppression of pituitaryadrenal integrity, GI effects, CNS effects and other effects such as weight gain, osteoporosis, hyperglycemia, flushed face and neck, acne, hirsutism, cushingoid moon face and buffalo hump and increased susceptibility to infection.

48.Answer: C. 5-deiodinase Explanation: Peripheral deiodination converts T4to T3by the enzyme 5'-deiodinase.

49.Answer: E. I & III Explanation: The production o f thyroid hormone is regulated by hypothalamic-pituitary-thyroid feed back system. The hypothalamus secrets thyrotropin-releasing hormone (TRH) which stimulates the

release o f thyroid-stimulating hormone (TSH, thyrotropin) from the anterior pituitary. The thyroid gland is stimulated by thyrotropin which produces T4 and T3.

50. Answer: D. thyrotropin Explanation: Thyrotropin is a thyroid preparation isolated from bovine anterior pituitary gland. It is highly purified and lyophilized thyrotropic hormone.

51 .Answer: B. levothyroxine Explanation: Levothyroxine is less potent but has longer duration o f action 6-7 days compared to liothyronine which lasts for 1-2 days.

52. Answer: A. 4 to 1 o f T4 to T3 Explanation: The sodium salts o f both levothyroxine and liothyronine can be used therapeutically. Since levothyroxine can he converted to liothyronine peripherally, the administration o f levothyroxine sodium can yield the natural 4 to 1 ratio o f T4 to T3

53 .Answer: C. levothyroxine is more potent than liothyronine Explanation: Liothyronine is more potent when compared to levothyroxine but has short duration o f action 1-2 days.

54.Answer: B. liotrix Explanation: Liotrix is a thyroid preparation which contains 4 to 1 mixture o f levothyroxine sodium to liothyronine sodium.

55.Answer: D. propylthiouracil Explanation: The thyroid inhibitor thiourylenes inhibit the enzyme iodoperoxidase which inhibits two crucial steps in thyroid synthesis; the incorporation o f iodine into tyrosine precursor molecules and the coupling o f iodinated tyrosines to form T4and T3. Additionally, propylthiouracil inhibits the conversion o f T4 to T3

56.

Answer: C. ionic inhibitors

Explanation: Ionic inhibitors such as thiocyanate and perchlorate are inorganic monovalent anions that interfere with the concentration o f iodide ion by the thyroid gland.

57.Answer: E. all Explanation: Thyroid hormone preparations are therapeutically used for hypothyroidism i.e. myxedema, myxedema coma, cretinism, simple goiter, endemic goiter and thyrotropin-dependent carcinoma.

58.Answer: C. thyrotropin Explanation: Thyrotropin is the drug that is used as an adjunct in the detection and treatment o f thyroid cancer.

59.Answer: B. radio active iodine Explanation: Radio active iodine (3jll ) is used particularly in treating hyperthyroidism in older patients and in patients with heart disease.

60.Answer: C. ferrous sulfate Explanation: The absorption o f thyroid hormones can be decreased by aluminum hydroxide antacids, ferrous sulfate, calcium, bile acid sequestrants (BAS), sucralfate and iron. Adequate spacing during administration o f these agents is required.

61.Answer: B. palpitation Explanation: The use o f thyroid hormones is rarely associated with side effects but over dosage o f these agents can cause palpitation, nervousness, insomnia and weight loss.

62.Answer: C. radioactive iodine Explanation: The adverse effects associated with the use o f radio active iodides are delayed hypothyroidism and there is a possible effect on the future offspring o f young adults.

63.Answer: A. carbamazepine Explanation:

Phenytoin, carbamazepine and rifampin accelerate thyroid metabolism and the dose o f thyroid hormone should be increased in patients taking these agents.

64.Answer: B. thiourylenes Explanation: The adverse effects associated with the use o f thiourylenes is dermatological effects such as urticarial papular rash and dermatitis, hematological effects such as agranulocytosis, thrombocytopenia, and granulocytopenia, GI effects such as vomiting, nausea and GI distress, pain, stiffness in joints, headache and paresthesias.

65.Answer: B. 2 Explanation: Insulin is an endocrine hormone secreted by the P-cells o f the pancreas. It has 51 amino acids composed o f two polypeptide chains an A chain o f 21 amino acids and a B chain o f 30 amino acids.

66.Answer: C. II & III Explanation: Human insulin is prepared either by enzymatic conversion o f the terminal amino acid o f porcine insulin or by means o f recombinant DNA technology.

67.Answer: E. all Explanation: The solubility o f insulin at the injection site depends on the physical state, the zinc content, the nature o f the buffer and the protein content.

68.Answer: D. regular insulin Explanation: Most insulin preparations are suspensions and they contain particulate matter. Since only clear solutions can be administered intravenously, regular insulin which contains water-soluble crystalline zinc insulin can be administered intravenously.

69.

Answer: C. insulin glargine

Explanation: Regular insulin is the only preparation that has a rapid onset o f action and can be given IV because it is a clear solution. All others are suspensions.

70.Answer: B. insulin glargine

Explanation: Insulin glargine is long acting insulin. It differs from normal insulin in that Gly replaces the ASN2j residue o f the a-chain and a basic Arg-Arg dipeptide replaces the Thr30 o f the p-chain. Because o f this structural alterations; the solubility at physiological pH is decreased, precipitation occurs and the absorption is delayed following subcutaneous injection. This increases the duration o f action.

71 .Answer: D. insulin zinc suspension Explanation: Lente insulin which is also called insulin zinc suspension an intermediate-acting insulin. It is a mixture o f 70% ultralente crystals and 30% semilente powder.

72.Answer: B. glimepride Explanation: Glimepride, glyburide and glipizide are second generation sulfonylurea ora] hypoglycemic agents. They differ from the first generation sulfonylureas by the larger group attached to the aromatic ring which makes it more lipid soluble and more potent than the first-generation agents.

73.Answer: C. protamine zinc insulin Explanation: Lente insulin does not contain modifying protein and are prepared with an acetate buffer. Isophane insulin and protamine zinc insulin are prepared with a phosphate buffer which is incompatible with the acetate buffer o f the lente insulins.

74.Answer: A. metformin Explanation: The only biguanide that is still used as oral hypoglycemic agent is metformin. Phenformin was withdrawn from the market because o f high incidence o f fatal lactic acidosis. Nateglinide is a meglitinide and precose is a-glucosidase inhibitor.

75.Answer: B. biguanide Explanation: Biguanides and inhibitors o f a-glucosidase are class o f oral hypoglycemic agents that are basic compound. All the other class or oral hypoglycemic agents are acidic compounds.

76.Answer: C. meglitinides Explanation: Repaglinide and nateglinide are acidic compounds and belong to meglitinides.

77.Answer: B. troglitizone Explanation: Rosiglitazone. pioglitazone and troglitizone belong to thiazolidinediones oral hypoglycemic agent. Troglitizone is no longer available in the market because of rare but severe hepatic toxicity.

78.Answer: A. meglitinides Explanation: Repaglinide and nateglinide are chemically classified as meglitinides.

79.Answer: C. acarbose Explanation: Acarbose (precose) is a basic analogue with 1-4 linked tetrasaccharide. It is a-glucosidase inhibitor with less oral absorption than the monosaccharide miglitol.

80.Answer: B. sulfonylureas Explanation: Sulfonylureas block adenosine triphosphate(ATP) sensitive potassium channels. This ATP sensitive potassium channels stimulate the release of insulin form pancreatic (3-cells. That is why sulfonylureas are also classified as potassium channel blockers.

81.Answer: B. insulin Explanation: Insulin preparations mimic the activity o f endogenous insulin, which is required for the proper utilization o f glucose in normal metabolism. To facilitate the transport o f glucose and amino acids, insulin interacts with a specific cell surface receptor.

82.Answer: A. metformin Explanation: Biguanides are best described as antihyperglycemic agent because they do not stimulate the release o f insulin and thus do not cause hypoglycemia. They reduce glucose levels by causing an increase in insulin action in peripheral tissues as well as inhibition o f gluconeogenesis. They increase glucose transport across skeletal muscle cell membranes. All the other classes o f hypoglycemic agents cause hypoglycemia.

83.Answer: C. rosiglitazone - inhibits gluconeogenesis

Explanation: Thiazolidinediones (rosiglitazone and pioglitazone) bind to nuclear peroxisome proliferatoractivated receptors which is involved in the transcription o f insulin-responsive genes and regulation o f adipocyte differentiation and lipid metabolism which decreases insulin resistance and improves target cell response to insulin.

84.Answer: C. tolazamide Explanation: O f the five class o f oral hypoglycemic agents, sulfonylureas (tolazamide) and meglitinides stimulate the secretion o f insulin from pancreatic p cells. The other three classes have different mechanism o f action. Biguanides (metformin) increase the peripheral use o f insulin. They also suppress gluconeogenesis. a-Glucosidase inhibitors decrease the digestion o f carbohydrates in small intestine and decrease the absorption o f glucose. Thiazolidinediones decrease insulin resistance by binding to nuclear peroxisome proliferator-activated receptors which are involved in transcription of insulin-responsive genes and in regulation o f adipocyte differentiation and lipid metabolism. This improves target cell response to insulin.

85.Answer: D. I and III Explanation: Insulin preparations can be used to treat insulin dependent diabetes mellitus that cannot be controlled by diet alone. It can also be used non-insulin diabetes mellitus in patients whose glucose levels cannot be controlled by diet and oral antidiabetic agents.

86.

Answer: A. cholestatic jaundice

Explanation: The adverse effects associated with insulin preparation are hypoglycemia which causes sweating, tachycardia and hunger with a possibility o f progressing to insulin shock with hypoglycemic convulsions. Hypersensitivity reaction and local irritation at the injection site are also the adverse effects o f insulin.

87. Answer: B. chlorpropamide Explanation: Chlorpropamide primarily causes hyponatremia due to the potentiation o f the effects o f antidiuretic hormone.

88.Answer: A. biguanides Explanation: Biguanides do not stimulate the release of insulin and they do not cause hypoglycemia. They act by increasing the action o f insulin in peripheral tissue. They also suppress gluconeogenesis. All other classes o f antidiabetic agents can cause hypoglycemia.

89.Answer: D. hypoglycemia Explanation: Biguanides are described as antihyperglycemic agents because they do not cause hypoglycemia as they act by increasing the action o f insulin in the peripheral tissue and they inhibit gluconeogenesis. The adverse effects o f biguanides are fatal lactic acidosis, metallic taste and GI effects such as epigastric distress, nausea, vomiting, diarrhea and anorexia.

90.Answer: A. increase the blood glucose level Explanation: Thiazides can cause an increase in blood glucose by altering the metabolism o f carbohydrates.

91 .Answer: B. P-blockers Explanation: p-Blockers have varying effects on glucose levels. They inhibit the effects o f catecholamine on glycogenolysis and glucagon release and potentiate hypoglycemia. They promote hyperglycemia by inhibiting insulin secretion and decreasing tissue sensitivity to insulin, p-blockers can mask hypoglycemia by blunting the reflux tachycardia. Thiazide diuretics can cause an increase in blood glucose level by altering carbohydrate metabolism. Monoamine oxidase inhibitors cause hypoglycemia by stimulating insulin secretion. Oral contraceptives decrease the efficacy of antidiabetic agents by promoting insulin resistance.

92. Answer: D. minoxidil Explanation: Minoxidil and diazoxide are potassium channel openers and sulfonylureas act by causing the release o f insulin by blocking potassium channels in pancreatic cells.

93.Answer: C. glimepride Explanation: All sulfonylureas except acetohexamide are oxidatively metabolized by the CYP450 enzymes. Glimepride is metabolized by the CYP2C9 isoform. Pioglitazone and repaglinide are metabolized by CYP3A4. Rosiglitazone requires CYP2C8 to metabolize. Drug interactions involving metabolism would be limited to those capable o f inducing or inhibiting these isozymes.

94.Answer: E. all Explanation: Cationic drugs which are eliminated by renal tubular secretion such as amiloride, cimetidine, dofetilide, midodrine, morphine, procainamide, quinidine, quinine, ranitidine, triamterene, trimethoprim and vancomycin can interfere with the renal tubular secretion o f metformin. If

metformin is co-administered with any o f these agents, there is an increased risk o f lactic acidosis and acute renal failure.

95.Answer: B. a-glucosidase inhibitors Explanation: a-glucosidase inhibitors impair the oral absorption o f digoxin.

96.Answer: D. rosiglitazone Explanation: Rosiglitazone is metabolized by CYP2C8 and has no drug interaction involving CYP450 enzyme.

97.Answer: B. pioglitazone Explanation: Pioglitazone requires CYP3A4 for oxidative metabolism. It induces CYP3A4 isozyme and decrease the bioavailability o f oral contraceptives.

98.

Answer: B. nateglinide - CYP2C8

Explanation: Nateglinide is oxidatively metabolized by cytochrome P450 enzymes, specifically by CYP2C9 and CYP3A4 isozymes. '

Optimism is a kind of heart stimulant- the digitalis of failure

Elbert Hubbard

Heart Failure

A. low-out put failure

10. Which of the following are treatment approaches for HF: A. B. C. elimination o f substances that exacerbate HF reducing metabolic demands administration o f combination of diuretics, ACE inhibitors, (3adrenergic blockers and digitalis reducing fluid volume excess all o f the above

14. All o f the following are sings and symptoms of fluid accumulation behind the left ventricle, EXCEPT A. B. C. D. dyspnea dry wheezing cough nocturia complaints by the tightness and swelling E. none o f the above

patient

of

D. E.

15.In which stage o f HF is digitalis included as part o f therapy A. B. C. D. E. stage A stage B stage C stage D A and B

11 .Which one o f the following is/are included in the compensatory mechanisms in HF? A. B. C. D. E. sympathetic response hormonal stimulation concentric cardiac hypertrophy frank-starling mechanism all o f the above

16. Which one of the following is NOT correct about the physical findings in HF? A. crackles indicate the movement o f air through fluid filled passages B. tachycardia is an early compensatory response detected through an increased pulse rate C. S4 atrial gallop is a vibration produced by rapid filling o f the left ventricle early in diastole D. A & B E. none o f the above

12.In cardiac cycle, the term / After load indicates A. the tension in ventricular muscles during contraction B. ventricular end diastolic pressure C. the force exerted on the ventricular muscle at the end o f diastole D. B & C - ' E. None

13. What produces the signs and symptoms o f HF? A. increased TPR B. decreased percentage o f blood ejected C. pressure in the pulmonary artery D. the fluid back up either in lungs or peripheral circulation E. increased degree o f muscle fiber stretch

17. Which one o f the following is NOT one o f diagnostic test results o f HF? A. B. C. D. cardiomegaly transudative pleural effusion venous stasis arm-to-tongue circulation time is prolonged E. none o f the above

18. An early sign o f right-sided HF is:

Heart Failure

248

A. jugular vein distention B. hepatomegaly C. bilateral leg edema D. pitting ankle edema E. none o f the above

23.The dosage forms in which digoxin is available is/are: A. B. C. D. E. tablet injection elixir capsule all o f the above

19. Which one o f the following is NOT an advantage o f bed rest in HF patients? A. B. C. D. E. decreased cardiac work load decreased excess fluid volume promoted diuresis decreased risk o f venous stasis none

24.0.125 mg o f digoxin tablet is equivalent to how many milligrams capsule A. B. C. D. E. 0.5 mg 0.25 mg 0.125 mg 0.1 mg none o f the above

20. Which one o f the following is a correct dietary control in HF patients? A. consuming small but frequent low calorie meals B. consuming diary food products C. using water softeners in the water D. all except C E. all

25. Which one o f the following statements is true? A. 0.8-2.0 ng/mL of serum digoxin is associated with therapeutic response with minimal toxicity B. rapid digitalization is achieved within 24 hours C. In a patient with renal dysfunction, digitalization takes 7 -8 days D. all except B E. all except C

21 .Which one o f the following is/are part o f the basic core o f treatment for HF? A. B. C. D. E. ACE inhibitors diuretics P-adrenergic blockers digitalis all of the above

26.Digoxin effect decreases with increased level o f which o f the following ions? A. B. C. D. E. potassium calcium magnesium A&B A&C

22. Which o f the following acts by furthering the activation o f neurohormonal systems rather than as a positive inotropic agent A. B. C. D. E. dopamine digitalis milrinone A&B All

27.Risk o f digoxin toxicity increases with coadministration o f which o f the following? A. verapamil B. quinidine C. spironolactone

D. amiodarone E. all o f the above

28. Which o f the following are signs of digoxin toxicity? A. B. C. D. E. anorexia mental confusion alteration in visual perception Nausea and vomiting all o f the above

A. B. C. D. E.

diuretics cardiac glycosides vasodilators B&C None o f the above

33. Which o f the following agents decreases after load and increases cardiac output in patients with HF A. B. C. D. E. nitroprusside hydralazine prazosin nitrates none o f the above

29. Which one o f the following agents is/are used in the treatment o f toxicity? A. lidocaine B. cholestyramine C. purified digoxin-specific fragment antibodies D. A & C E. All of the above

Fab

34.In chronic HF, which combination is used to reduce preload A. hydralazine - nitroglycerine B. hydralazine isosorbide dinitrate C. hydralazine - prazosin D. hydralazine - furosemide E. none of the above

30.HF patients who experience diuretic resistance need A. a combination o f two agents with differing mechanisms B. addition o f agents which increase renal blood flow C. intravenous administration of the diuretic D. addition o f an agent that increase renal blood flow E. All o f the above

35.Currently, which o f the following are considered the first line agents in the treatment o f HF? A. B. C. D. E. vasodilators ACE-inhibitors Diuretics Digitalis glycosides None o f the above

31 .Diuretics have been shown to reduce A. B. C. D. E. peripheral edema jugular venous pressure pulmonary congestion body weight all of the above 36.ACE inhibitors are contraindicated in which o f the following conditions? A. when serum potassium > 5.5 mEq/L B. symptomatic hypotension C. severe renal artery stenosis D. pregnancy E. all of the above

32. Which o f the following agents reduce pulmonary congestion and increase cardiac output by reducing preload and/or after load

37. Which o f the following agents is recommended to treat patients with HF due to left ventricular dysfunction A. B. C. D. E. ACE inhibitors calcium channel blockers p- adrenergic blockers A&B A&C

D. A & B E. All o f the above

42.The calcium channel b)ocker? which is less likely to cause a worsening in nonischemic HF is A. B. C. D. E. nifedipine felodipine amlodipine diltiazem none o f the above

38. Which o f the following can be used in the emergency treatment o f patients with HF A. B. C. D. E. ACE inhibitors p- adrenergic blockers Calcium channel blockers inotropic agents none o f the above

4 3.Which inotropic agent is a recombinant form o f human B type natriuretic peptide? A. B. C. D. E. dopamine dobutamine inamrinone milrinone nesiritide

39.Patients with fluid retention should take P- adrenergic blockers for treatment o f HF along with which o f the following? A. B. C. D. E. Ace inhibitors Diuretics Digoxin Calcium channel blockers None o f the above

44. Which o f the following inotropic agents possesses both positive inotropic effect and a vasodilating effect A. B. C. D. E. dopamine dobutamine inamrinone milrinone C&D

40. p- adrenergic blockers may be considered in all the following cases, EXCEPT A. B. C. D. class II HF class IV HF for acute management o f HF in HF post myocardial infarction E. none o f the above

45.Which o f the following inotropic agents stimulates specific receptors within the kidney A. B. C. D. E. dopamine dobutamine inamrinone nesiritide A&D

41 .Which one o f the following is selective p- adrenergic blocker used in HF? A. carvedilol B. metoprolol C. bisoprolol 46.At what dose does dopamine increase cardiac output in HF patients? A. 2 5 ^g/kg/min intravenous

B. 5 - 1 0 jig/kg/min intravenous C. > 1 0 [ig/kg/min intravenous D. none o f the above

47. Which o f the following can be used in patients with HF that have been refractory to treatment with other inotropic agents? A. B. C. D. E. dobutamine inamrinone milrinone nesiritide none o f the above

48. Which o f the following inotropic agents is approved to treat patients with acutely decompensated HF associated with shortness o f breath at rest or with minimal activity? A. B. C. D. E. milrinone inamrinone nesiritide A&C None o f the above

ANSW ERS

Heart Failure
1. Answer: D. all except C Explanation: Heart failure (HF) is a complex clinical syndrome that can result from any cardiac disorder that impairs the ability o f the ventricles to deliver adequate quantities of blood to the metabolizing tissue during normal activity or at rest. The condition in the past has been referred to as congestive heart failure due to the edematous state commonly produced by the fluid back up resulting in shortness o f breath, fatigue, limitation o f exercises tolerance and fluid retention. Fluid retention may lead to pulmonary and peripheral edema. Most recently, due to the fact that all patients do not necessarily present with fluid over load at the initial or follow up evaluations, the term heart failure more adequately reflects the clinical syndrome.

2. Answer: C. HF is considered an independent diagnosis Explanation: There is currently no diagnostic test for HF, and the clinical diagnosis is based on patients history and physical examination and HF should not be considered an independent diagnosis, as it is superimposed on an underlying cause.

3. Answer: B. Coronary artery disease

'

Explanation: HF is superimposed on an underlying cause and in about 2/3 o f the patients with left ventricular systolic dysfunction. Coronary artery disease is the cause and the remaining V3 o f patients have non-ischemic cause o f systolic dysfunction due to other causes o f myocardial stress, which include trauma, disease or other abnormal states( e.g. pulmonary embolism, infection, anemia, pregnancy, drug use or abuse, fluid over load, arrhythmia, valvular heart disease, cardiomyopathies and congenital heart disease).

4. Answer: C. Class III Explanation: The NYHA has developed a classification system and it is still utilized today to quantify the functional limitations o f HF patients. In class I - degree o f effort necessary to elicit HF symptoms equals those that would limit normal individuals. Class II - degree o f effort necessary to elicit HF symptoms occurs with ordinary exertion. Class 111 - degree o f effort necessary to elicit HF symptoms occurs with less than ordinary exertion. Class IV - degree o f effort necessary to elicit HF symptoms occurs while at rest.

5.

Answer: A. low-out put failure

Explanation: Low output failure is the most common type o f HF in which the metabolic demands are within normal limits but the heart is unable to meet them. When the metabolic demands increase (e.g. hyperthyroidism, anemia) and the heart is unable to meet them, the failure is designated high output. In left sided failure, blood cannot be pumped from the left ventricle to peripheral circulation and it accumulates in the left ventricle. And in the right sided failure blood cannot be pumped from the right ventricle into the lungs and accumulates with in the right ventricle.

6.

Answer: E. All o f the above

Explanation: Patients at high risk of developing heart failure (HF) because o f the presence o f conditions that are strongly associated with the development o f HF are patients with systemic hypertension;

coronary artery disease; diabetes mellitus; history of cardiotoxic drug therapy or alcohol abuse; personal history o f rheumatic fever or family history o f cardiomyopathy. Such patients
have no identified structural or functional abnormalities o f the pericardium, myocardium or cardiac valves and have never shown sings and symptoms o f HF. Dyspnea or fatigue due to left ventricular systolic dysfunction is symptom of HF associated with underlying structural heart disease.

7. Answer: C. left sided failure produces systemic edema Explanation: In left sided failure, given the accumulation, the left ventricle is unable to accept blood from the left atrium and lung; therefore, the fluid portion o f the blood backs up into the pulmonary alveoli, producing pulmonary edema. And in the right sided failure, when blood is not pumped from the right ventricle, the fluid portion o f the blood backs up through out the body (e.g. in the veins, liver, legs, bowels), producing systemic edema.

8. Answer: B. lithium carbonate Explanation: Albumin, glucose, mannitol, saline and urea exacerbate HF by producing osmotic effect but lithium carbonate promotes sodium retention.

9. Answer: C. diltiazem Explanation: Androgen, corticosteroids, diazoxide, estrogen, licorice, lithium carbonate, NSAIDs all promotes sodium retention. But antiarrhythmic agents, p-adrenergic blockers, select calcium channel blockers (e.g. diltiazem, nifedipine, and verapamil), direct cardiotoxins (e.g. doxorubicin, ethanol, cocaine, amphetamines) and tricyclic antidepressants exacerbate HF by decreasing cardiac contractility.

10. Answer: E. all o f the above

j
j

Explanation: | The treatment goals of HF are to remove (or mitigate the underlying causes or risk factors and to relieve the symptoms and improve pump function and the above statements are all approaches to the goal.

11 .Answer: E. all o f the above Explanation: HF and decreased cardiac output trigger a complex scheme o f compensatory mechanisms designed to normalize cardiac output! In sympathetic response, inadequate cardiac output stimulates reflex activation o f the sympathetic nervous system and an increase in circulating catecholamines and in hormonal stimulation the redistribution o f blood flow results in reduced renal perfusion which decreases the glotfnerular filtration rate (GFR) which then results in sodium and water retention and activation o f renin-angiotensin-aldosterone system. While concentric cardiac hypertrophy describes a mechanism that thickens cardiac walls, providing larger contractile cells and diminishing the capacity o f the cavity in an attempt to precipitate expulsion at lower volumes. And the premise o f frank-starling mechanism is that increased fiber dilation heightens the contractile force, which then increases the energy released.

12. Answer: A.the tension in ventricular muscles during contraction Explanation: After load is the tension in ventricular muscles during contraction and it is also known as intraventricular systolic pressure. But the pre load is the force exerted on the ventricular muscle at the end o f diastole that determines the degree o f muscle fiber stretch. This concept is also known as ventricular end-diastolic pressure.

13.Answer: D. the fluid back up either in lings or perpheral circulation. Explanation: As the fluid volume expands in the compensation mechanism, so do the demands on an already exhausted pump allowing increased Volume to remain in the ventricle. The resulting fluid back up( from the left ventricle into the lungs, from the right ventricle into peripheral circulation) produces sings and symptoms o f HF thus causing decompensation.

14.Answer: D. complaints by the patient o f tightness and swelling Explanation: When fluid accumulates behind the left ventricle signs and symptoms like dyspnea, dry wheezing cough, exertional fatigue and nocturia are exhibited. But complaints by the patient o f tightness and swelling including nausea, vortiiting, anorexia, bloating or abdominal pain are signs and symptoms o f fluid accumulation behind the right side o f the heart.

15.Answer: C. Stage C Explanation: In stage A, there is high risk of developing HF but no structural heart disease. The therapy in this stage includes treating hypertension, encouraging smoking cessation and regular exercise , discouraging alcohol intake, treating lipid disorders and taking ACE inhibitors in appropriate patients.In stage B, there is structural heart disease but with no symptoms o f HF.Therapy includes all the measures in stage A plus taking ACE inhibitors and p-adrenergic blockers in appropriate patients. In stage C, there is structural heart disease with prior or current symptoms o f HF. Therapy includes all the measures under stage A plus taking ACE inhibitors, p-adrenergic blockers and digitalis and dietary salt restriction. In stage D, there is refractory HF requiring specialized interventions. Therapy includes all the measures under stages A, B and C, mechanical assist devices, heart transplantation and continuous intravenous inotropic infusion for palliation and hospice care.

16. diastole

Answer: C. S4 atrial gallop is a vibration produced by rapid filling o f the left ventricle early in

Explanation: A & B are correct about the physical findings in HF but the S4 atrial gallop is a vibration produced by increased resistance to sudden, forceful ejection of atrial blood in late diastole and it is S3 ventricular gallop which is the vibration produced by rapid filling o f the left ventricle early in diastole.

17.Answer: C. venous stasis Explanation: The diagnostic test results o f HF include cardiomegaly, left ventricular hypertrophy, pulmonary congestion (evidenced by chest radiograph, ECG), reduction in left ventricular function (evidenced via echocardiography and radionuclide ventriculography), prolonged arm-to-tongue circulation and transudative pleural effusion.

18.Answer: C. Bilateral leg edema Explanation:

Bilateral leg edema is an early sign o f right sided HF; pitting ankle edema signals more advanced H F. Since edema is more common in many disorders a concurrent neck vein distention is required for differential diagnosis. Other physical findings include jugular vein distention, S3 ventricular gallop, S4 atrial gallop and hepatomegaly.

19.

Answer: D. decreased risk of venous stasis

Explanation: The advantage o f bed rest includes decreased metabolic needs, which reduces cardiac work load which in turn reduces pulse rate and dyspnea. Bed rest also helps decrease excess fluid volume by

promoting diuresis. The risk o f venous stasis increases with bed rest and can result in thromboembolism.

20.Answer: A. consuming small but frequent low calorie meals Explanation: Consuming small but frequent meals (4 to 6 daily) that are low in calories and residues provides nourishment without unduly increasing metabolic demands. There should be sodium restriction (2-4 gm o f dietary sodium/day) and the patient should be advised about medications and common products that contain sodium and cautioned about their use (e.g. antacids, sodium bicarbonate or baking soda commercial diet food products, water softeners).

21 .Answer: E.all o f the above Explanation: ACE-inhibitors. diuretics, P-adrenergic blockers and usually digitalis form the basic core o f treatment for HF.

22.Answer: B. digitalis Explanation:

Dopamine, dobutamine and milrinone act as positive inotropic agents but a recent evidence suggests that digitalis acts by furthering the activation o f neurohormonal systems rather than as a positive inotropic agent.

23.

Answer: E. all o f the above

Explanation: Digoxin is available as tablet injection, elixir and capsule.

24.Answer: D. 0.1 mg Explanation: Digoxin solution in capsules is more bioavailable than digoxin tablets; therefore, 0.125 mg tablets are equivalent to 0.1 mg capsules.

25.

Answer: E. all except C

Explanation: Digoxin has a narrow range between therapeutic and toxic doses. There is not magic threshold level for digoxin therapy, but serum concentration o f 0.8 - 2.0 ng/mL have been associated with therapeutic response and minimal toxicity. Rapid digitalization is achieved within 24 hours but the actual administration rate is usually slow and delivered in divided doses. In slow digitalization, when urgency is not the driving force, oral

Heart Failure

257

administration o f maintenance does should achieve steady state levels in 7- 8 days for the average patient ( 3 - 4 weeks in patient with renal dysfunction).

26. Answer: E. A & C Explanation: Potassium seems to antagonize digitalis preparations. Increased potassium levels seems to decrease digoxin binding and decrease its effect( this is likely in patients taking potassium or a captopril-like agent, which increases reabsorption). Calcium ions act synergistically with digoxin( an increased level increases the force o f myocardial contraction). Magnesium levels are inversely related to digoxin activity. As magnesium levels decrease the predisposition to digitalis toxicity increases and vice versa.

27. Answer: E. all o f the above Explanation: Risk o f toxicity o f digoxin, increases with coadministration o f quinidine, verapamil, flecainide, propafenone, spironolactone and amiodarone.

28.Answer: E. all o f the above Explanation: Signs o f digoxin toxicity include anorexia, fatigue, headache, malaise, nausea, vomiting, mental confusion, disorientation, alteration in visual perception and cardiac effects like premature ventricular contraction, ventricular tachycardia and fibrillation; SA and atrioventricular(AV) block, and atrial tachycardia with AV block.

29.

Answer: E. all o f the above

Explanation: In the treatment o f digoxin toxicity, digitalis is discontinued immediately, if the patient is hypokalemic, potassium supplements are administered. The arrhythmia is treated with lidocaine (lOOmg bolus followed by infusion at 2 - 4 mg/ min) or phenytoin (slow IV o f 25- 50 mg/min to a maximum o f 1.0 g). Cholestyramine, which binds to digitalis glycoside, may help prevent absorption and reabsorption o f digitalis in the bile. Patients with very high serum digoxin levels (e.g. from suicidal overdose) may benefit from the use o f purified digoxin-specific Fab fragment antibodies (one vial, 40 mg, will bind 0.6 mg of digitalis).

30.Answer: E. all o f the above Explanation: Patients who experience diuretic resistance or tolerance to their effect might need intravenous administration, a combination o f two agents with differing mechanisms (furosemide and metolazone) or the addition o f agents such as dopamine or dobutamine, which increase renal

blood flow. Additionally, evaluation o f patient drug profiles may identify the addition o f sodium retaining agents such as NSAIDs. 31 .Answer: E. all of the above Explanation: Diuretics have been shown to cause a reduction in jugular venous pressures, pulmonary congestion, peripheral edema, and body weight in short-term studies, and have been shown to improve cardiac function and exercise tolerance in intermediate-term studies. 32. Answer: C. vasodilators Explanation: Vasodilators reduce pulmonary congestion and increase cardiac output by reducing preload and/or after load. However, at the current time, there are no large scale trials supporting the use of vasodilators (nitrates or hydralazine) alone in the treatment o f HF. 33.Answer: B. hydralazine Explanation:

Nitroprusside is a potent dilator of both arteries and veins and prazosin is a-adrenergic blocker that acts as a balanced arteriovenous dilator.
Venous dilation by nitrates increases venous pooling, which decreases preload. Their arterial effects seem to result in decreased after load with continued therapy.And hydralazine is an arteriole dilator that decreases after load to increase cardiac output in patients with HF. 34.Answer: A. hydralazine - nitroglycerine Explanation: Hydralazine has been used with isosorbide dinitrate to reduce after load or with nitroglycerine to reduce preload for treating chronic HF. These combination therapies should not be used as initial therapy over ACE inhibitors but should be considered in patients who are intolerant o f ACEinhibitors. 35.Answer: B. ACE-inhibitors Explanation: Currently ACE inhibitors are considered the first line agents in the treatment of HF and have been shown to have a beneficial effect on cardiac remodeling. 36.Answer: E. all o f the above Explanation: Relative contraindications in using ACE inhibitors include history o f intolerance or adverse reactions, serum potassium > 5 . 5 mEq/L, symptomatic hypotension, severe renal artery stenosis and pregnancy. 37.Answer: E. A & C Explanation:

Recent guide lines recommend the use o f ACE inhibitors and (3- adrenergic blockers in all patients with HF due to left ventricular systolic dysfunction unless they have a contraindication to their use or have demonstrated intolerance to their use. Calcium channel blockers, due to the lack o f supporting efficacy, should not be used for the treatment o f HF. 38.Answer: D. inotropic agents Explanation:

Inotropic agents have been used in the emergency treatment o f patients with HF and in patients refractory to, or unable to take, digitalis.
39.Answer: B. Diuretics Explanation: (J- adrenergic blockers are generally used in conjunction with diuretics, ACE inhibitors and usually digoxin to treat HF. p- adrenergic blockers should not be taken without diuretics in patients with a current or recent history o f fluid retention to avoid its development and to maintain sodium balance. 40.Answer: C. for acute management o f HF Explanation: Studies support the use o f p- adrenergic blockers in patients with class I - IV HF, and not in the acute management o f patients, as in an ICU, where other, short term therapies such as digoxin may be more beneficial. Additionally, p- adrenergic blockers should be considered in patients who develop HF post-myocardial infarction if they are able to tolerate the negative inotropic effects. 41 .Answer: E. All o f the above Explanation: BisoproJol, carvedilol and metoprolol tartrate are all selective p- adrenergic blockers used in HF with a target dose o f 10 mg once daily, 25 mg twice daily( wt < 85 kg or 50 mg twice daily for wt > 85 kg) and 75 mg twice daily respectively.

42.Answer: C. amlodipine Explanation: Large scale trials utilizing felodipine and amlodipine have not provided persuasive evidence that long term treatment can improve the symptoms o f HF or prolong survival. However, current guidelines suggest that amlodipine seems less likely to cause a worsening in nonischemic HF. 43.Answer: E. nesiritide Explanation: Nesiritide is a recombinant form o f human B-type natriuretic peptide, which is naturally occurring hormone secreted by the ventricles. It is the first o f this drug class to become available for human use in USA.

44.Answer: E. C & D Explanation: Inamrinone is referred to as non-glycoside, nonsympathomimetic inotropic agent and it has both positive inotropic effect and a vasodilating effect. Milrinone is similar to inamrinone, it possesses both inotropic and vasodilatory properties. 45.Answer: A. Dopamine Explanation: Dopamine stimulates specific dopamine receptors within the kidney to increase renal blood flow and thus increase urine output. Dobutamine although resembles dopamine chemically, it does not directly affect renal receptors. It,therefore, does not act as a renal vasodilator. 46.Answer: B. 5 - 10 pg/kg/min intravenous Explanation: Dopamine at low doses( 2 -5 pg/kg/min ) stimulates specific receptors within the kidney to increase urine output; at moderate doses( 5 - 1 0 pg/kg/min ),it increases cardiac output and at high doses( > 10 pg/kg/min ) alpha peripheral activity increases, resulting in increased total peripheral resistance and pulmonary pressures and the patient should be monitored for tachycardia.

47.Answer: B. inamrinone Explanation: Inamrinone inhibits phosphodiesterase located specifically in the cardiac cells thus increasing the amount o f cyclic adenosine monophosphate( cAMP). It is used, in patients that have been refractory to treatment with other inotropic agents, at a loading dose o f 0.75 mg/kg over 3-4 minutes followed by maintenance infusion o f 5-10 jig/kg/min.

48.Answer: C. nesiritide Explanation: Nesiritide binds to natriuretic peptide receptors in blood vessels , resulting in increased production o f guanosine 3' 5-cyclic monophosphate( cGMP) in target tissues, which mediate vasodilation. It reduces pulmonary capillary wedge pressure and systemic vascular resistance. So it is approved for the intravenous treatment o f patients with acutely decompensated HF associated with shortness o f breath at rest or with minimal activity.

Hypertension

One way to break up any kind of tension is good deep breathing.

Byron Nelson

]. What is hypertension (HTN)? A. Blood pressure elevated enough to perfuse tissues and organs B. A systolic reading greater than or equal to 140 mmHg C. A diastolic reading greater than or equal to 90 mmHg D. A systolic blood pressure reading o f 120-139 or diastolic blood pressure o f 80-89 mmHg E. All except D

A. B. C. D. E.

Nitric oxide Endothelin Bradykinin Epinephrine none o f the above

6. Which one o f the following statements is false? A. Stage one hypertension has a systolic blood pressure o f 160 mmHg B. No antihypertensive is indicated for pre hypertension C. Thiazide diuretics are indicated for most with stage 1 hypertension if there is no compelling indication D. Two drug combination is indicated for stage 2 hypertension E. None o f the above

2. Hypertension (HTN) could lead to which o f the following? A. B. C. D. E. Myocardial infarction( MI) Heart failure Kidney disease Stroke All o f the above

3. When the pressure receptors are stimulated to constriction, all the following happen except A. B. C. D. E. Heart rate increases Peripheral resistance augments Cardiac output decreases A&B None o f the above

7. Which o f the following are indicated for stage 2 hypertension? A. B. C. D. E. Thiazides + ACE inhibitor ARB P-blocker CCB all o f the above

8. Which o f the following are major risk factors for high blood pressure? 4. All the following can increase the blood pressure except A. B. C. D. increased venous system distention aldosterone release increased sodium reabsorption blocking sympathetic nervous system E. all o f the above lead to an increased blood pressure A. B. C. D. E. cigarette smoking obesity dyslipidemia microalbuminuria all o f the above

9. Which o f the following are some o f the findings o f secondary hypertension A. sudden onset and worsening hypertension B. BP elevations not responding treatment C. Pheochromacytoma

5. Which one o f the following is not involved in the maintenance o f normal blood pressure?

D. Obesity E. All o f the above

14.Increased total peripheral resistance in hypertensive patients is caused due to I.Primary aldosteronism II.Renal artery stenosis Hl.Pheochromocytoma A. B. C. D. E. if I only is correct if III only is correct i f l and IJ are correct if II and III are correct ifl , II and III are correct

10. Which o f the following agents may induce hypertension (HTN)? A. B. C. D. E. steroids nasal decongestants appetite suppressants MAO inhibitors All o f the above

11 .Which o f following is a correct laboratory finding that confirms an underlying cause o f secondary hypertension? A. blood urea nitrogen( BUN) confirms renal disease B. increased urinary excretion o f catecholamine - confirms cushings syndrome C. hypokalemia(serum potassium) confirms pheochromocytoma D. B and C E. all o f the above *

15. Which one o f the following is the objective in treating primary hypertension? A. ruling out uncommon secondary causes o f hypertension B. to determine the presence and extent o f target-organ damage C. to determine the presence o f other cardiovascular risk factors in addition to high blood pressure D. to reduce morbidity and mortality through multiple strategies that reduce blood pressure though life style modifications with or without pharmacological treatment with minimal side effects E. all o f the above

12. Which o f the following may suggest an underlying cause for secondary hypertension A. B. C. D. E. weight gain sleep apnea repeated UT1 muscle cramps all o f the above

16. Which o f the following are predisposing factors o f Hypertension? A. B. C. D. E. premature cardiac disease obesity stress dyslipidemia all o f the above

13.All the following are diagnostic tests o f secondary HTN except A. B. C. D. E. renal artery stenosis ventricular hypertrophy ischemia ketoacidosis none o f the above 17.In the examination o f ocular fundi, all of the following are exhibited in the late stages o f hypertension, except A. B. C. D. cotton-wool patches shiny deposits exudates retinal edema

E. none o f the above

21.The initial choice o f anti hypertensive therapy is: A. B. C. D. E. Vasodilators Thiazide diuretics p-blockers Calcium channel blockers(CCBs) ACE inhibitors

18. Which one o f the following statements is not true? A. A single elevated reading o f > 140/90 is sufficient basis for diagnosis B. Essential hypertension (primary hypertension) becomes clinically evident when vascular changes affect heart C. A secondary hypertension requires treatment o f underlying cause D. A & B E. None o f the above

22. ACE inhibitors are especially useful in hypertensive patients having A. B. C. D. E. systolic dysfunction after MI diabetic neuropathy CHF A&B All o f the above

19. All o f the following are the general principles in the treatment o f Hypertension, except A. to cure primary hypertension B. to lower blood pressure towards normal C. to prevent organ damage D. to reverse organ damage E. none o f the above

23. Which one o f the following is an incorrect match? A. B. C. D. diuretics- ethacrynic acid vasodilators- diazoxide calcium channel blockers- diltiazem angiotensin II receptor antagonists minoxidil E. p-adrenergic blocking agentsatenolol

20. Which one o f the following statements is not true? A. Patients with diastolic pressure o f 80-89 or a systolic pressure o f 120 139 mmHg are candidates for drug treatment B. Before initiating antihypertensive drug therapy, controllable risk factors should be eliminated C. Patients with hypertension who have diabetes or renal diseases, the blood pressure goal recommended by JNC is 130/80 mmHg D. Most hypertensive patients will require two or more antihypertensive drugs E. None o f the above

24. Which one of the following is grouped as post ganglionic adrenergic neuron blockers? A. B. C. D. E. Prazosin Verapamil Reserpine Clonidine Nadolol

25. All o f the following are actions o f thiazide diuretics except A. increase urinary excretion o f sodium and water B. increase urinary excretion of potassium and bicarbonates

C. increase the effectiveness o f other agents by preventing re-expansion o f extra cellular and plasma volumes D. stimulation o f renin secretion is blocked E. none o f the above

30. All the following are loop diuretics except A. B. C. D. E. Furosemide Ethacrynic acid Amiloride Bumetanide Torsemide

26.One o f the following diminishes the effectiveness o f thiazide diuretics A. B. C. D. E. ACE inhibitors NSAIDs p-adrenergic blockers angiotensin II receptor antagonists none o f the above

31. Which o f the following diuretics is particularly useful in patients with hyperaldosteronism A. B. C. D. E. Furosemide Torsemide Benzthiazide Spironolactone None o f the above

27.In hypertension patients taking thiazide diuretics all o f the following happens except A. B. C. D. E. potassium ion depletion uric acid retention blood glucose increase calcium levels decrease none o f the above

32.Diuretics used in hypertension patients with impaired renal function A. B. C. D. E. Thiazides Loop-diuretics Potassium sparing Beta blockers none o f the above

28.All the following may occur in patients taking thiazides except A. B. C. D. E. hypertriglyceridemia cardiac arrhythmias palpitation depression impotence

33.Transient deafness has been reported with the usage o f which o f the following diuretics? A. B. C. D. E. Thiazides Loop diuretics Potassium sparing A&b None o f the above

29. Which one o f the following is an incorrect match o f thiazides with their daily dose? A. Chlorothiazide^ 125-2000mg daily B. Bendroflumethiazide = 2.5-15 mg daily C. Benzthiazide = 50-150 mg daily D. Chlorthalidone = 12.5 - 50 mg daily E. Quinethazone ^ 2 - 4 mg daily

34. Which o f the following is an incorrect match o f loop diuretics with their daily dose? A. Bumetanide = 0 . 5 - 2 mg daily B. Ethacrynic acid = 50 - 200 mg daily C. Furosemide = 20-80 mg daily

D. Torsemide = 2 5 - 5 0 mg daily E. none o f the above 39.In the sympatholytic group, one o f the following agents are particularly effective in patients with rapid resting heart rates A. B. C. D. P-adrenergic blockers peripheral al-adrenergic blockers centrally active a-agonists post ganglionic adrenergic neuron blockers E. none o f the above

35. Which one o f the following is a correct order o f increasing potency o f the diuretics? A. loop diuretics - potassium sparingthiazide diuretics B. potassium sparing- loop diureticsthiazide diuretics C. thiazide diureticspotassium sparing- loop diuretics D. thiazide diuretics- loop diureticspotassium sparing E. potassium sparingthiazide diuretics- loop diuretics

40.All the following are actions o f pblockers except A. stimulation o f renin secretion is blocked B. cardiac contractility is decreased C. heart rate is reduced D. causes vasodilation o f both arteries and veins E. none o f the above

36.There is an increased risk o f hyperkalemia when potassium sparing diuretics are co-administered with which o f the following? A. B. C. D. E. thiazides loop diuretics ACE-inhibitors A&B none o f the above

41 .A patient with the following characteristics responds best to p-blocker therapy A. B. C. D. a white patient ,age < 45 years a patient with high heart rate a patient with high cardiac output a patient with normal vascular resistance E. all o f the above

37. Which o f the following diuretics is never used in patients with kidney stone or hepatic disease? A. B. C. D. E. amiloride spironolactone triamterene eplerenone none o f the above

42.p-blocker drugs withdrawal syndrome may produce all the following except A. B. C. D. exacerbated angina] attacks bronchospastic disease MI a life threatening rebound o f blood pressure E. none o f the above

38. All are correct matches o f potassium sparing diuretics with their usual effective daily doses for hyertension, EXCEPT. A. B. C. D. E. amiloride = 5- 10 mg daily spironolactone = 100 -400 mg daily triamterene = 50- 100 mg daily eplerenone = 50-100 mg daily none

43. have

P-blocker is not safe in patients that

A. arterial fibrillation B. paroxysmal supraventricular tachycardia C. heart failure D. bronchospastic disease E. none o f the above

48.Which o f the following was the first blocking agent that combined efficacy with once daily dosing possessing intrinsic sympathomimetic activity and having relative cardioselective blocking activity. A. B. C. D. E. metoprolol nadolol atenolol pindolol acebutolol

44.Patients on p-blockers therapy, should be monitored for A. B. C. D. E. cardiac decompensation ECGS hypertriglyceridemia A&B All o f the above

49.Which o f the following was the first pblocking agent shown to be effective after an acute Ml A. B. C. D. E. timolol esmolol betaxolol labetalol none o f the above

45. Which one o f the following statements is not true? A. p-blockers have a greater tendency to occupy p2-receptors B. p-blockers have the ability to release catecholamines C. p-blockers have the ability to maintain a satisfactory heart rate D. p-blockers intrinsic sympathomimetic activity may prevent bronchoconstriction E. none o f the above

50. Which o f the following agents possesses both a and p-blocking activity A. B. C. D. E. labetalol esmolol carvedilol A&B A&C

46. Which o f the following agents block both pi and p2-receptors? A. B. C. D. E. Propranolol nadolol timolol Metoprolol A ,B and C

51. Which o f the following is the first p* adrenergic blocker to have an ultrashort duration o f action and is primarily used in preoperative situations A. B. C. D. E. propranolol esmolol betaxolol labetalol phentolamine

47. Which o f the following has no intrinsic sympathomimetic activity? A. B. C. D. pindolol acebutolol carteolol penbutolol

Hypertension

52.In patients taking peripheral aadrenergic blockers all the following may be exhibited, except A. B. C. D. E. a syncopal episode increase in serum lipids postural hypotension dizziness palpitation

A. B. C. D. E.

methyldopa clonidine guanabenz guanfacine none o f the above

57.A positive coombs test develops in 25 % o f patients with chronic use o f which of the following? A. B. C. D. E. methyldopa clonidine guanabenz guanfacine none o f the above

53. Which one o f the following is a correct match o f peripheral al-adrenergic blockers and their daily doses? A. B. C. D. E. prazosin = 1-16 mg in one dose terazosin = 1-20 mg in one dose doxazosin= 2-30 mg in one dose A&B All o f the above

58. Which one of the following is not an effect seen in patients taking methyldopa? A. B. C. D. E. flu-like symptoms sleep disturbances impotence lactation in either gender reduced heart rate

54.From the following centrally acting aagonists, which one has different mechanism o f action? A. B. C. D. E. methyldopa clonidine guanabenz guanfacine none o f the above

59. Which one o f the following statements is not true? A. intravenous administration of clonidine causes an initial increase in pressure B. guanabenz is the drug o f choice if there is severe coronary insufficiency C. clonidine has a tendency to cause or worsen depression D. clonidine heightens the sedating effects o f alcohol E. patient compliance is a major issue for most hypertensive patients

55. Which one of the following is a correct match o f centrally acting a2-receptors and their daily dose A. methyldopa = 500mg - 3g in two to four doses B. clonidine = 0.2-1.2 mg in 2 to 3 doses C. guanabenz = 8 -32 in 2 doses D. guanfacine = I-3mg in one dose E. all o f the above

56. Which o f the foil wing is an effective antihypertnesive in patients with renal impairment?

60. Which one o f the following statements are true about the post ganglionic adrenergic neuron blocker, reserpine? A. it acts centrally as peripherally by well as depleting

B. C. D. E.

catecholamine stores in the brain and in the peripheral adrenergic system a history o f depression is contraindicated the average daily dose is 0.05 - 0.25 mg in one dose a peptic ulcer is also a contraindication all o f the above

65. Which one o f the following vasodilators is closely related to thiazides chemically but unlike thiazides promotes sodium and water retention A. B. C. D. E. hydralazine minoxidil diazoxide nitroprusside none of the above

61 .Which one of the following statements about vasodilators is not true? A. it is used as a second line agent B. they directly relax peripheral vascular smooth muscle C. direct vasodilators can be used alone D. direct vasodilators may increase heart rate E. none o f the above 66. Which o f the following is/are correct matching o f vasodilators with their adverse effects? A. Hydralazine = reflex tachycardia B. minoxidil = sodium and water retention C. nitroprusside = thiocyanate toxicity D. diazoxide = transient hyperglycemia E. all of the above

62. Which vasodilator has a potent effect on both the arterial and venous systems? A. B. C. D. E. hydralazine minoxidil nitroprusside Diazoxide A&B

67.Hydralazine may induce all the following, except A. B. C. D. E. angina systemic lupus erythematosus( SLE) hypertrichosis peripheral neuropathy none o f the above

63. Which one o f the following is not usually used in hypertensive crisis? A. B. C. D. E. hydralazine labetalol minoxidil nitroprusside diazoxide

68.ACE inhibitors are indicated in hypertension patients having the following cases except A. B. C. D. E. diabetes post MI high coronary disease risk hyperkalemia chronic kidney disease

64. Which vasodilator has the shortest onset o f action? A. sodium nitroprusside B. nitroglycerine C. Enalaprilat
D. Hydralazine

69.ACE inhibitors are not recommended to be taken with

A. B. C. D. E.

ibuprofen spironolactone hydrochlorothiazide A&B B&C

A. patients with angina B. patients with bronchospastic diseases C. patients with Raynauds disease D. patients with second or third degree AV block E. none o f the above

70. Which one o f the following is not an effect o f ACE inhibitors? A. B. C. D. E. neutropenia proteinuria renal insufficiency flushing dry cough 75. Which one o f the following statements is false? A. calcium channel blockers (CCB) inhibit the influx o f calcium through slow channels o f vascular smooth muscle B. CCBs cause relaxation o f vascular smooth muscles C. each agent produces the same degree o f atrioventricular nodal depression D. CCBs, when used with p-blockers, have an additive effect on inducing CHF and bradycardia E. none o f the above

71 .Which o f the following is a long acting analogue o f enalapril A. B. C. D. E. captopril lisinopril quinapril ramipril fosinopril

72. Which one o f the following is a prodrug whose metabolite is used for treating acute hypertensive crisis. A. B. C. D. E. captopril enalapril lisinopril quinapril perindopril

76.All o f the following are second generation CCBs except A. B. C. D. E. amlodipine felodipine nifedipine nisoldipine nicardipine

73. Which o f the following is the original ACE inhibitor A. B. C. D. E. captopril enalapril benazepril quinapril ramipril

77. Which CCB besides being used for mild to moderate hypertension has proven efficacy as an antiarrhythmic and an antiangina] agent? A. B. C. D. E. diltiazem nifedipine verapamil felodipine none o f the above

Hypertension

ANSW ERS

Hypertension

78. Which o f the following CCBs has been associated with a significant degree o f constipation A. B. C. D. E. diltiazem nifedipine verapamil felodipine none of the above

79. Which one o f the following statements is false about angiotensin II type I receptor antagonists? A. similar to ACE inhibitors, increase in serum potassium levels occur B. they should not be used in special hypertensive populations such as diabetics with nephropathy or CHF C. cough associated with ACE inhibitors also occurs in these agents D. in the treatment o f hypertension, there do not appear to be a significant difference between ACE inhibitors and angiotensin receptor blockers E. none -

80.In hypertensive emergency, all o f the following conditions require immediate reduction, except A. B. C. D. E. hypertensive encephalopathy acute left ventricular failure malignant hypertension dissecting aortic aneurysm intracranial hemorrhage

ANSWERS

lypertension
1. Answer: E. All except D Explanation: The recent recommendations o f the Seventh report o f the joint National Committee on Detection evaluation and treatment on high blood pressure(JNC-7) has added a pre hypertension' category, which includes individual^ with systolic blood pressure readings o f 120-139 or diastolic blood pressure readings of 80-89 mmHg and is now included in contemporary management strategies. Choices A, B and C are all definitions! o f hypertension.

2. Answer: E. All o f the above Explanation: Relationship between elevated blood pressure and cardiovascular disease has been addressed in the JNC-7 report and formalizes the fact that the higher blood pressure, the greater the chance o f MI, heart failure, stroke or kidney disc; ase.

3. Answer: C. Cardiac output decreases Explanation: Baroreceptors in the carotids and aorti c arch respond to changes in blood pressure and influence arteriolar dilation and arteriolar constri ction. When stimulated to constriction the contractile force strengthens, increasing the heart rat and augmenting peripheral resistance, thus increasing cardiac output.

4. Answer: D. Blocking sympathetic nervous system Explanation: Increased fluid volume increases venous system distention and venous return, affecting cardiac output and tissue perfusion. These changes alter vascular resistance, increasing blood pressure. In the renin-angiotensin-aldosterone sysem , the renin reacts with circulating angiotensinogen to produce angiotensin I. This in turn, is hydrolyzed to form angiotensin II( a very potent natural vasoconstrictor). This vasopressor sti nulates aldosterone release from the adrenal gland (zona glomerulosa), which results in increase d sodium reabsorption, fluid volume and blood pressure. But blocking the sympathetic nervous system lowers blood pressure by dilating the peripheral blood vessels.

5.

Answer: D. Epinephrine

Explanation: Vasoactive substances that are invol|ed in maintenance o f normal blood pressure have been identified and these include nitric oxide (vasodilating^ factor), endothelin (vasoconstrictor

peptide), bradykinin (potent vasodilator inactivated by angiotensin converting enzyme (ACE) and atrial natriuretic peptide (naturally occurring diuretic). But little evidence suggests that epinephrine and norepinephrine have a clear role in the etiology o f hypertension.

6. Answer: A. Stage one hypertension has a systolic blood pressure o f 160 mmHg Explanation: The systolic blood pressure o f normal hypertension is <120, prehypertension 120-139 mmHg, stage 1 hypertension 140-159 mmHg and stage 2 hypertension is > 160 mmHg.

7. Answer: E. all of the above Explanation: For most stage 2 hypertension, two drug combinations are indicated e.g. thiazide + ACE inhibitor or ARB or P-blocker or CCB.

8. Answer: E. all o f the above Explanation: Major risk factors for high blood pressure include DM, and physical inactivity, cigarette smoking, obesity, dyslipidemia and microalbuminuria.

9. Answer: E. All o f the above

Explanation: Secondary hypertension results from an identifiable cause, such as renal disease or adrenal hyperfunction and the blood pressure elevations do not respond to anti hypertensive treatment.

10. Answer: E. All o f the above Explanation: Steroid or estrogen intake, including oral contraceptives, NSAIDs, nasal decongestants, tircyclic antidepressants, appetite suppressants, cyclosporine, erythropoietin and MAO inhibitors, may induce hypertension.

11 .Answer: A. Blood urea nitrogen( BUN) - confirms renal disease Explanation: In the laboratory findings, BUN and creatinine elevations suggest renal disease. Increased urinary excretion o f catecholamines or its metabolites confirms pheochromacytoma and hypokalemia suggests primary aldosteronism or Cushings syndrome.

12. Answer: E. all o f the above

Explanation: Weight gain, moon face, truncal obesity, hirsutism and hypokalemia may signal Cushings syndrome. Weight loss, episodic flushing, diaphoresis and increased urinary catecholamines suggest pheochromocytoma. Repeated UTI, elevated serum creatinine levels may signify rena] involvement and muscle cramps, excess urination and weakness may suggest primary aldosteronism. Cushings syndrome pheochromocytoma, renal disease and primary aldosteronism, sleep apneas are all underlying causes o f secondary HTN.

13.Answer: D. Ketoacidosis Explanation: Ketoacidosis happens in type 1 DM patients but choices A, B and C are all diagnostic tests of HTN.

14.Answer: B. Ill only is correct Explanation:

Pheochromocytoma is a tumor o f the adrenal medulla which stimulates hypersecretion o f


epinephrine and nor epinephrine and directly results in increased total peripheral resistance (TPR). Primary aldosteronism is hyper secretion o f aldosterone by the adrenal cortex which increases distal tubular sodium retention, expanding the blood volume, thus indirectly increasing TPR. And renal artery stenosis results in a decreased renal tissue perfusion activating the reninangiotensin-aldosterone system.

15.

Answer: E. AH o f the above

Explanation: All the above statements are objectives in treating primary hypertension.

16. Answer: E. all o f the above Explanation: Major risk factors according to the JNC-7 include smoking, DM, age >55 years(men), > 65 years( women), a family history o f cardiovascular disease and dyslipidemia. Other predisposing factors include racial predisposition (African-Americans), high dietary intake o f saturated fats or sodium and hyperlipidemia.

17. Answer: B. Shiny deposits Explanation: Examination o f the ocular fundi is valuable; their condition can indicate the duration and severity o f hypertension. In the early stages, hard, shiny deposits, tiny hemorrhages and elevated arterial blood pressure occur. While in the late stages, cotton-wool patches, exudates, retinal edema, papilledema caused by ischemia, capillary insufficiency, hemorrhages and microaneurysms become evident.

18. Answer: A. A single elevated reading o f> 140/90 is sufficient basis for diagnosis Explanation: Serial blood pressure readings greater than or equal to 140/90 should be obtained on at least two occasions before specific therapy is begun, unless the initial blood pressure levels are markedly elevated( i.e. > 2 1 0 mmHg systolic, > 120 mmHg diastolic, or both) or are associated with target organ damage. A single elevated reading is an insufficient basis for diagnosis. Essential hypertension usually does not become clinically evident other than through serial blood pressure elevations until vascular changes affect the heart, brain, kidneys and ocular fundi.

19. Answer: A. To cure primary hypertension Explanation: In the general principles, the treatment primarily aims to lower blood pressure toward normal with minimal side effects and to prevent or reverse organ damage. Currently, there is no cure for primary HTN.

20.Answer: A. Patients with diastolic pressure o f 80-89 or a systolic pressure o f 120-139 mmHg are candidates for drug treatment Explanation: All patients with a diastolic pressure o f > 90 mmHg and a systolic pressure o f greater than 140 mmHg, or a combination o f both should receive antihypertensive drug therapy. For those patients with a diastolic pressure of 80-89 mmHg or a systolic pressure o f 120-139 mmHg( prehypertension), no drug treatment is indicated unless the patient has a compelling indication. The goal BP for patients with diabetes or renal disease is 130/80mmHg.

21 .Answer: B. Thiazide diuretics Explanation: Thiazide diuretics are the initial choice o f therapy due to the fact that they have demonstrated a reduction in morbidity and mortality when used as initial monotherapy.

22. Answer: E. All o f the above Explanation: ACE inhibitors are used in hypertension patients having systolic dysfunction after myocardial infarction, a diabetic nephropathy patient who might benefit from a ACE inhibitor in combination with a diuretic, or a patient with congestive heart failure( CHF). 23.Answer: D. Angiotensin 11 receptor antagonists - minoxidil Explanation: Angiotensin II receptor antagonists include candesartan, eprosartan, irbesartan, losartan and others. But minoxidil is a vasodilator, including others like hydralazine and nitroprusside.

24.Answer: C. Reserpine Explanation: All the above drugs are generally grouped as sympatholytics. Prazosin is a-adrenergic blocking agent( doxazosin, terazosin), verapamil is a calcium channel blocker( diltiazem, amlodipine, felodipine, nifedipine etc), clonidine is a centrally acting a-agonists ( guanabenz, guanfacine, methyldopa) and nadolol is a P-adrenergic blocking agent( betaxolol, carvedilol, metoprolol, propranolol etc).

25.

Answer: D. Stimulation o f renin secretion is blocked

Explanation: Stimulation o f renin secretion is blocked is the action o f p-adrenergic blockers.

26. Answer: B. NSAIDs Explanation: N SAlDs, such as ibuprofen, interact to diminish the antihypertensive effects of the thiazide and loop diuretics. ACE inhibitors, p-adrenergic blockers and angiotensin II receptor antagonists work well with thiazide diuretics because a thiazide diuretic increases the effectiveness o f other antihypertensive agents by preventing the re expansion o f extracellular and plasma volume.

27.Answer: D. Calcium levels decrease Explanation: Hypertension patients taking thiazide diuretics face potassium ion ( k+) depletion which may require supplem entation increased dietary intake or potassium sparing diuretic), uric acid retention may occur ( this is potentially significant in patients who are predisposed to gout). Blood glucose level may increase (which may be significant in patients with diabetes) and calcium levels may increase because o f the potential for retaining calcium ions.

28.Answer: D. Depression Explanation: Common effects of thiazides include fatigue, headache, palpitations, rash, vertigo and transitory impotence. The alterations in fluid and electrolytes (e.g. hypokalemia, hypomagnesemia, and hypercalcemia) may predispose patients to cardiac irritability, with a resultant increase in cardiac arrhythmias. Electrocardiograms (ECGs) should be performed routinely to prevent the development o f life threatening arrhythmias.

29.

Answer: E .Quinethazone = 2 -4 mg daily

Explanation: Quinethazone dose is 50-200 mg daily but polythiazide and 2-4 mg is the dose of trichlormethiazide taken daily.

30.Answer: C. Amiloride Explanation: Furosemide, Ethacrynic acid, Bumetanide and Torsemide act primarily in the ascending loop o f henle. Hence, they are called loop diuretics by acting with in the loop o f hence, they decrease sodium reabsorption. Their action is more intense but o f shorter duration (1 4 hours) than that o f the thiazides; they may also be more expensive. Amiloride is potassium sparing diuretic.

31 .Answer: D. Spironolactone Explanation: Spironolactone is particularly useful in patients with hyperaldosteronism as it has direct antagonistic effects on aldosterone (aldosterone-receptor blocker).

32.Answer: B. loop-diuretics Explanation: Loop diuretics are indicated when patients are unable to tolerate thiazides, experience loss o f thiazide effectiveness or have impaired renal function (clearance <30 ml/min). And potassiumsparing diuretics should be avoided in patients with acute renal failure and used with caution in patients with impaired renal function because they can retain potassium.

33.Answer: B. loop diuretics Explanation: In patients taking loop-diuretics, transient deafness has been reported. I f the patient is taking a potentially ototoxic drug (e.g. aminoglycoside antibiotic), another class o f diuretic ( e.g. a thiazide diuretic) should be substituted for a loop diuretic.

34.Answer: D.Torsemide-25-50 mg daily Explanation: All are correct matches, except Torsemide whose correct daily dose is 2.5 - 10 mg.

35.Answer: E. Potassium sparing- thiazide diuretics- loop diuretics Explanation: Loop diuretics action is more intense but o f shorter duration( 1-4 hours) than that o f thiazides. Potassium sparing diuretics achieve their diuretic effects differently and less potently than the thiazides and loop diuretics. 36.Answer: C. ACE-inhibitors
Explanation: ~

Co-administration o f potassium sparing diuretics with ACE inhibitors or potassium supplements significantly increases the risk of hyperkalemia. But they are often used in combination with a thiazide diuretic because they potentiate the effects o f thiazide while minimizing potassium loss.

37.Answer: C. triamterene Explanation: Triamterene( a potassium sparing diuretic) should not be used in patients with a history o f kidney stones or hepatic disease.

38.Answer: B. spironolactone = 100 -400 mg daily Explanation: Spironolactone is taken 100 - 400 mg daily to treat hyperaldosteronism but in the treatment o f hypertension the dose taken is 25 - 100 mg daily.

39.Answer: A. p-adrenergic blockers

Explanation: P-blockers are particularly effective in patients with rapid resting heart rates( i.e. artrial fibrillation, paroxysmal supraventricular tachycardia) or compelling indications such as heart failure, post-MI, high coronary disease risk, and diabetes.

40.Answer: C. heart rate is reduced E xplanation:


p -B lock ers action m ay includ e blockade o f stim ulation o f renin secretion, decrease in cardiac contractility and reduction in heart rate. B ut peripheral a l-a d ren erg ic blockers b lo ck the peripheral p ostsynaptic a l-a d ren erg ic receptor causing vasodilatation o f both arteries and vein s.

41 .Answer: E. All o f the above Explanation: Young (<45 years) whites with high cardiac output, high heart rate and normal vascular resistance respond best to p-blocker therapy.

42.Answer: B. bronchospastic disease Explanation: Suddenly stopping p-blocker therapy puts the patient at a risk for a withdrawal syndrome that may produce exacerbated anginal attacks (particularly in patients with coronary artery disease), MI and a life threatening rebound o f blood pressure to levels exceeding pretreatment readings.

43.Answer: D. bronchospastic disease Explanation: P-adrenergic blockers are particularly effective in patients with rapid resting heart rates ( i.e. artrial fibrillation, paroxysmal supraventricular tachycardia) or compelling indications such as heart failure, post-MI, high coronary disease risk or diabetes. But no P-blocker is totally safe in patients with bronchospastic disease( e.g. asthma, chronic obstructive pulmonary disease ( COPD). 44.Answer: E. All o f the above Explanation: Patients must be monitored for signs and symptoms o f cardiac decompensation ( i.e. increasingly reduced cardiac output) because decreased contractility can trigger compensatory mechanisms, leading to CHF. ECGs should be monitored routinely because all p-blockers can decrease electrical conduction within the heart. Hypertriglyceridemia, reduced HDL cholesterol or increased LDL cholesterol have been reported as major consequences of p-blockers, which require routine lipid evaluations with chronic therapy. 45.Answer: A. p-blockers have a greater tendency to occupy p2-receptors Explanation: Relative to propranolol, P-blockers have a greater tendency to occupy the pi Receptor in the heart, rather than the p2-receptors in the lungs( relative cardioselective activity). P-blockcrs have the ability to release catecholamines and to maintain a satisfactory heart rate( intrinsic sympathomimetic activity). Intrinsic sympathomimetic activity may also prevent bronchoconstriction and other direct p-blocking actions. 46.Answer: E. A, B and C Explanation: Propranolol, nadolol and timolol block both pi and p2-receptors and metoprolol, atenolol, betaxolol and bisoprolol are all cardioselective. 47. Answer: E. bisoprolol

Explanation: Bisoprolol has no intrinsic sympathomimetic activity. Pindolol was the first p-blocking agent shown to have high intrinsic sympathomimetic activity while penbutolol has a weak intrinsic sympathomimetic activity and carteolol has moderate intrinsic sympathomimetic activity. Acebutolol also possesses intrinsic sympathomimetic activity. 48.Answer: E. acebutolol Explanation: Metoprolol was the first P-blocking agent with relative cardioselective blocking activity, the average daily dose is 50-300 mg and nadolol was the first P-blocking agent that allowed once daily dosing. It blocks both pi and p2 receptors, the average daily dose is 40-320 mg. while atenolol was the first p-blocking agent to combine once daily dosing with relative cardioselective

blocking activity, the average daily dose is 25-100 mg and pindolol was the first p-blocking agent shown to have high intrinsic sympathomimetic activity, the average daily dose is 10-60 mg. Acebotolol was the first blocking agent that combined efficacy with once daily dosing, possessing intrinsic sympathomimetic activity and having relative cardio selective blocking activity. 49.Answer: A. Timolol Explanation: Timolol was the first p-blocking agent shown to be effective after an acute M] to prevent sudden death. It blocks both pi and P2 receptors. The average daily dose is 20-60 mg.

50.Answer: E. A and C Explanation: Labetalol was the first p-blocking agent shown to possess both a and p-blocking activity. The average daily dose is 200 1200 mg. Labetalol is also effective for treating hypertensive crisis. Carvedilol is a P-blocking agent that has ({-blocking properties as well as a-blocking properties, with a resultant vasodilatation. The drug is administered twice daily with a starting dose o f 6-25 mg titrated at 7-14 day intervals to a dose o f 25 mg twice daily( maximum daily dose is 50 mg daily). But esmolol is a P-blocking agent with an ultra short acting action.

51 .Answer: B. esmolol Explanation: Esmolol was the first p-blocking agent to have an ultrashort duration of action (1-2 minutes). This agent is not used routinely in treating hypertension owing to its duration o f action and the need for intravenous administration. The average daily dose is 25-50 fjg/kg/min up to 300 (ig/kg/min intravenously. Propranolol is available both as rapid acting product and a long acting product, the average daily dose is 40-48 mg. Betaxolol is a new P-blocker with a half life that allows for once daily dosing. The average daily dose is 5-20 mg. Labetalol has an onset of action o f 5-10 minutes. Phentolamine is an a-adrenergic blocker with an onset o f action of 1-2 minutes.

52.Answer: B. increase in serum lipids Explanation: In the first dose phenomenon, a syncopal episode may occur with in 30-90 minutes of the first dose. Similarly associated are postural hypotension, nausea, dizziness, headache, palpitations, and sweating. To minimize these effects the first dose should be limited to 1 mg o f each agent and administered just before bed time. These agents have no adverse effects on serum lipids and other cardiac risk factors.

53.Answer: B. terazosin = 1-20 mg in one dose Explanation: Prazosin has a daily dose of 2-30 mg in two doses and doxazosin is taken

1-16 mg in one dose 54.Answer: A. methyldopa Explanation:

Methyldopa decreases total peripheral resistance by acting on a2-receptors to decrease


sympathetic out flow to the cardiovascular system, while having little effect on cardiac output or heart rate(except in older patients). While clonidine, guanabenz and guanfacine all stimulate 2-receptors centrally, decreasing vasomotor tone and heart rate. 55.Answer: E. All o f the above Explanation: All the above matches are correct.

56.Answer: B. clonidine Explanation: Clonidine is effective as antihypertensive in patients with renal impairment although they may require a reduced dose or a longer dosing interval. Guanabenz and guanfacine are recommended as adjunctive therapy with other antihypertensives for additive effects when initial therapy has failed.

57.Answer: A. methyldopa Explanation: ' A positive coombs test develops in 25 % o f patients with chronic use o f methyldopa ( longer than 6 months). Less than 1% o f these patients develop a hemolytic anemia. The anemia is reversible by discontinuing the drug.

58.Answer: E. reduced heart rate

Explanation: Common untoward effects o f methyldopa include orthostatic hypotension, fluid accumulation (in the absence o f diuretic) and rebound hypertension upon abrupt withdrawal. Sedation is a common finding upon initiating therapy and when increasing doses, however, the sedative effect usually decreases with continued therapy. Other effects include dry mouth, subtly decreased mental activity, sleep disturbances, depression, impotence and lactation in either gender. Reduced heart rate is a side effects exhibited by guanabenz and guanfacine, including others like sedation, dry mouth and dizziness.

59.

Answer: B. guanabenz is the drug o f choice if there is severe coronary insufficiency

Explanation: Guanabenz and guanfacine should be used cautiously with other sedating medications and in patients with severe coronary insufficiency, recent MI, cerebrovascular accident (CVA), and hepatic or renal disease.

60. Answer: E. all o f the above Explanation: Because o f the high incidence o f adverse effects with reserpine, other agents are usually chosen first. When used, Reserpine is given in low doses and in conjunction with other antihypertensive agents. A history o f depression is contraindicated, even low doses such as 0.25 mg/day, can trigger a range o f psychic responses, from nightmares to suicide attempts. Drug induced depression may linger for months after the last dose. Peptic ulcer is also a contraindication for using reserpine, even single dose tends to increase gastric acid secretion.

61 .Answer: C. direct vasodilators can be used alone Explanation: Vasodilators are used as a second-line agents in patients refractory to initial therapy with diuretics, p-blockers or supplemental agents such as ACE inhibitors or CCBs. Vasodilators directly relax peripheral vascular smooth muscle arterial, venous or both. The direct vasodilators should not be used alone owing to increase in plasma renin activity, cardiac output and heart rate.

62.Answer: C. Nitroprusside Explanation: Hydralazine directly relaxes arterioles, decreasing systemic vascular resistance. And minoxidil is a more potent vasodilator than hydralazine; it relaxes arteriolar smooth muscle directly, decreasing peripheral resistance. It also decreases renal vascular resistance while preventing renal blood flow. Nitroprusside is a direct acting peripheral dilator, it has potent effects on both the arterial and venous systems. Diazoxide exerts a direct action on the arterioles but has a little effect on venous capacity.

63.Answer: C. Minoxidil Explanation: Hydralazine is used intravenously or intramuscularly in managing hypertensive crisis. Nitroprusside is usually used only in short-term emergency treatment o f acute hypertensive crisis, when a rapid effect is required( it is administered intravenously with continuous blood pressure monitoring). And diazoxide is used intravenously in the emergency treatment o f acute hypertensive crisis. But minoxidil is commonly used to treat patients with severe hypertension that has been refractory to conventional drug regimen. Labetalol is a P-blocking agent that has an onset o f action o f 5-10 minutes and is effective for treating hypertensive crisis.

64.Answer: A. sodium nitroprusside Explanation: Sodium nitroprusside has an onset o f action o f 0.5-1 minute (thus the shortest). Nitroglycerine has 2-5 minutes while diazoxide has 2-4 minutes but hydralazine has 10-20 minutes if it is IV or 20 30 minutes if it is IM and enalaprilat has onset o f action o f 15-30 minutes. ~

65.Answer: C. diazoxide Explanation: Diazoxide is closely related to the thiazides chemically and patients with thiazide sensitivity cross-react to diazoxide. But unlike the thiazides this agent promotes sodium and water retention, potentiating edema. Hypotensive reactions may be severe.

66.

Answer: E. all o f the above

Explanation: When using hydralazine, reflex tachycardia is common and should be considered before initiating therapy and it triggers compensatory reactions that counteracts its antihypertensive effects, it is most useful when combined with a p-blocker, central a-agonist, or diuretic. Minoxidil promotes sodium and water retention, particularly in the presence o f renal impairment so patients should be monitored for fluid accumulation and signs of cardiac decompensation. And peripheral dilation results in reflex activation o f the sympathetic nervous system and an increase in heart rate, cardiac output and renin secretion. Administering along with a sympatholytic agent and a potent diuretic( e.g. furosemide) minimizes increased sympathetic stimulation and fluid retention. Nitroprusside with long term treatment may cause thiocyanate toxicity particularly in patients with reduced renal activity (but can be treated with hemodialysis). Symptoms may include fatigue, anorexia, disorientation, nausea, psychotic behavior or muscle spasms. Cyanide toxicity can occur (rarely) with long term, high dose administration. It may present as altered consciousness, convulsions, tachypnea or even coma. Diazoxide produces transient hyperglycemia, requiring caution if administered to patients with diabetes.

67.Answer: C. hypertrichosis Explanation: Hydralazine may induce angina, especially in patients with coronary artery disease and those not receiving p-blocker. Drug induced SLE may occur but the risk may be reduced by administering doses o f less than 200 mg /day( fatigue, malaise, low grade fever and joint aches may signal SLE). Other effects may include headache, peripheral neuropathy, nausea, vomiting, fluid retention and postural hypotension. But hypertrichosis( i.e. excessive hair growth) is a common side effect o f minoxidil particularly if the drug is continued for more than 4 weeks.

68.Answer: D. hyperkalemia Explanation Recent JNC-7 recommendations have identified specific patient populations that have compelling indications such as diabetes, post myocardial infarction, high coronary disease risk, chronic kidney disease, and recurrent stroke prevention as where ACE inhibitors are indicated in the treatment o f hypertensive or prehypertensive patients. The mechanism o f action o f ACE inhibitors tends to increase potassium levels,so serum potassium levels should be monitored regularly for hyperkalemia.

Explanation: The antihypertensive effect o f ACE inhi^>itors may be diminished by NSAIDs (e.g. ibuprofen) and potassium sparing diuretics increase serum potassium levels when used with ACE inhibitors, Hydrochlorothiazide is the diuretic used with various ACE inhibitors in a combination product for hypertension. 70. Answer: D. Flushing Explanation: ACE effects include neutropenia (rare but serious), proteinuria, renal insufficiency (in patients with predisposing factors) and a dry cc iugh which could disappear within a few days after ACE inhibitor is discontinued. Other untoward effects include rashes, altered sense o f taste(dysgeusia), vertigo, headache, fatigue, first dose hypotension, minor GI disturbance];. Flushing is the adverse effects o f the CCB, nifedipine. 71.Answer: B. lisinopril Explanation: Lisinopril is a long acting analogue of nalapril, given initially as a 5-1 Omg daily dose and adjusted to an average daily dose o f 5-^ 0 mg in one dose.

72.Answer: B. enalapril Explanation: Enalapril is a prodrug, which is rapidIV converted to its active metabolite, enalaprilat. Initial doses are 5 mg daily, with an average daily c ose o f 5-40 mg. The enalaprilat form o f the drug has been used effectively for treating acute hypertensive crisis.

73.Answer: A. Captopril Explanation: Captopril is the original ACE inhibito given initially as 6.25 mg dose three times daily and is increased to an average daily dose o f 25-150 mg in two or three doses.

74. Answer: D. patients with second or third degree AV block Explanation: CCBs are considered alternative dru 1 $ for the initial treatment o f hypertension in select patient populations that are unable to take f adrenergic-receptor blockers, such as patients with angina who also have bronchospastic diseases or raynauds disease. But CCBs especially diltiazem and verapamil must be used with extreme caution or not at all in patients with conductive disturbances involving the SA or AV node, such s second or third degree AV block, sick sinus syndrome and digitalis toxicity.

75.Answer: C. each agent produces the same degree o f atrioventricular nodal depression

Explanation: Although the CCBs share a similar mechanism o f action, each agent produces different degrees of systemic and coronary arterial vasodilation, sinoatrial (SA) and atrioventricular (AV) nodal depression, and a decrease in myocardial contractility

76.Answer: C. nifedipine Explanation: Amlodipine, isradipine, felodipine, nicardipine and nisoldipine are second generation CCBs. These agents have been developed to produce more sedative effects on specific target tissues than the first-generation agents diltiazem, nifedipine and verapamil. These 2nd generations are chemically similar to nifedipine and are referred to as dihydropyridine derivatives.

77.Answer: A. diltiazem Explanation: Diltiazem in a daily dose o f 120-360 mg in two doses is effective for treating mild to moderate hypertension. Diltiazem also has proven efficacy as an antiarrhythmic and an antianginal agent.

78.Answer: C. Verapamil Explanation: Verapamil use has been associated with a significant degree o f constipation, which must be treated to prevent stool straining and non compliance. Other effects include dizziness and hypotension. Nifedipine has been associated with flushing, headache and peripheral edema.

79.Answer: C. Cough associated with ACE inhibitors also occurs in these agents Explanation: Cough associated with ACE inhibitors does not appear to occur with this group o f drugs.

80.Answer: C. malignant hypertension Explanation: In hypertensive emergency is a severe elevation o f blood pressure( > 200 mmHg/ >140 mmHg) that demands immediate(within minutes) reduction include hypertensive encephalopathy, acute left ventricular failure with pulmonary edema, dissecting aortic aneurysm, acute MI an intracranial hemorrhage. Conditions requiring prompt( within hours) reduction include malignant or accelerated hypertension.

Immunology

Xbrf<s(D

M any o f lifes failures are men w ho did not realize how close they were to success when they gave up.

Thomas Edison

1. Chemical compounds that bind to products o f an immune response A* B. C. D. Immunogens Antigens Haptens Tolerogens

A. B. C. D. E.

T-lymphocytes Macrophages Natural killer cells Basophils Mast cells

6. Which one o f the following statements is NOT TRUE? 2. Which one o f the following is a hapten? A. B. C. D. E. pentadecyl catechol penicillin pollens A&B All o f the above A. B-cells have thousands o f identical antibodies in their membrane B. Different B-cells have different antigen specificities C. Each B-cell has only one specificity D. B-cells that recognize specific antigens divide to form new Bcells E. None 7. The memory B-cells membrane antibodies are immunoglobulin classes of I. IgA II.IgD A. B. C. D. E. III. IgM IV. IgE

3. Which one o f the following statements is NOT TRUE?

A. compounds associated or secreted by parasitic bacteria may act as both immunogens and antigens B. for a molecule to be immunogenic it must contain protein or peptide C. insulin can act as immunogenantigens D. the route o f administration o f a compound may lead to immunogen-antigen effect E. none

I & III II, III, V 1, III, IV I,IV ,V II, IV, V

8. T-cells mature in A. B. C. D. bone-marrow thymus-gland lymph nodes none

4. The primary cells o f specific immune responses are A. B. C. D. E. B-lymphocytes neutrophils T-lymphocytes A&C B&C

9. These cells suppress immune responses through the secretion o f IL-10 and TGF-(3 A. Tc B. Tr C. T -

5. These cells recognize and destroy tumors

D. CD4+CD25+ E. none

15.Eliminating o f an antigen from the body involves the process A. B. C. D. E. phagocytes pro inflammatory cytotoxic regulatory all

10. All the following are membrane glycoproteins o f T cells, EXCEPT A. B. C. D. E. CD4 CD8 CD3 CTL None

16.In humoral immune responses, antigens are recognized by A. B. C. D. E. antigen antigen antigen antigen A&B specific specific specific specific B-cells TH cells leukocytes macrophages

11 .T-cells normally recognize peptide epitopes that are chemically combined with A. B. C. D. antigen presenting cells(APC) MHC Memory cells None

17.The first time a specific antigen is encountered the antibody secreted in the primary immune system is A. B. C. D. E. IgD IgG IgM IgA IgE

12.These cells activate B-cells to divide and produce antibody A. B. C. D. E. Plasma cells TH 2 cells CD8 cells Virgin T cells none

18.The most antibody produced with a second or subsequent encounter with the same antigen is A. B. C. D. E. IgA IgG IgD IgM IgE

13.The best understood APCs are A. B. C. D. macrophages dendritic cells o f lymph nodes dendritic cells o f spleen All o f the above

14. Any cell in the body acts as APC for immune responses involving A. B. C. D. CTL cells Macrophages TH cells none

19. The function o f an antibody is A. B. C. D. E. to act as antigen receptor to eliminate antigens neutralization o f toxins A&C All

20. Which one o f the following statements is false about the structure o f immuno globulins?

24. Which cytokine is responsible for promotion o f cell mediated immunity and activation o f TC and NK cells A. B. C. D. E. IL-1 IL-12 IL-13 IL-14 IL-10

A. immunoglobulin has four polypeptide B. each chain is divided into a Cterminal constant region and Nterminal variable region C. the C-terminal constant region is responsible for antigen binding D. antibody and immunoglobulins could mean the same thing E. none

25.Immnoglobulins cross-reactivity may occur through the sharing o f antigens by two strains of A. B. C. D. E. bacteria viruses other microorganisms A&B All

21 .The immunoglobulin that protects the mucosa from colonization is I. IgA IV. IgE A. B. C. D. E. I only I& III IV only II & IV II & HI II. IgG III. IgD

26. Which one o f the following is NOT true about Fab and F (ab')2 fragments A. they are enzymatically cleaved from immunoglobulins B. they are clinically useful C. they retain antigen specificity D. they are class specific E. none

22.Their serum immunoglobulin content in a decreasing order is A. B. C. D. E. V, II , I , I V I I , I , V, III 1, II, III, V II, V , I , III 1 1 ,1 , V , I V 27.Complement is responsible for all the following EXCEPT A. preparation o f extra cellular antigen for phagocytosis B. for increasing inflammatory response C. phagocytosis o f antigen D. lysis o f cells E. None

23. Which cytokine is responsible for memory cell formation and eosinophil production? A. B. C. D. E. IL-5 1L-6 1L-7 IL-8 IL-9

28.In which type o f pathway does an immune complexes o f IgM or IgG antibodies bind to subunits o f complement component

A. B. C. D. E.

classic activation pathway alternative activation pathway mannose-binding pathway B&C None

33.Non-viral intracellular parasites are primarily eliminated by A. B. C. D. E. NK cells CTL cells T-cell macrophage A&B None

29.Proinflammatory cells that rapidly initiate acute inflammation A. B. C. D. E. basophiles neutrophils mast cells A&B A&C

34.Which one o f the following statements is true about a cell infected with a virus? A. CTL cells recognize infected cells and directly kill them B. NK cclls kill infected cells in an antigen specific manner C. Antibodies are generally ineffective against infected cells D. All except B E. All except C

30.A11 the following are the primary effects o f mast cells and basophile mediators, EXCEPT A. vascular dilation B. increased vascular permeability C. contraction o f respiratory and gastrointestinal smooth muscles D. neutrophil and eosinophil chemotaxis E. none

35-IFN-y is secreted during the elimination o f virus from all the following sources EXCEPT A. B. C. D. E. CTL NK Macrophages TH1 cells None

31 .In antibody dependent cell mediated cytotoxicity the cells involved are 36.Tumors are eliminated by A. B. C. D. E. NK cells Macrophages Tc cells All except A All A. B. C. D. E. NK cells CTL cells Macrophages A&B All

32.Cell mediated immunity is involved A. B. C. D. E. non-viral intracellular parasite viruses tumors B&C All 37.Type I hypersensitivity reaction is due to hyper secretion of A. B. C. D. E. IgM IgE IgG A &C None

38. A childs probability o f being a hyper secretor o f IgE with two hyper secretor parents is A. B. C. D. E. 25% 50% 75% 80% 90%

43. The early reaction o f immediate hypersensitivity reaction begins with in A. B. C. D. 15-30m in 1-2 min 1-2 hour none

39.In normosecretors o f IgE A. 100 ^ g - 1 mg/dl o f IgE is secreted B. local mast cells are armed C. basophiles are armed D. A & B E. All

44. Which agents are used in the diagnosis o f type I hypersensitivity reactions A. B. C. D. E. RAST assay RIST assay Agglutination test A&B All

40.Drugs that act as cell or plasma protein bound haptens are A. B. C. D. E. respiratory allergens gastrointestinal allergens skin or mouth aHergens intravenous allergens none

45. Which one o f the following is not part o f therapy against type I hypersensitivity reaction? A. B. C. D. E. competitive Hi antagonists passive immunization epinephrine topical steroids none

41 .Vasodilation and increased capillary permeability are caused by A. B. C. D. E. histamine platelet activating factor chemotactic factors A&C All

46.Drug that reverses anaphylaxis through its a-agonist and P-agonist effects A. B. C. D. E. competitive H]-antagoinsts epinephrine coromolyn sodium topical steroids none

42.In sensitizes individuals absorption of peanuts across the mucus membrane can cause A. B. C. D. E. systemic edemic hypovolemic shock asphyxiation cardiac arrhythmia all

47.Non-IgE mediated type I hypersensitivity reaction is contributed by A. hyper reactivity o f mast cells B. respiratory p2-receptors unresponsiveness C. a high concentration o f antigen or antibody D. A & B

E. All

D. A & B E. A & C

48.Type II hypersensitivity reactions are due to A. B. C. D. E. anaphylaxis cytotoxicity immune-complex A&B B&C

53.Type II hypersensitivity in the first sensitization inflammation begins in A. B. C. D. 3 days 7-10 days 1-2 weeks none

49. Which one o f the following is not a common allergen in type II hypersensitivity reactions? A. B. C. D. E. foreign blood surface antigens anti sera drug allergens self antigens none

54.The major clinical symptoms exhibited in type II hypersensitivity reactions are A. B. C. D. E. hemolytic anemia lymphadenopathy thrombocytopnea A&C all

50.The leading cause o f hemolytic anemia A. B. C. D. self antigen drug allergens foreign blood surface antigens none

55.Transfusion mismatch (type U hypersensitivity reactions) reactions begins A. B. C. D. E. 1 day after transfusion 12 hours after transfusion 5-7 hours after transfusion 1-2 hours after transfusion none

51 .Autoimmune hemolytic anemia is associated with administration o f A. B. C. D. E. a-methyl dopa thiouracil sulfonamides B&C None

56.In type III hypersensitivity reactions, the immune complexed activate complement and induce positive chemotaxis in A. B. C. D. E. macrophages basophils neutrophils eosinophils none

52. Which one o f the following is a


mpdif^tnr ir> 11 -

Immunology

A. B. C. D. E.

classic activation pathway alternative activation pathway mannose-binding pathway B&C None

33.Non-viral intracellular parasites are primarily eliminated by A. B. C. D. E. NK cells CTL cells T-cell macrophage A&B None

C. granulomas D. A & C E. none

B. cross reactivity with antigens from microorganisms C. loss o f tolerance D. a high concentration o f antibody E. none

58. Which cells are involved in the pathogenesis o f type IV HYPERSENSITIVITY? A. B. C. D. E. mast cells Th 1 cells Macrophages Neutrophils B&C

63.All the following reactions are more common in woman EXCEPT A. B. C. D. E. myasthenia gravis SLE Sjogrens disease Good pastures syndrome C&D

59.The inappropriate skin reaction to haptens in type IV reactions A. B. C. D. tuberculin reaction contact dermatitis granulomas erythema

64. All the following are thought to contribute to pathogenesis o f autoimmunity reactions, EXCEPT A. streptococcus group A pharyngitis B. rheumatic fever C. exposure to organic solvents D. ultraviolet irradiation E. Obesity

60. Common allergens include all the following EXCEPT A. B. C. D. E. mycobacterium tuberculosis lysteria monocytogens E. coli Topical neomycin Candida

65.Which one o f the following is NOT an organ-specific autoimmunity? A. B. C. D. E. rheumatic fever sj ogren5s syndrome myasthenia gravis goodpastures syndrome multiple sclerosis

61 .This reaction come after the onset o f chronic immunoresponse and takes the longer time to show A. B. C. D. granulomas contact sensitivity tuberculin reactions none

66.In which subtype o f antithyroid autoimmunities does the antibodies act as agonists o f thyroid-stimulating hormone (TSH) A. B. C. D. E. primary autoimmune myxedema hashimotos disease graves disease A&B None

62. The etiology of autoimmune response includes all the following effects EXCEPT A. aberrant regulation o f TH and Tc cells

67.The antibodies act as competitive antagonists o f acetylcholine binding in A. B. C. D. E. rheumatic fever myasthenia gravis goodpastures syndrome multiple sclerosis insulin dependent diabetes mellitus

D. vaccination with auto reactive T cells E. A & B

72.All the following are primary immunodeficiencies, EXCEPT A. B. C. D. X-linked agammmaglobulinemia Digeorge syndrome Leukemias Chronic granulomatous deficiency E. Chediak-higashi syndrome

68. Which autoimmunities and treatment match is incorrect A. myasthenia gravis - neostigmine B. good pastures syndrome corticosteroids C. multiple sclerosis - baclofen D. sjogrens syndrome - dantrolene E. SLE - oral methyl prednisolone

( For Questions 73 and 74) I. X-linked agamaglobulinemia I], common variable immunodeficiency III. selective IgA deficiency IV. Digeorge syndrome V. N ezelof syndrome VI. SCIDs VII. CGD VIII. LAD IX. Chediak-higashi syndrome X. defects in complement 73. Which ones are associated with T-cell deficiency? A. B. C. D. E. I, I I , III, V I, IV, V, VI I, III, V, IX I, VI, IX Ill, VI, IX

69.In this type of autoimmunity absorption o f vitamin B ]2 is decreased A. B. C. D. E. autoimmune pernicious anemia autoimmune hemolytic anemia thrombocytopnea neutropenia none

70. Which one o f the following is NOT included in the pathogenesis o f SLE? A. B. C. D. progressive necrotizing vasculitis hypertension may develop behavioral changes inhibition o f exocrine gland secretion E. hemolytic anemia

74. Which ones are associated with a defect with phagocytic cells? A. B. C. D. E. V, VII, X VII only VII, VIII,X VIII only VII &VIII

71. All the following therapies suppress only lymphocytes that are activated, EXCEPT A. corticosteroids B. feeding auto antigens C. administration o f conjugates o f interleukin-2

75.This immuno deficiency occurs primarily in men

A. selective IgA deficiency B. commone-variable immunodeficiency C. X-linked agammaglobulinemia D. B & C E. none

D. Herpes simplex virus( HSV) E. all

80.The HIV, viral envelope glycoprotein 120(gpl20) has a strong affinity to A. B. C. D. E. CD8 CD4 APCs Macrophases none

76.filgrastim is a drug used in the treatment o f secondary immunodeficiency due to A. B. C. D. E. leukemias myelomas cytotoxic drugs lymphomas none

81. Which of the following statements is incorrect? A. because o f molecular differences, grafts are likely to be antigenically different from the recipient and therefore may stimulate an immune response B. class 1 glycoproteins are known as HLA-DR, -DP and -D Q antigens C. human leukocyte antigen is each persons set o f MHC glycoproteins D. the likelihood of two siblings to be HLA identical is approximately 25%

77.Optimal anti-HIV therapy is combination therapy with antiretroviral drugs A. B. C. D. two Three four it depends on the stage o f the disease E. none

78.A11 the following are non-nucleoside reverse transcriptase inhibitors (NNRTIs), EXCEPT A. B. C. D. E. nevirapine didanosine delavirdine efavirenz none

82. Which o f the following are common solid-organ transplants? A. B. C. D. kidney heart-lung pancreas All

83. In which organ transplant is HLA matching not important? 79.Opportunistic infections are the major consequences of AIDS, particularly by A. P. carinii B. Candida albicans C. Mycobacterium-avium intracellulare A. B. C. D. kidney Cornea pancreas all

84. In which type o f transplant is rejectic decreased if HLA-KR and HLA-B are matched? A. cardiac graft B. liver graft C. pancreas graft D. none

kidneys and atherosclerosis in the heart C. is resistant to therapy D. All

89. All are correct about bone marrow transplantation EXCEPT A. it is attempted in patients with immunodeficiency disease, aplastic anemias, some leukemias and certain genetic diseases B. graft T-cell recognition o f the host is important in GVH disease C. in bone marrow transplantation, the host-versus-graft response is very important D. HLA matching is important in bone marrow transplantation

85.AH are correct about graft rejection EXCEPT A. HLA matching is not always a factor in rejection B. Parents and children are almost always haploidentical C. The only reason for tissue rejection is HLA-incompatibility D. HLA matching is not important in liver transplantation

86.A T-cell macrophage-mediated attack on the graft based on HLA and other tissue antigen mismatch is A. B. C. D. chronic rejection hyperacute rejection acute rejection all -

90.The clinical symptoms o f GVH disease are A. B. C. D. desguamation o f the skin intestinal bleeding necrosis o f the liver agranulocytosis

91 .All are immunosuppression o f the graft recipient EXCEPT 87.Hyperactue rejection is A. T-cell-macrophage-mediated attack on the graft B. An ABO-mismatched graft C. The release o f inflammatory cytokines by macrophages D. A rejection that occurs in 10-14 days A. B. C. D. corticosteroids tacrolimus azathioprine methotrexate

92.For the prophylaxis and treatment o f graft rejection, corticosteroids are used in combination with A. B. C. D. ALG/ATG Tacrolimus Muromonab CD3 Rampamycin

88.Chronic

rejection

A. occurs several months to years after transplantation B. causes fibrosis and occlusion of small arteries and arterioles in the

93.Which o f the following drugs is primarily used for bone marrow transplantation in combination with antilymphocyte globulins/antithymocyte globulins (ALG/ATG)? A. B. C. D. azathioprine methotrexate cyclosporine tacrolimus

98. All are correct about muromonab-CD3 (OKT3) EXCEPT A. it may also be used in vitro to purge host(recipient) bone marrow o f T cells to reduce the risk o f GVH disease B. OKT3 is contraindicated in patients with fluid overload C. The side effects o f OKT3 include high fever, chills blood pressure changes and vomiting D. The main action o f OKT3 is the opsonization o f T cells for enhanced phagocytosis

94.Cyclosporine inhibit A. TH -cell response to IL-2 and prevents TH -cell activation B. T-cell antigens by a variety of antibody specificities C. Specific CD3 antigen by a monoclonal antibody D. TH-cell secretion o f IL-2 and lFN-y and prevents T-cell activation

99. All are true about active vaccination, EXCEPT A. the immunity produced by active vaccine is long lasting B. the response o f active vaccination generates antibody, activated T cells and specific memory C. active vaccination is the intramuscular or intravenous injection o f antibody preparations to enhance a patients immune competence D. protection through memory varies with the vaccine

95. Which o f the following drugs should NOT be used together? A. B. C. D. rampamycin and cyclosporine corticosteroids and cyclosporine cyclosporine and tacrolimus azathioprine and corticosteroids

96. Which o f the following is an antisera derived from animals and is used in bone marrow and organ transplantation? A. B. C. D. cyclosporine ALG and ATG Tacrolimus None

100. Which o f the following is incorrect about standard human serum immune globulin for intramuscular vaccination? A. they are individual sera prepared from plasma lots o f subjects actively immunized against or recovering from specific disease B. it is a polyclonal antiserum prepared from pooled plasma o f donors

97. Which o f the following is used to h alf and reverse acute rejection? A. muromonab-CD3 B. ALG C. Tacrolimus

C. it is unsuitable for intravenous injection D. the side effects are confined to minor inflammation and pain at the site o f in jection

105. All are equine (horse) antisera EXCEPT A. B. C. D. Rho(D) immune globulin Botulism antiserum Polyvalent antivenin Black widow antivenin

101. Tetanus immune globulin (TIG) is A. B. C. D. IVIGs Animal antisera Special IGIM IGIM

106. For which o f the following illness is intravenous passive vaccines used? A. B. C. D. measles rubella chronic lymphocytic leukemia varicella

102. All are correct about IVIGs EXCEPT A. the side effects can be diminished by reducing the rate of intravenous infusion B. premeditation with corticosteroids is recommended; C. intravenous epinephrine is usedi anaphylaxis occurs 1 D. chills, nausea and abdominal p a h occurs in all patients

107. For which o f the following illnesses both intramuscular and intravenous passive vaccine is used? A. B. C. D. hypogammaglobulinemia measles cytomegalovirus infection idiopathic thrombocytopenic pupurea -

103. Which o f the following is an example o f passive vaccination for the prophylaxis o f infectious diseases? A. hepatitis immune globulin B. IGIM for hypogammaglobulinemia C. Muromonab CD-3 for acute renkl graft rejection D. 1VIG for idiopathic thrombocytopenic purpura

108. The contents of active vaccines is A. B. C. D. low doses of antibiotics one or more antigens whole pathogenic organisms all of the above

109. AH are routes o f administration o f active vaccines EXCEPT A. B. C. D. Intravenous intranasal oral intradermal

104. Which o f the following vaccine is used for the prophylaxis and therapy fOi snakebite? A. B. C. D. botulism antiserum black widow antivenin polyvalent antivenin none

110. A vaccine whose seroconversion does not indicate established immunity is A. botulism antiserum

B. bacillus calmette-Guerin C. rubella D. oral polio(opvj trivalent)

111. The vaccines that can be given immediately after birth is A. B. C. D. bacillus calmette-Guerin varicella HBV Measles, mumps, rubella(MMR)

produce a strong immune response D. live attenuated vaccines multiply after vaccination but are attenuated to reduce their pathogenecity

115. Tetanus toxoid is an example of A. B. C. D. live, attenuated vaccine subunit vaccine killed inactivated vaccines experimental vaccines

112. All vaccines require booster vaccinations EXCEPT A. rabies B. diptitheria, tetanus, perussis(DTP) C. tetanus and diphtheria toxoids(Td) D. Rubella 116. All are true about killed, inactivated vaccines EXCEPT A. the inactivation o f isolated antigens eliminates pathogenicity but preserves some antigenicity B. vaccines in which the antigenic fragment is a polysaccharide are usually best at eliciting immune response and memory C. in killed, inactivated vaccines, reversion to pathogenicity is not a problem D. the doses o f cells or antigens must be higher than in live, attenuated vaccines

113. All are true about active vaccine EXCEPT A. it is used for prophylaxis B. the side effects are inflammation at the site o f injection, malaise, mild fever, chills, headache, myalgia and arthralgia C. all vaccines require a series of vaccinations D. the success o f the series of vaccinations is indicated by seroconversion o f the patient

117. HBV vaccine and the lyme disease vaccine are example of A. B. C. D. experimental vaccines killed inactivated vaccines live, attenuated vaccines subunit vaccines

114. All are correct about live, attenuated vaccines EXCEPT A. it is safe to give live, attenuated viral vaccines to pregnant women B. some vaccines elicit life long immunity in two doses C. because the antigen concentration increases when the organism multiplies, a small dose can

118. Experimental vaccines are A. peptides produced by chemical B. anti-idiotype antibodies used for active vaccination C. recombinant DNA viruses D. All

119. Which o f the following vaccines has a risk o f vaccine-induced paralysis? A. B. C. D. measles, mumps, rubella(MMR) rubella varicella oral polio(opvj trivalent)

B. hepatitis B C. influenza D. all

125. All are correct regarding inactivated polio EXCEPT A. there is a risk o f vaccine-induced paralysis B. the number o f vaccination is 4 C. the target population are immunodeficient children and families and as booster in health and day car workers D. one vaccine is given at school entry

120. Which o f the following vaccine is given to adolescent girls not previously vaccinated? A. B. C. D. Rubella varicella MMR Influenza

121. Which vaccine is a live, attenuated bacterial vaccine? A. B. C. D. varicella rubella BCG tuberculosis Oral polio

126. Which killed inactivated bacterial subunit is given to children above 7 years and as a booster every 10 years or on exposure through a wound if more than 10 years or vaccine history is unavailable? A. B. C. D. diphtheria, tetanus, pertussis meningococcus tetanus and diphtheria toxoid none

122. A vaccine that is given to animalcare workers is A. B. C. D. influenza rubella rabies none 127. All are correct regarding diphtheria, tetanus, pertussis(DTP) EXCEPT A. it is given for infants and children only B. there are 4 vaccination with boosters C. it is given on the 2nd, 3rd, 4lh , 15th - 18th months and one at school entry D. since it is a polysaccharide vaccine, conjugate vaccines should be used

123. Which vaccine is given annually for maximum protection? A. B. C. D. Influenza hepatitis B inactivated polio rabies

124. A vaccine that is a recombinant subunit is A. rabies ~

128. A vaccine that is given for infants, children and HIV infected adults is A. haemophilus b B. pneumococcus

C. meningococcus D. rubella

patient has received a full series o f active vaccination

129. A vaccine that is given to college freshmen living in dormitories is A. B. C. D. pneumococcus haemophilus meningococcus all

333. Which o f the following statements is incorrect? A. for a clean, minor wound, no treatment is necessary if the patient received a full series and the last Td dose was received within 5 years B. for a tetanus prone wound( and clean, minor wound), if the last dose was received more than 10 years ago, Td but not TIG is given to boost memory immunity and antibody production C. combined prophylaxis o f tetanus is sometimes used depending on the type o f wound and the patients history o f active vaccination D. if the patients history o f active vaccination is uncertain or includes fewer than three doses, both TIG and Id are administered

130. A killed inactivated bacterial subunit that is given for at risk adults such as immunocompromised patients and geriatric patients is A. B. C. D. varicella hepatitis B menigococcus pneumococcus

131. Active and passive vaccines are administered simultaneously in A. infants with HBV who are born to mothers who have the hepatitis B surface antigen B. as a2 post exposure prophylaxis for rabies C. a tetanus prone wound that produces anaerobic conditions D. All

134. All are correct about monoclonal antibodies EXCEPT A. monoclonal antibodies are used for in vitro diagnostic tests B. it is used for screening cancer-related antigens C. it is useful to treat certain leukemias and lymphomas D. it is used for testing HIV infection E. it is used for HIV treatment

132. AH are correct about vaccine EXCEPT A. combined active and passive vaccines are sometimes used B. if the last dose was received more than 10 years ago. Td but not TIG is given C. if the patients history o f active vaccination is uncertain both TIG and Td are administered D. for tetanus prone wound , no treatment is necessary if the

135. Monoclonal antibodies against neoplastic cells are used to treat all EXCEPT A. certain leukemias and lymphomas B. breast cancer C. bone cancer D. colon cancer

136. Which o f the following shows improvement in certain autoimmune disorders? A. Fab antidigoxin antibody B. Muromonab-CD3 C. Monoclonal antibodies against T cells D. Monoclonal antibodies against neoplastic cells 137. Monoclonal antibodies are conjugated to A. B. C. D. enzymes drugs prodrugs All

C. IFN- y is used to treat hair cell leukemia and genital warts D. Influenza-like symptoms are the most common side effects

141. All are correct regarding immunostimulation EXCEPT A. in adoptive immunotherapy, a patients blood lymphocyte or tumor-infiltrating lymphocytes are removed B. the effect o f sulfur-containing compounds such as levamisole and diethyldithiocarbamate is greater on humoral immunity than on cell mediated immunity C. certain cell-mediated immune functions are increased by hormones o f the thymus which induce T-cell maturation and other functions D. inosine pranobex induces T-cell differentiation and auguments cell-mediated immune functions with minimal toxicity

138. Diphtheria toxin is an example o f A. immunotoxins B. monoclonal antibodies conjugated to radioisotopes C. monoclonal antibodies conjugated to enzymes D. none

142. Which o f the following is a component o f mycobacterial cell walls and stimulates macrophage activation? A. B. C. D. muramyl dipeptide levamisole interferon a inosine pranobex

139. Which o f the following is used to treat hairy cell leukemia, kapaosis sarcoma in patients with AIDS and genital warts? A. B. C. D. IFN -y IF N -a Muramyl dipeptide Levamisole

140. Which o f the following is incorrec t about interferons? A. IFN- y provides greater immunosuppression in the intait immune system B. The combined use o f IF N -a ar(' IFN - y yields better results

mmunology

Answers Immunology
1. Answer: B. Antigens. Explanation: Immunogens are chemical compounds th t cause specific immune response. While antigens are compounds that bind to products o f an im nune response. Haptens are low molecular weight compounds that act, as immunogens after chemically complexing to a larger molecule or cell surface and tolerogens are chemical comj ounds that elicit specific non-responsiveness.

2. Answer: D. A and B. Explanation: Haptens may be present in the environment (e.g. pentadecyl catechol o f poison ivy) and several types o f drugs (e.g. penicillin). Haptens n a k e a complex with a larger molecule or cell surface and after they stimulate the immune systi m in this complex, these compounds, act as antigens in the uncomplexed or complexed state. Where as pollens are an immunogen-antilgen that can be contacted environmentally.

3. Answer: D. the route o f administrati >n o f a compound may lead to immunogen-antigen effect. Explanation: Immunogen-antigens are compounds ass ociated with or secreted by parasitic bacteria, protozoa, fungi and viruses, and o f molecular weij; ht greater than 10000 daltons may act as immunogens and antigens. Molecular complexity is a: , important as molecular weight in determining the status of a compound as an immunogen. For a molecule to be very good immunogenic, it must contain protein or peptide. Therefore proteins, g ycoproteins, lipoproteins and nucleoproteins are the most potent immunogen antigens. Drugs o f sufficient molecular weight (e.g. insulin) can act as immunogen-antigens. The cells o f anotl er individual and the cells o f ones own body can act as immunogen antigens. Immunogen antig :ns can also be contacted from the environment (e.g. pollens). But the route o f administration (e.g. oral administration) may be the cause o f specific non responsiveness thus being a tolerog ;n.

4. Answer: D. A and C Explanation: B-lymphocytes and T-lymphocytes are the primary cells o f specific immune responses. AH B & T lymphocytes are antigen specific becau >e they have specific antigen receptors as part o f their plasma membranes. Neutrophils simply assist in eliminating antigens from body.

Explanation: Natural killer (NK) cells are large, granular lymphocytes without specific T- or B- cell antigen receptor. Their cytotoxicity is similar to that o f cytotoxic T lymphocyte (CTL) cells. NK cells recognize and destroy tumors.

6. Answer: E. None Explanation: B-cells have thousands o f identical antibodies in their membrane that allow them to bind chemically to a small group o f chemically related antigens. This group defines the antigen specificity o f each B-cell. Different B-cells have different antigen specificities, but each B-cell has only one specificity. B-cells that recognize specific antigens divide to form new B-cells (memory B-cells) and plasma cells (antibody forming cells) which secrete free, soluble (humoral) antibody molecules into extracellular fluids.

7. Answer: D. 1, IV, V Explanation: Virgin B-cells have never responded to an antigen since their release into the circulation from bone marrow and their membrane. Antibodies are o f immunoglobulin M and D (IgM, IgD) classes. Memory cells are derived by cell division from another B-cells that has responded to an antigen. Their membrane antibodies are o f immunoglobulin classes A, E, or G (IgA, IgE. IgG).

8. Answer: B. thymus-gland Explanation: T-cells originate in pluripotential stem cells in the bone marrow and differentiate into immune cells in the thymus gland.

9. Answer: B. Tr Explanation: Tr cells have recently been described; most o f these cells are CD4+, although there is CD8+ subset as well. All o f these cells suppress immune responses through the secretion o f IL-10 and TGF-|3, in addition cells designated CD4+CD25+ are able to inhibit through direct contact. Tc (cytotoxic T-lymphocyte) is able to kill cells that are infected by viruses and T h cells are the helper cells.

10.Answer: C. CD3 Explanation: Most T-cells can be classified by the presence o f membrane glycoprotein known as CD4, the helper, or TH cell, or the presence o f CD8, the cytotoxic T lymphocyte (CTL) or Tc cell. Antigen receptors o f T cells have two membrane proteins (a and p or y and 8) that define the antigen specificity o f each T cell and several other integral membrane proteins known as CD3 complex (T cells are CD3+).

i 1.Answer: B. MHC Explanation: The antigen receptors o f T cells do not recognize antigens alone. Rather, they normally recognize peptide epitopes (fragments o f antigen) that are chemically combined with MHC proteins (Major Histocompatibility Complex). MHC proteins are divided into two classes o f class 1 proteins (which are present on all nucleated cells) and class II proteins (which are present on the surfaces o f special APCs).

12. Answer: B. TH2 cells Explanation: T h cells (the helper) can be divided into two functional groups, TH1 and TH 2. These cells have different functions in the immune response. These cells regulate immune responses through the production o f lymphokines, which are small proteins that act on other cells in an autocrine, paracrine or endocrine manner. TH1 cells activate other cells, including some TH cells, Tc cells, and macrophages. In addition they decrease antibody (Ab) production by inhibiting the formation o fT H 2 cells. TH 2 cells activate B cells to divide and produce Ab. They can also inhibit the production TH1 cells. Lymphokines are part o f a larger net work o f regulatory cytokines and CD8 are suppressor T cells. While virgin T cells are T cells that are released from thymus into circulation.

13. Answer: D. All of the above Explanation: APCs are essential for most immune responses and are found in the sites at which these responses originate and the best understood APCs are macrophags and dendritic cells o f lymph nodes, spleen. Most immune responses with in these organs begin when these cells present epitopes bound to their surface MHC class II molecules to Th cells and secrete cytokines as accessory signal.

14. Answer: A. CTL cells Explanation: Any cell in the body can act as an APC for immune responses involving CTL cells. Nucleated cells can present fragments of antigens bound to their surface MHC class 1 molecules to Tc (CD8) lymphocytes.

15.Answer: E. all

Explanation:

Neutrophils, macrophages, eosinophils, basophils, platelets and mast cells assist in eliminating antigens from the body. Their functions may be phagocytic, pro inflammatory, cytotoxic, and regulatory or a combination o f these

16.Answer: E. A & B Explanation: In most humoral immune responses, antigen is recognized by antigen specific B cells and TH cells.

17.Answer: C. IgM Explanation: The first time a specific antigen is encountered only virgin B cells and virgin TH cells are present to respond to the antigen. Initially, these cells produce plasma cells that secrete IgM antibody. Later in the immune response, plasma cells producing other classes o f antibody develop. In a primary immune response, IgM is produced first and is followed by IgG. Memory B and TH 2 cells are also produced. Memory B-cells can also be activated to produce the other classes o f antibody in subsequent immune responses.

18.Answer: B. IgG Explanation: The second or subsequent encounter with the same antigen or a closely related antigen produces responses by memory B cells and memory TH 2 cells. These responses are more rapid because memory cells require less antigen for stimulation and are o f greater magnitude because there are more antigen specific B & T cells to respond. Most antibody produced is IgG, with smaller amounts o f IgA and IgE.

19.

Answer: E. All

Explanation: The first function o f an antibody is to act as an antigen receptor for B cells so that the B-cells can recognize and respond to antigens. The second function is to aid in the elimination o f antigen. Elimination occurs through non specific functions, such as phagocytosis or complement activation. The mechanism o f elimination depends on the class o f antibody involved. And the third function o f an antibody is neutralization o f toxins which occurs when the antibody binds to the toxin and prevents it from reaching the target.

20.Answer: C. the C-terminal constant region is responsible for antigen binding Explanation: The standard immunoglobulin has four polypeptide chains: two identical light polypeptides chains and two identical heavy polypeptide chains. The structure is represented as H2L2. Each chain can be divided into a C-terminal constant region and an N-terminal variable region of amino acids. The N-terminal variable region formed from the H & L variable domains is

responsible for antigen binding by the immunoglobulin. The C-terminal constant regions o f the H chain determine the class o f the immunoglobulin.

21 .Answer: A. I only Explanation: IgA is secreted across mucosal surfaces into gastrointestinal, respiratory, lachrymal, mammary and genitourinary secretions, where it protects mucosa from colonization. IgE mediates allergic reactions while IgG opsonizes antigens for phagocytosis and activates the complement system and IgM is the most potent activator o f the complement system. But IgD has no known function as a secreted immunoglobulin.

22. Answer: D. II, V , I , III Explanation: IgG accounts for approximately 70% o f adult serum immunoglobulin while IgM accounts for 20% o f adult serum immunoglobulin and IgA accounts for approximately 10% o f serum immunoglobulin. But IgD and IgE account for less than 1% o f serum immunoglobulin.

23.Answer: A. IL-5 Explanation: IL-5(secreted by TH 2 cells) is responsible for memory cell formation and eosinophil production. IL-6(secreted from TH 2 cell and other types) is responsible for plasma cell maturation while IL7(secreted from bone marrow stroma) is responsible for lymphocyte maturation; IL-8(secreted from Th 1 cells, macrophages, endothelial cells) is responsible for neutrophil activation and 1L9(secreted by TH1 cells) is responsible for proliferation and differentiation o f bone marrow cells and thrombocytes as is IL-11(secreted from bone marrow stroma).

24.

Answer: B. 1L-12

Explanation: IL-1 (secreted form macrophages, APCs) is responsible for T and B-cell activation, pyrogenic and pro-inflammatory actions. IL-12(secreted from macrophages, B-cells) is responsible for promotion o f cell-mediated immunity, activation o f TC and NK cells and suppression o f humoral immunity; IL-13 (secreted from TH cells) is responsible for activation o f B-cells, inhibition o f production o f inflammatory cytokines by monocytes. IL-14(secreted from TH cells) is important for the generation o f B memory cells and IL-10(secreted from macrophages, TH 2 cells, CD8+ Tcells, B-cells) is responsible for increased humoral (antibody), decreased cell mediated immunity and mast cell growth.

25.Answer: E. All Explanation: Each immunoglobulin specificity can bind to several different, but closely related antigens. The ability illustrates the phenomenon o f cross-reactivity o f a single antibody for multiple antigens.

Cross reactivity may also occur through the sharing o f some, but not all. antigens by two strains o f bacteria, viruses or other microorganisms.

26.Answer: D. they are class specific Explanation: Immunoglobulins can be enzymatically cleaved into fragments [e.g. Fab and F (ab')2(antigenbinding fragments), Fc (crystallizable fragment), Fv (variable region fragment)]. Fab and F (ab) 2 fragments are clinically useful because they retain antigen specificity, but not class-specific (e.g. inflammatory) functions, and are readily excreted renally. Conversely, this characteristics limits their effectiveness in certain situations.

27.Answer: E. None Explanation: Compliment is a group o f approximately 20 serum proteins that, when activated, form a proteolytic cascade similar to clotting and fibrinolytic sequence. With in this complex o f proteins, there are some that inhibit complement activation. Complement is responsible for increasing the inflammatory response, phagocytosis o f antigen, lysis o f cells and clearance o f immune complexes. But opsonization is the preparation o f extra cellular antigen for phagocytosis through binding o f antibody. But certain complement proteins also provide opsonization.

28.

Answer: A. classic activation pathway

Explanation: In classic activation pathway, immune complexes o f IgM or IgG antibodies bind subunits of complement component 1 (C l) and trigger an initial series o f proteolytic cleavages. In an alternative activation pathway, the cell walls o f certain microorganisms (e.g. gram negative bacteria) are able to bind C3b and other complement proteins that initiate a different sequence o f proteolytic cleavages and in the mannose-binding pathway, mannosebinding protein (MBP) is produced by the liver during the acute-phase response. 29.Answer: E. A & C Explanation: Circulating basophiles and connective tissue mast cells are mainly proinflammatory cells that rapidly initiate acute inflammation. Triggers o f secretion include mechanical and thermal trauma and immunologic triggers, compliment and IgE.

30.Answer: E. none Explanation: Mast cells and basophile, when triggered, immediately secrete the contents o f their storage granules, including histamine, proteases and chemotactic proteins for neutrophils and eosinophils. In additions, activation o f phospholipase A2 releases arachidonic acid from membrane phospholipids and results in the synthesis o f various leukotrienes, prostaglandins and throrriTJoxanes. The primary effect of these mediators is vascular dilation, increased vascular

permeability, contraction o f respiratory and gastrointestinal smooth muscles, neutrophil and eosinophil chemotaxis.

31 .Answer: E. All Explanation: Antibody dependent cell-mediated cytotoxicity is mediated by cells with cytotoxic potential as well as receptors for IgG. These cells NK cells, macrophages and some Tc cells bind to and lyse target cells coated with IgG.

32.Answer: E. AH Explanation: Cell mediated immune responses are those in which antibody is not involved in the elimination o f antigen. Non-viral intracellular parasite, viruses, tumors and graft rejection trigger cell mediated immunity. 33.Answer: C. T-cell macrophage Explanation: Non-viral intracellular parasites o f macrophages such as myobacteria, listeria and certain protozoa are primarily eliminated by T-cell macrophage immunity. CD4+ TH1 cells recognize infected macrophages and secrete lymphokines, particularly interferon-y (IFN-y).

34.

Answer: D. All except B

Explanation: Viruses must be eliminated from both extracellular sites and infected cells. Antibodies opsonize virus particles in blood and tissue fluids for phagocytosis, but antibodies are generally ineffective against infected cells and CTL cells recognize infected cells and directly kill them in an antigen specific manner secreting lymphokines, such as tumor necrosis factor-P(IFN-P) while NK cells are believed to kill infected( and tumor) cells in a non-antigen specific manner.

35.Answer: C. Macrophages Explanation: INF-y is secreted by CTL, NK and TH 1 cells and IFN-a and IFN-p is secreted by macrophages and other cells thus providing antiviral immunity by binding to receptors on other end.

36.Answer: E. All Explanation: NK cells are primarily responsible for killing tumor cells. They may act by recognizing changes in cell surface proteins or by antibody dependent cell mediated cytotoxicity. CTL cells recognize tumor cells in an antigen specific manner and kill them by secreting lymphokines (TNF-P) and macrophages also kill tumor cells in a non-specific manner through the release o f TNF-a.

37.Answer: B. IgE Explanation: A type I hypersensitivity reaction is caused by inappropriate production and hyper secretion of IgE to specific allergens, plus auxiliary factors such as increased mucosal permeability to allergens (e.g. S 0 2, N 0 2, diesel fumes). Type II hypersensitivity reaction is mediated by IgM or IgG.

38.Answer: C. 75% Explanation: The tendency to hypersecrete IgE is inheritable; a childs probability o f being hypersecetor is 50% with one hyper secretor parent and 75% with two hyper secretor parents.

39.Answer: B. local mast cells are armed Explanation: In normosecretors ( 1 - 1 0 pg/dl), arming local mast cells occurs. And in hyper secretors ( typically 100 pg- 1 mg/dl) , IgE spill over occurs, arming basophils and non-local mast cells and causing increased occupancy o f mast cell and basophile IgE receptors by IgE.

40.Answer: D. intravenous allergens Explanation: Respiratory allergens include pollens o f various plants(ragweed, grasses, trees); gastrointestinal allergens include dietary products, shellfish, soybeans and peanuts; skin and mouth allergens include topically applied drugs( e.g. procaine) and intravenous allergens include insect venoms and drugs that act as cell or plasma protein bound haptens( e.g. penicillin, cephalosproins,vaccines). These drugs may cause type II or III hypersensitivity reactions in people who do not hypersecrete IgE in response to these drugs.

41 .Answer: A. histamine Explanation: Vasodilation and increased capillary permeability are caused by histamine; the leukotrienes C4, D4 and E4; PGD2 secreted by mast cells. Gastrointestinal and respiratory smooth muscle constriction is caused primarily by the leukotrienes C4, D4 and E4; PGD2; and platelet activating factor secreted by mast cells and other leukocytes. And eosinophil and neutrophil infiltration is caused by chemotactic factors secreted by mast cells.

42.Answer: E. all Explanation:

In sensitized individuals; intravenous injection o f an allergen (e.g. bee venom) or absorption across the mucus membranes (e.g. peanuts) can cause systemic edemic and hypovolemic shock, with cardiac arrhythmia, asphyxiation as a result o f bronchoconstriction and mucous hyper secretion and urticaria. Death usually occurs because o f asphyxiation.

43.A nsw er:B . 1-2 min Explanation: Immediate hypersensitivity reaction has two phases. The early reaction, resulting from mediator secretion by mast cells, begins with in 1-2 min after allergen contact and peaks with in 1-2 hours. The late phase reaction begins 3-12 hours after contact with the allergen and lasts for several hours.

44.Answer: D. A & B

Explanation: In scratch tests, a variets o f allergens are injected intradermally to screen for the presence of wheal and flare (i.e. edema and erythema) response in the skin. Radioallergenosorbent (RAST) and radio immuno-sorbent (R1ST) assays used radio labeled reagents to detect serum IgE concentrations. But the results o f these assays do not always agree with each other or with clinical manifestations o f type I hypersensitivity.

45.Answer: B. passive immunization Explanation: In type I hypersensitivity reaction, prophylaxis includes hyposensitization (injecting weekly, increasing does o f allergen intramuscularly to elicit an allergen specific IgG response and decrease the allergen specific IgE) and the therapy includes competitive H] antagonists of histamine, epinephrine, cromolyn sodium and topical steroids. But passive immunization is used in the prophylaxis and therapy o f type 11 hypersensitive reactions (e.g. anti RhD administered during pregnancy and with in 72 hours postpartion for each RH+ pregnancy in RH mothers).

46.Answer: B. epinephrine Explanation: Competitive Hj-antagoinsts are useful in local forms they do not completely reverse inflammation and have a little effect on anaphylaxis. Epinephrine reverses anaphylaxis through its a-agonist (e.g. oti agonist phenyl propanolamine decreases nasal congestion) and p-agonist (e.g. (32 agonist, albuterol promotes brochodilation); cromolyn sodium (cormoglycate) is locally administered inhibitor o f mast cell degranulation and topical steroids inhibit inflammation and immune responses.

47.Answer: D. A & B

Explanation: Non-IgE mediated type I hypersensitivity reactions (anaphylactoid reactions) are contributed by the factors like respiratory p2-receptors unresponsiveness which leads to diminished bronchodilator effect o f the sympathetic nervous system and hyper reactivity o f mast cells through H2 receptor unresponsiveness, this decrease the negative feed back o f histamine on the activation o f mast cells.

48.Answer: B. cytotoxicity Explanation: In type II hypersensitivity reaction, antibody mediated cytotoxicity occurs through the production o f IgM or IgG. These antibodies are able to bind to specific allergens located on cell surfaces. Anaphylaxis is IgE mediated type I hypersensitivity reaction while immune complexes persistence in the circulation or at local tissues causes type III hyper sensitivity reaction. Type II reactions may exhibit anaphylactic signs and symptoms if enough complement is activated; how ever they usually do not progress to this stage.

49.Answer: B. antisera Explanation: Antisera is a common allergen in type III hyper sensitivity reactions (others include bacterial or protozoan antigens, drugs, fungal or bacterial spores and self antigens is most non-organ specific autoimmune disorder). The common antigens in type U hypersensitivity reactions include foreign blood surface antigens that produce transfusion mismatches or Rh disease; drug allergens( or metabolites) that act as haptens; self allergens which are the allergens in certain autoimmune diseases and hyperactue rejection o f transplanted tissue. 50.Answer: B. drug allergens Explanation: Drug allergens( or metabolites) acting as haptens are the leading cause o f hemolytic anemia they may directly adsorb to cell surfaces and be specifically bound by antibodies( e.g. penicillin , cephalosporin, quinidine). Alternately they may form serum-phase immune complexes, which adsorb nonspecifically to blood cells surfaces. This makes the cell susceptible to lysis due to the innocent bystander effect (e.g. rifampicin, sulfonamides, and chlorpromazine). 51 .Answer: A. a-methyl dopa Explanation: Autoimmune hemolytic anemia is sometimes associated with administration o f a-methyldopa, which induces autoantibodies against the red blood cells but the drugs like penicillin, sulfonamides, and thiouracil are one o f the common allergens in type III hypersensitivity reactions.

52. Answer: D. A & B Explanation:

In type II hypersensitivity, complement proteins produce cytotoxicity and inflammation, which stimulate macrophages and granulocytes to secrete cytokines and enzymes, which in turn enhance inflammation. And in type III anti-inflammatory reactions, complement proteins cause inflammation and stimulate mast cell and basophile secretion.

53.Answer: B. 7-10 days Explanation: In the first sensitization to a drug allergen, the blood cell lysis and inflammation begin 7-10 days after initiation o f drug therapy. The second exposure to the drug causes symptoms within 3 days. But in type III hypersensitivity reactions, patients with no prior exposure to the allergen, the symptoms appear in 1-2 weeks (possibly longer) after the exposure. In patients with preexisting antibodies symptoms appear with in several hours to one day after exposure. This is in case o f systemic reaction, incase o f local reactions, for patients with preexisting antibodies, hypersensitivity pneumonitis symptoms appear 6-8 hours after exposure to the antigen.

54.Answer: D. A & C Explanation: Clinical symptoms o f type II hypersensitivity reactions depend on the type o f antigen/allergen involved. Hemolytic anemia and thromboxytopnea are the major clinical signs o f type II hypersensitivity reactions. But the clinical symptoms o f type III hypersensitivity reactions include the first symptoms lymphadenopathy, splenomegaly, fever and rash. And a more serious symptoms like vasculitis and glomerulonephritis.

55.Answer: D. 1-2 hours after transfusion Explanation: Transfusion mismatch hemolysis begins 1-2 hours after transfusion. Peak effects occur after approximately 12 hours. 56.Answer: C. neutrophils Explanation: In the pathogenesis o f type III hypersensitivity, immune complexes activate complement, cause inflammation and induce positive chemotaxis in neutrophils. Persistence o f immune complexes may be caused by a high concentration o f antigen or antibody. Chronic formation of immune complexes and other factors, which cause insoluble immune complexes to from and precipitate intravascularly or on basement membranes.

57.Answer: B. pneumonitis Explanation: The most common types o f local type III hypersensitivity reactions are pneumonitis to inhaled fungi and bacteria to which the patient is occupationally exposed (e.g. mold hay in farmers lung) and reactions to spores borne in aerosol micro droplets from dirty ultrasonic humidifiers( e.g. humidifier lung). The etiology o f these diseases is not completely understood, but both IgE and

IgG are involved. IgE causes the first inflammation and trapping o f antigen, and IgG is responsible for the long term effects. Symptoms include nasal congestion, bronchoconstriction, joint pain and inflammation of rheumatoid arthritis. Lymphadenopathy is the first symptom exhibited but granulomas and contact sensitivity is symptoms exhibited by type IV reactions.

58.Answer: E. B & C Explanation: Type IV reactions include prolonged inappropriate and appropriate immune responses mediated by antigen-specific TH1 cells in concert with activated macrophages. The TH1 cells infiltrate tissue in which the antigens are presented and recruit and activate macrophages. The release of enzymes and cytokines by these cells results in inflammation and disruption o f tissue structure in the absence o f antibodies.

59. Answer: B. contact dermatitis Explanation: Contact dermatitis is an inappropriate skin reaction to haptens (e.g. pentadecyl cathecoles o f poison ivy) which binds to epidermal cell surfaces and elicits TH1 response. Tuberculin reactions observed in the dermis and are an appropriate reaction to mycobacterial antigens. This reaction indicates the state o f active TH1 immunity (due to an active infection) or T cell memory to the organism. Granulomas are local aggregations o f T cells, macrophages and giant epitheoloid cells (derived from fusion o f activated macrophages). They occur at sties o f chronic infection and serve to restrict the spread o f infection. And erythema is caused by tuberculin tests.

60.Answer: C. E. coli Explanation: From the common allergens, infectious allergens include M. tuberculosis, M. leprae, lysteria monocytogens, trypanosomes and viruses. Haptens allergens include pentadecayl cathechols from poison ivy, poison oak, chromates, nickel ions( leached from watch backs and other jewelry), acrylates, hair dyes that contain P. phenylene diamine, paraminobenzoic acid, and certain antibiotic ointments( topical neomycin). And antigens that induce tuberculin reactions include purified protein derivatives (PPD), tuberculin (mantoux reactions), Candida, malps and other antigens from microorganisms.

61 .Answer: A. granulomas Explanation: Granulomas form at various times after the onset o f a chronic immunoresponse but generally require a minimum o f 2 weeks while contact dermatitis may not occur with the first transient exposure, however in sensitized individual, skin inflammation will appear 12-24 hours after contact and reaches peak between 24 and 48 hours after exposure. And tuberculin reactions follow the same time course as contact sensitivity; this reaction is often called cutaneous hypersensitivity.

62. Answer: D. a high concentration o f antibody Explanation: The etiology o f autoimmune responses (response directed specifically and inappropriately against one or more self-antigens) is not generally known and probably involves several deregulations in the control networks that normally prevent development o f autoimmune disease. This deregulations may include aberrant regulation o f T h and Tc cells, cross reactivity with antigens from microorganisms loss o f self-tolerance or failure to develop tolerance, and aberrant presentation o f self-antigen on specific HLA molecules. And the predisposition is associated with specific MHC types (e.g. rheumatoid arthritis with the MHC class II molecules HLA-DR4).

63.Answer: E. C & D Explanation: These reactions are more common in women. Myasthenia gravis, with a female to male ratio o f 2:1, SLE with a ratio o f 10:1 but in contrast, Sjogrens disease and good pastures syndromes is more common in men than in women.

64.Answer: E. Obesity Explanation: Environmental factors are thought to contribute to pathogenesis. However, specific associations have been found in only a few cases; these include streptococcus group A pharyngitis and rheumatic fever, exposure to organic solvents and good pastures syndrome, ultraviolet irradiation and SLE. It is likely that environmental factors act in concert with genetic predisposition to induce disease.

65.Answer: B. sjogrens syndrome Explanation: Organ-specific autoimmunites include rheumatic fever, antithyroid autoimmunities, myasthenia gravis, autoimmune pernicious anemia, good pasturessyndrome, autoimmune hemolytic anemia, thrombocytopenia, neutropenia, lymphopenia, insulin dependent diabetes mellitus (IDDM) and multiple sclerosis. And non organ-specific autoimmunities include sjogrens syndrome and SLE.

66.Answer: C. graves disease Explanation: An antithyroid autoimmunities, aspects o f several subtypes may occur in the same patient. In primary autoimmune myxedema, antibodies against TSH receptor on thyroid follicle cells act as antagonists to the stimulation o f growth o f the follicle cells normally provoked by TSH; in hashimotos thyroiditis, antibodies against thyroid peroxidase on follicle cells cause cytotoxicity and inflammation through the activation o f complement. But in graves disease antibodies act as agonists o f TSH, binding to TSH receptor and stimulating hyper secretion o f thyroid hormone [(thyroid stimulating immunoglobulin (TSIs)].

67. Answer: B. myasthenia gravis Explanation: In myasthenia gravis, antibodies against the nicotine acetylcholine receptor on skeletal muscle plasma membrane at neuromuscular junctions act as competitive antagonists o f acetylcholine binding. In goodpastures syndrome, antibodies against glomerular capillary basement membrane (GBM) activate compliment and neutrophil mediated damage; in multiple sclerosis (MS), T-cells and macrophages which are thought to be cytocidal for oligodendrocyts, infiltrate the central nervous system (CNS) and attack the basic protein o f myelin as an autoantigen; in IDDM, progressive and ultimately complete destruction o f pancreatic p-cells occurs in diabetes. But rheumatic fever is not technically an auto immune response because antibodies are produced against group A streptococci and cross react with cardiac muscle fibers that are damaged by complement.

68.Answer: D. sjogrens syndrome - dantrolene Explanation: Anticholinestrase therapy( e.g. neostigmine) is indicated for myasthenia gravis; in good pastures syndrome immunosuppressive therapy(corticosteroids) ; in multiple sclerosis, spasticity is treated with baclofen, the peripheral skeletal muscle relaxant dantrolene is effective is some patients and adrenocortioctropic hormone(ACTH) is the favored immunosuppressive agent. But sjogren's syndrome, mild cases are treated with artificial tears and frequent drinking of water and for most serious cases (e.g. vasculitis) treatment is similar to that o f SLE which is systemic corticosteroids like methyl prednisolone.

69.Answer: A. autoimmune pernicious anemia Explanation: In autoimmune pernicious anemia, antibodies against intrinsic factor are secreted into the stomach lumen, where they inhibit the association of intrinsic factor with vitamin B 12thus the absorption o f B 1 2 is decreased, therapy includes intramuscular injection o f cyanocobalamin or oral administration o f concentrated intrinsic factor preparations. But in case o f autoimmune hemolytic anemia (red blood cell), thromobocytopenia (platelet), neutropenia (neutrophil) and lymphopenia (lymphocyte), antibodies against membrane antigens o f one or more o f the indicated cell types may activate complement and posonize the cells for rapid splenic phagocytosis. These disorders are often acute and self limiting but when they become chronic, treatment begins with corticosteroids. 70. Answer: D. inhibition of exocrine gland secretion

Explanation: SLEs pathogenesis is that of type III hypersensitivity patients have hyperactivity o f B cells of unknown origin. This hypcractivity causes hypergammaglobulinemia, with circulating immune complexes o f DNA and other nuclear antigens that precipitate onto vascular basement membranes and active complement. Mild arthritis, fever rash and fatigue occur, hypertension may develop secondary to kidney disease, hemolytic anemia and thromobocytopnea are common; behavioral changes occur in approximately 25 % of patients and progressive necrotizing vasculitis with CNS involvement and glomerulonephritis are the most serious consequences occurring in

approximately 50% of patients. In sjogrens syndrome pathogenesis, primary symptoms include inhibition o f exocrine gland secretion.

71 .Answer: A. corticosteroids Explanation: Current therapies involve approaches that suppress all immune responses for example corticosteroids; however current clinical trials seek to suppress only lymphocytes that are activated e.g. feeding autoantigens(to induce immunologic suppression), vaccination with autoactive T cells( to induce immunologic suppression), administration o f anti-TH monoclonal antibodies(particularly anti-CD4, to eliminate auto reactive T cells) and administration o f conjugates of interleukin-2(lL-2) and toxins from plants or bacteria to eliminate auto reactive T cells with out generalized T-cell suppression.

72.Answer: C. Leukemias Explanation: Primary immunodeficiencies include X-linked agammaglubulinemia, common variable immunodeficiency, selective IgA deficiency, Digeorge syndrome, Nexelof syndrome, severe combined immunodeficiency disorders(SClDs), chronic granulomatous disease(CGD), leukocyte adhesion deficiency(LAD), Chediak-higashi syndrome and defects in complement while secondary immunodeficiencies include, cytotoxic drugs, leukemias, lymphomas, myelomals, protein calorie malnutrition, aging, acute infections and AIDS.

73.Answer: B. I, IV, V, VI Explanation: Digeoge syndrome results from development failure o f the thymus and parathyroid glands, accompanied by cardiovascular and the other developmental anomalies, patients have a decrease in total T-cell numbers (but normal immunoglobulin level), nezelof syndrome is probably inherited and cause lymphopenia and thymus abnormalities, but normal serum immunoglobulin levels. Gram negative sepsis may occur in addition to the opportunistic infections associated with T-cell deficiency and SCIDs are heterogeneous group of inherited disorders with deficiencies in T-cells, B-cells(variable) and serum immunoglobulin X-linked agammaglobulinemia is an inherited deficiency in antibody production(humoral immunity) in which T-cell function is relatively normal but B-cells do not fully mature. Common variable immunodeficiency is an acquired deficiency o f B-cell maturation to plasma cells while Chediak-higashi syndrome is a deficiency in fusion of lysosomes with phagocyte vesicles and selective IgA deficiency has low secretary IgA (slgA).

74.Answer: E. VII&VIIJ Explanation: Chronic granulomatous disease (CGD) is a defect in the ability o f phagocytes to kill bacteria and leukocyte adhesion deficiency (LAD) is associated with a defect in phagocytic cells. But defects in complement may be due to defects in the activation pathways, membrane attack complex or regulatory proteins.

75.Answer: C. X-linked agammaglobulinemia Explanation: X-linked agammaglobulinemia is liked to the X-chromosome so it occurs primarily in men. Treatment is passive immunization with intravenous human immune globulin. But commonvariable immuno deficiency and selective IgA deficiency may occur in either sex.

76.Answer: C. cytotoxic drugs Explanation: Cytotoxic drugs prevent the division o f responding lymphocytes, suppress the production o f blood cells in bone marrow and may directly kill cells. Patients who receive chemotherapy and exhibit a significant loss o f neutrophils may be treated with filgrastim, or recombinant G-CSF (neupogen), to restore the WBCs count to normal levels. But leukemias, lymphomas and myelomas are associated with decreased immune responsiveness.

77.Answer: B. Three Explanation: Optimal anti-HIV therapy is combination therapy with three antiretroviral drugs.

78.Answer: B. didanosine Explanation: At present, there are three classes o f antiretroviral drugs approved by the FDA; these are nucleoside reverse transcriptase inhibitors (NRTIs) (i.e. zidovadie, lamivodine, stavudine, zalcitabine, didanosine and abacavir), NNRTIs (e.g. nevirapine, delavirdine, efavirenz) and protease inhibitors (e.g. saquinavir, indinavir, ritonavir, nelfinavir).

79.Answer: E. all Explanation: Opportunistic infections are the major consequences o f AIDS, particularly by P. carinii. Candida albicans, Mycobacterium-avium intraccllulare, Herpes simplex virus (HSV), cytomegalovirus (CMV) and others. TB occurs as a reactivation o f latent infection in carriers.

80.

Answer: B. CD4

Explanation: The viral envelope g p l2 0 has a strong affinity for CD4, allowing the virus to directly infect TH cells. In addition, these proteins use a chemokine receptor CCR5 to gain entry to macrophages and dendritic cells. APCs are also affected by the infection. There is a loss o f follicular dendritic cells and interdigitating cells in the lymphoid tissue; this loss leads to decreased APCs to the CD4+ T cells. Macrophages may produce new viruses with out being killed and may spread the

virus to uninfected T cells and other cell types. CD8+ T cells are not significantly affected and the ratio o f circulating CD4+ to CD8 cells is inverted after infection.

81 .Answer: B. class 1 glycoproteins are known as HLA-DR, -DP and DQ antigens Explanation: There are individual differences in the molecular structures o f cells and tissues except in identical twins because o f the genetic variation inherent in humans. Because o f these molecular differences, transplanted tissues or organs i.e. grafts are likely to be antigenically different from the recipient and there fore may stimulate an immune response. Human leukocyte antigen (HLA) or histocompatibility type is each persons set o f MHC glycoproteins. Class-] glycoproteins are known as HLA-A, -B, and -C antigens. Class II glycoproteins are known as HLA-DR, -DP and DQ antigens. Each person receives from each parent one set o f genes encoding these protein antigens. Only identical twins have the same histocompatibility type. The probability o f two siblings with the same parents to be HLA-identical or matched is 25%.

82.Answer: D. All Explanation: The common solid-organ transplants are kidney, heart, liver, heart-lung and pancreas. The organs can be obtained from cadavers or living donors. In a cadaver graft, the probability o f an exact HLA match is approximately 1 in 10 million.

83.Answer: B. Cornea Explanation: In cornea transplant, is HLA matching not important.

84.

Answer: A. cardiac graft

Explanation: The rejection reaction is decreased in renal and cardiac grafts if HLA-DR and HLA-B are matched. But rejection does occur in HLA-matched situations.

85.Answer: C. The only reason for tissue rejection is HLA-incompatibility Explanation: The probability o f two siblings with the same parents to be one-half HLA-matched or haploidentical is 50%. But parents and children are almost always haploidentical. Some transplanted tissues are rejected because o f HLA incompatibility where as in other cases, the reason is unknown. HLA-matching is not always a factor in rejection.

86.Answer: C. acute rejection Explanation:

Acute rejection is a T-cell-macrophage- mediated attack on the graft based on HLA and other tissue antigen mismatches. They cause cellular necrosis and inflammation perivascularly after the T-cell and macrophages infiltrate the graft in 10-14 days. I f untreated, the entire graft starts to necrose. 87. Answer: B. An ABO-mismatched graft Explanation: Hyperacute rejection is mediated by preexisting antibody in the recipient, usually against ABO mismatches. Rejection occurs within 2 days after transplantation. Complement is activated, clotting occurs and the vasculature o f the transplanted organ is occluded. ABO-mismatched graft is rarely attempted and the rejection is untreated. 88.Answer: D. All Explanation: Chronic rejection occurs several months to several years after transplantation. It causes fibrosis and occlusion o f small arteries and arterioles in the kidneys and atherosclerosis in the heart. It may be controlled by immunologic injury, through antibody or cells, and includes the release o f inflammatory cytokines by macrophages. This form o f rejection is resistant to therapy. 89.Answer: C. in bone marrow transplantation, the host-versus-graft response is very important Explanation: Bone marrow transplantation is sometimes attempted in patients with immunodeficiency diseases, aplastic anemia, some leukemias and certain genetic diseases. A high proportion o f donor lymphocytes that respond to the host HLA and other antigens are contained in the graft. This response causes GVH disease. Graft T-cell recognition o f the host is important in GVH disease as shown by the decreased incidence o f GVH disease after procedures that purge mature T cells from the donor marrow. Although HLA matching is important in bone marrow transplantation, the failure rate even for matched grafts is high because o f GVH disease. The host-versus-graft response is less important because the host is immunosuppressed due to primary immunodeficiency or by drugs or radiation. 90.Answer: D. agranulocytosis Explanation: Clinical symptoms of GVH disease is seen on the skin which causes rash, and desquamation, gastrointestinal tract such as pain, vomiting and intestinal bleeding and liver necrosis indicated by increased serum bilirubin levels. Death commonly occurs. 91.Answer: B. tacrolimus Explanation: Corticosteroids, azthioprene and methotrexate are used for immunosupression o f the graft recipient. But tacrolimus is used to specifically suppress the T-cell. 92.Answer: A. ALG/ATG Explanation:

Corticosteroids such as prednisolone and methyl prednisolone are administered just before transplantation. They are tapered rapidly because o f their side effects. Corticosteroids are used in combination with azathioprine, cyclosporine or antilymphocyte elobulins/antithymocyte globulins (ALG/ATG).

93.Answer: B. methotrexate Explanation: Methorexate is used primarily for bone marrow transplantation in combination with ALG/ATG. It is administered either a few days before or at the time o f transplantation. Azathioprine is used for immunosuppression o f the graft recipient. It is given before transplantation followed by a maintenance dose afterwards. Cyclosporine and tacrolimus are specific suppressants o f T cells.

94.

Answer: D. TH-cell secretion o f IL-2 and IFN-y and prevents T-cell activation

Explanation: Cyclosporine binds to an intracellular protein known as cylcophilin and blocks the transcription o f cytokine agents in a T cell that has recognized antigens. It inhibits TH-celi secretion o f IL-2 and IFN-y and prevents complete T-cell activation. Because it is more effective if it is present when rejection begins, it is administered prophylactically. It is commonly combined with other agents. Nephrotoxicity is the major side effect.

95. Answer: C. cyclosporine and tacrolimus Explanation: Since cyclosporine and tacrolimus function through the same pathway i.e. by inhibition o f TH -cell secretion o f IL-2 and IFN-y and complete prevention of T-cell activation. Rampamycin functions by inhibiting TH cell response o f IL-2 to prevent T h- ccII activation. Since it functions through a different pathway, it is more effective in combination with cyclosporine and tacrolimus. Corticosteroids are used in combination with cyclosporine, azathioprine or antilymphocyte globulins/antithymocyte globulins (ALG/ATG).

96. Answer: B. ALG and ATG Explanation: ALG and ATG are antisera derived from animals. They contain a variety o f antibody specificities against T-cell antigens. They are used prophylactically and therapeutically in bone marrow and organ transplantation.

97.Answer: A. muromonab-CD3 Explanation: Muromonab-CD3 is a mouse monoclonal antibody specific for the CD3 antigen, which is present on all peripheral T cells. It is used therapeutically to half and reverses acute rejection.

98. Answer: A. it may also be used in vitro to purge host(recipient) bone marrow o f T cells to reduce the risk o f GVH disease Explanation: Muromonab-CD3s main actions are the opsonization o f T cells for enhanced phagocytosis. It can be administered daily for 10-14 days. Only one course is typically used because it causes an immune response against the foreign mouse antibody. Because o f nonspecific T-cell activation which causes the release o f cytokines, acute side effects are common. The side effects include high fever, chills, blood pressure changes, vomiting, diarrhea and respiratory distress. Patients with fluid overload should not use OKT3 because it may cause fatal pulmonary edema. OKT3 may also be used in vitro to purge donor bone marrow o f T cells to reduce the risk o f GVH disease.

99. Answer: C. active vaccination is the intramuscular or intravenous injection o f antibody preparations to enhance a patients immune competence Explanation: Active vaccination is the intramuscular, subcutaneous or oral introduction o f one or more antigens designed to stimulate the immune system to produce a specific immune response. This response generates antibody, activated T cells and specific memory. Protection through memory varies with the vaccine but immunity is long-lasting. Passive vaccination is the intramuscular or intravenous injection o f antibody preparations used to enhance a patients immune competence. The protection o f passive vaccination depends on the serum half-life o f the injected antibody and is limited to several weeks to several months for each administration o f human sera.

100. Answer: A. they-are individual sera prepared from plasma lots o f subjects actively immunized against or recovering from specific disease Explanation: Standard human serum immune globulin for intramuscular vaccination (IGIM) is a polyclonal antiserum prepared from pooled plasma o f donors. It contains 165 mg/ml human immunoglobulin, predominantly the four subclasses o f IgG i.e. IgG 1-4. The side effects are rare, minimal and usually confined to minor inflammation and pain at the site of injection. Since antibody aggregates form and may activate complement and platelets, it is unsuitable for intravenous injection.

101.

Answer: C. Special IGIM

Explanation: Special IGIM are individual sera prepared from plasma lots o f subjects actively immunized against or recovering from specific diseases. Each serum is enriched for antibody o f the desired specificity e.g. tetanus immune globulin (TIG) contains more antibodies against tetanus toxin than would be found in IGIM.

102.

Answer: D. chills, nausea and abdominal pain occurs in all patients

Explanation:

IVIGs are prepared from polled human serum and modified to minimize antibody aggregation. Approximately 10% o f patients experience chills, nausea and abdominal pain. By reducing the rate o f intravenous infusion, the side effects can be diminished. Premeditation with corticosteroids is recommended and intravenous epinephrine is used if prophylaxis occurs.

103.

Answer: A. hepatitis immune globulin

Explanation: Passive vaccination is used for the prophylaxis o f infectious disease e.g. tetanus immune globulin is used for the prophylaxis o f Clostridium tetani infection, hepatitis B immune globulin for individuals exposed to hepatitis virus, prophylaxis or therapy which prevents or attenuates the effects o f infection in special populations e.g. varicella zoster immune globulin for immunocompromised patients. IGIM is used in pregnant women exposed to rubella. Treatment o f antibody deficiency are used for persons who are deficient in antibody production, either because o f primary immunodeficiency or as a result o f chronic lymphocyte leukemia receive IVIG or IGIM every 2-4 weeks to maintain humoral immunity. It is also used for other situations such as for idiopathic thrombocytopenia purpura, intramuscular Ro (D) immune globulin as a prophylaxis for Rh disease and muromonab-CD3 for acute renal graft rejection. IGIM is used for hypogammaglobulinemia that is for antibody deficiency therapy.

104.

Answer: C. polyvalent antivenin

Explanation: Polyvalent antivenin is used for the prophylaxis and therapy for snakebite. Botulism antiserum is used for prophylaxis and therapy o f botulism. For the prophylaxis and therapy o f black widow bite, black widow antivenin is used.

105.

Answer: A. Rho(D) immune globulin

Explanation: Animal antisera i.e. equine(horse) antisera are used in certain situations such as in the preparation o f botulism antiserum for botulism, polyvalent antivenin for snakebite, black widow antivenin for black widow bites and mouse monoclonal antibody for acute renal rejection. Rho (D) immune globulin is used for the prophylaxis o f Rh disease.

106.

Answer: C. chronic lymphocytic leukemia

Explanation: Intramuscular passive vaccines are used for the prophylaxis o f hepatitis A and hepatitis B viruses, measles, rabies, rubella, varicella, tetanus, hypogammaglobulinemia, Rh disease, botulism, snakebite and black widow bite. As a therapy, intravenous passive vaccines are used for hypogammaglobulinemia, idiopathic thrombocytopenic purpura, chronic lymphoctyic leukemia, cytomegalovirus infection. To reverse acute rejection, intravenous passive vaccine i.e. muromonab-CD3 is used.

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i a

Explanation:

Explanation: In the therapy for antibody deficiency caused by hypogammaglobulinemia, both intramuscular (1GJM) and intravenous (IVIM) passive vaccines can be used. In all the other illnesses, either intravenous or intramuscular passive vaccines can be used.

108.

Answer: D. all o f the above

Explanation: Active vaccines contain low doses o f antibiotics, one or more antigens or whole pathogenic organisms. It may also contain preservatives and other compounds that do not affect the immune response.

109.

Answer: A. Intravenous

Explanation: Active vaccines are administered subcutaneously, or intramuscularly, intradermally. Some are introduced adsorbed to aluminum hydroxide or aluminum phosphate adjuvants. The antigenicity o f the vaccine is increased by an adjuvant. A few vaccines are administered orally or intranasally. 110. Answer: B. bacillus calmette-Guerin

Explanation: Seroconversion indicates that a person who previously did no have specific serum antibodies (i.e. seronegative) now has these antibodies( i.e. seropostivie). The success o f the series o f vaccination for most active vaccines is indicated by seroconversion o f the patient. For certain vaccines, seroconversion does not indicate established immunity e.g. bacillus calemtte-Guerin vaccine for tuberculosis.

111.

Answer: A. BCG

Explanation: The vaccine that can be given immediately after birth is BCG vaccine. Most o f the vaccines are given after the infant is 6 weeks old because responses are normally inadequate in newborns and because maternal antibodies remain in the new born circulation.

112.

Answer: D. Rubella

Explanation: Most vaccines require a series o f vaccinations where as other are effective with a single vaccination. For those that require a series, the protection does not diminish if the interval between vaccinations is greater than the recommended. Booster vaccinations are often necessary for vaccines in which the duration o f memory varies with each vaccine. Rabies, DTP and Td require booster vaccinations after 4 or 5, 4 and 3 vaccines respectively.

113.

Answer: C. all vaccines require a series o f vaccinations

Explanation: Active vaccination is used for prophyl axis. It contains one or more antigens or whole pathogenic organisms, preservatives low doses of antibiotics and other compounds that do not affect the immune response. It can be administe ied intramuscularly, intradermally, subcutaneously, adsorbed to aluminum hydroxide or a.l uminum phosphate adjuvants, orally or intranasally. For most active vaccines, the success o f th e series o f vaccination is indicated by seroconversion o f the patient. A schedule o f active vaccinati 3n is recommended for infants and children. But some vaccines are intended for use primaril; in noninfant populations. Most vaccines require a series o f vaccination where as others are effecti ve with a single vaccination. The side effects include inflammation at the site o f vaccinatidr malaise, mild fever, chills, headache, myalgia and arthralgia. Febrile illness, somnolence seizures or anaphylactic hypersensitivity to vaccine antigens or accessory components sue i as antibiotic, chicken protein is the more sever side effects. Sever reactions contraindicate continuation o f a series. A person with sever febrile illness should not be actively vaccinated unti the illness resolves.

114.

Answer: A. it is safe to give live, attenuated viral vaccines to pregnant women

Explanation: Live, attenuated vaccines consists o f jjwhole organisms usually viruses. Since these organisms multiply after vaccination, they are att enuated to reduce their pathogenecity. A small dose can produce strong immune response becj use the antigen concentration increases when the organism multiplies. Some vaccines such as me isles, mumps, and rubella (MMR) vaccine elicit life long immunity in two doses. Because o f th : ir relative genetic instability, viruses can revert to virulence and cause the disease again't which the patient is vaccinated e.g. oral polio vaccine(OPV). Live attenuated viral y accines are not recommended for pregnant women or those intending to become pregnant within months o f vaccination. Immunocompromised individuals should not be given live, attenuated V i ral or bacterial vaccines.

115.

Answer: C. killed inactivated vaccines

Explanation: Killed, inactivated vaccines may contk:in whole killed cells for e.g. phenol-killed bordetella petussis or any antigenic fraction isolated from the organism. They are usually given adsorbed to adjuvant. Tetanus toxiod(Td) is an ex;ample o f killed, inactivated vaccine which is isolated antigen which may require inactivatiion before they are used in a vaccine. The inactivation eliminates pathogenicity but preserves; some antigenicity.

116. Answer: B. vaccines in whidl the antigenic fragment is a polysaccharide are usually best at eliciting immune response and mernory Explanation: In killed, inactivated vaccines, isolate|d antigens may require inactivation before they are used in a vaccine. This inactivation eliminates; pathogenicity but preserves some antigenicity. Since no live organisms are present, reversion to p ji Jathogenicity is not a problem. The doses o f cells or antigens must be higher than in live, attenuated vaccines. Flypersensitivity reactions to vaccine components are more common. Vac<j; nes in which the antigenic fragment is a polysaccharide are usually poor at eliciting immune resp<j>nses and memory, probably because they do not evoke T-

cell activation. In this type o f vaccines, the polysaccharides are conjugated to another antigenic compound. These vaccines are known as conjugate vaccines.

117.

Answer: D. subunit vaccines

Explanation: HBV vaccine and the vaccine that is not currently available lyme disease vaccine are examples of subunit vaccines. Subunit vaccines are proteins and glycoprotein of an organism that are produced by recombinant DNA technology in bacteria, yeast or mammalian cells. These are used as the antigens for vaccination.

118.

Answer: D. All

Explanation: Experimental vaccines include other subunit vaccines i.e. peptides produced by chemical, cellfree synthesis, recombinant DNA viruses containing genes for the antigens o f multiple organisms and anti-idiotype antibodies used for active vaccination.

119.

Answer: D. oral polio(opvj trivalent)

Explanation: Oral polio(opvj trivalent) is a live attenuated viral vaccine. The target populations were infants, children, health and day-care workers. It was given four times with a schedule o f 2,4,15-18 months and one at school entry. Because of 1 in 2.6 million risk o f vaccine-induced paralysis; it is no longer recommended and is substituted by killed vaccine.

120.

Answer: A. Rubella

Explanation: Rubella is the vaccine hat is given to adolescent girls not previously vaccinated. It is given to protect future fetus from congenital rubella injury. It is given once after puberty. MMR(measles, mumps rubella) is given to infants and children. It is given twice on the 15 month and at school entry. This vaccine affords life long immunity. Varicella virus is given to children and to individuals at risk. It is given once but if the patient is 13 year or older it is given twice. In children below 13 years or older it is given twice. In children below 13 years o f age it is given between the 12 and 18 months or 2-3 years. For individuals above 13 years it is given 2-4 weeks apart. Influenza(tri or polyvalent) is given.to geriatric patients, health care workers and for those who are at risk for complications o f flu. It is given annually for maximal protection . the vaccine must be updated annually because variant strains may appear each year.

121.

Answer: C. BCG tuberculosis

Explanation: Oral polio(opv trivalent, measles, mumps rubella(MMR) rubella and varicella are live attenuated viral vaccine. BCG tuberculosis is a live attenuated bacterial vaccine. It is given to persons

exposed to sputum-positive tuberculosis patients. The schedule o f BCG tuberculosis vaccine depends on the success o f the initial vaccination. Its effectiveness is unpredictable. It induces cell mediated immunity. 122. Answer: C. rabies

Explanation: Rabies is given to animal-care-workers 4 or 5 times with booster vaccination. It should be taken 7 days apart. The boosters are taken as required to maintain immunoglobulin. Only tow doses are given to exposed, already immune individuals. Influenza vaccine is given to geriatric patients, health care workers and to those who are at risk for complications o f flu. Rubella vaccine is given to adolescent girls not previously vaccinated.

123.

Answer: A. Influenza

Explanation: A vaccine that is given annually is influenza vaccine. It is given to geriatric patients, health care workers and those at risk for complications o f flu. The vaccine must be updated annually because variant strains may appear each year. 3 vaccines o f hepatitis B are given inactivated polio 4 vaccines and rabies 4 or 5 vaccines. 124. Answer: B. hepatitis B

Explanation: Hepatitis B is a recombinant subunit. It is given to each individual. Three vaccines are given, the first between 1-2 months, the second 2-3 months and the last one after 6 months.

125.

Answer: A. there is a risk of vaccine-induced paralysis

Explanation: Inactivated polio vaccine is given to immunodeficient children and families. It is given as booster vaccination in health and day care workers. Four vaccinations are given scheduled at 2,4,15-18 months and one at a school entry. Inactivated polio has no paralysis risk. 126. Answer: C. tetanus and diphtheria toxoid

Explanation: Tetanus and diphtheria toxiod(Td) is given for children 7 years or older , and for adults with no vaccination. It is three vaccination with boosters. The second dose is given in 4-8 weeks and the third dose 6 months later. Td booster is given every 10 years or on exposure through a wound if more than 10 years or vaccine history is unavailable.

127.

Answer: D. since it is a polysaccharide vaccine, conjugate vaccines should be used.

Explanation: Diphtheria, tetanus pertussis(DTP) is given for infants and children. There are four vaccinations with boosters. It is given on the 2nd, 4th, 15th - 18th month and one at school entry. Tetanus toxiod(Td) boosters are given every 10 years or on exposure through a wound.

128.

Answer: A. haemophilus b

Explanation: Hemophilus b is given to infants, children and HIV infected adults. The number o f vaccine and schedule depends on the formulation. Conjugated vaccines enhance the potency polysaccharide capsule is poor antigen. Pneumococcus is given to adults or children 2 years or older and are at risk o f e.g. immunocompromised patients and geriatric patients.

129.

Answer: C. meningococcus

Explanation: Menigococcus(quadrivalent A,C,Y, and W-135) is given to college freshmen living in dormitories, high-risk adults or children 2 years or older including individuals with terminal complement component deficiencies or anatomic or functional asplenia. It is given once subcutaneously. It is given as necessary to individuals at risk, in 3-5 year intervals. Polysaccharide vaccine gives poor response in children younger than 2 years. It dose not protect against serotype B, which accounts for 46% o f cases.

130.

Answer: D. pneumococcus

Explanation: Pneumococcus is a polyvalent vaccine. The target population are adults at risk or children 2 years or older for e.g. immunocompromised patients, geriatric patients. It is given once or once per year. It can be given once per year in geriatric patients, it is given as necessary in at risk patient who were not given during active infection. In children younger than 2 years o f age, the polysaccharide antigen has poor response.

131.

Answer: D. All

Explanation: Active and passive vaccines are administered simultaneously to maximize post exposure prophylaxis. The immune globulin offers immediate protection where as the active vaccine stimulates an immune response. In order to prevent antigen and antibody from reacting and inactivating one another these vaccines are given at separate sites. Infants with HBV who are bom to mothers who have the hepatitis B surface antigen, this combined prophylaxis is given to protect them from becoming chronic carriers. Combined active and passive vaccines are used as a post exposure prophylaxis o f rabies. Because o f the lethal nature o f the unchecked infection. The exceptions are patients with a previous active vaccination with sufficient existing serum antibody concentration. 132. Answer: B. if the last dose was received more than 10 years ago, Td but not TIG is given

Explanation: Active and passive tetanus vaccine is sometimes used depending on the type of wound and the patients history o f active vaccination. A tetanus-prone wound is one that produces anaerobic conditions for e.g. deep puncture or one in which exposure to clostridium or its spores is probable

e.g. contaminated with animal feces. Both TIG and Td vaccines are administered if the patients vaccination history is uncertain or includes fewer than three doses. The patient must return to complete the toxoid series for tetanus prone wound no treatment is necessary if the last Td dose was received with in the last 5 years and if the last dose was received more than 10 years ago, Td and not TIG is given to boost memory immunity and antibody production.

133. Answer: A. for a clean, minor wound, no treatment is necessary if the patient received a full series and the last Td dose was received within 5 years Explanation: For a clean minor wound, if the patients history o f active vaccination is uncertain or includes fewer than three doses only Td is administered. No treatment is necessary if the last Td dose was received within 10 years and full series o f active vaccination was received by the patient. If the last dose was received more than 10 years ago, Td but not TIG is given to boost memory immunity and antibody production.

134.

Answer: E. it is useful for HIV treatment

Explanation: Monoclonal antibodies are used for in vitro diagnostic tests such as blood group and tissue typing for HLA, screening o f cancer-related antigens e.g. carcinoembryonic antigen, urine testing for drugs and metabolites and testing for HIV infection. Monoclonal antibodies are conjugated to enzymes, radioisotopes or florescent dyes for these and many other diagnostic applications.

135.

Answer: C. bone cancer

Explanation: Monoclonal antibodies against neoplastic cells show some success and are used to treat certain leukemias and lymphomas, breast cancer and colon cancers.

136.

Answer: C. Monoclonal antibodies against T cells

Explanation: The clinical trials o f monoclonal antibodies against T cells have shown improvement in certain autoimmune disorders. Fab antidigoxin antibody which is obtained from sheep is approved for the reversal o f toxicity associated with toxic digoxin serum levels. Muromonab-CD3 is used to treat acute graft rejection. Monoclonal antibodies against neoplastic cells are useful in treating certain leukemias and lymphomas as well as breast and colon cancers.

137.

Answer: D. All

Explanation:

Monoclonal antibodies are conjugated to enzymes, drugs, prodrugs, radioisotopes or plant and bacterial toxin. It is conjugated in order to provide specific delivery o f the conjugated agent to one or more focused in vivo sites o f action.

138.

Answer: A. immunotoxins

Explanation: Immuotoxins are usually produced by the conjugation o f a monoclonal antibody to a biological polypeptide toxin that is modified to reduce nonspecific toxicity e.g. diphtheria toxin. Immunotoxins are primarily as antineoplastic agents but they are being tested for graft rejection and autoimmunity. 139. Answer: B. IFN- a

Explanation: Since IFN-a inhibits cell growth, it is used to treat hairy cell leukemia, kaposPs sarcoma in patients with AIDS and genital warts. Immune cellular functions are stimulated by interferons at low dose e.g. T cclls, NK cells, macrophages but higher doses have immunosuppressive effects. 140. Answer: C. IFN- y is used to treat hair cell leukemia and genital warts

Explanation: IFN- a and IFN- y are the only approved interferons. IFN- a is used to treat hairy cell leukemia, kaposis sarcoma in patients with AIDS and genital warts. The low doses o f IFN- a are immune cellular function stimulants where as higher doses are immunosuppressants. Greater immune stimulation is provided by IFN- y in the intact immune system. Its effect depends on dose and timing. IFN- y is used as a macrophage-activating factor in chronic granulomatous disease. The most common side effects o f interferons are influenza like symptoms. Better results are obtained when IFN- a and IFN- y are used in combination. 141. Answer: B. the effect o f sulfur-containing compounds such as levamisole and diethyldithiocarbamate is greater on humoral immunity than on cell mediated immunity Explanation: Sulfur-containing compounds such as levamisole( a phenylimidothiazole anthelmintic) and diethyldithiocarbamate( imuthiol) have immunostimulatory activity. Their effect is greater on cell mediated immunity than on humoral immunity. Adoptive immunotherapy is a technique in which a patients peripheral blood lymphocytes or tumor-infiltrating lymphocytes are removed. Hormones o f thymus which induce T-cell maturation and other functions are used to increase certain cell-mediated immune functions. Inosine pranobex induces T-cell differentiation and it augments cell mediated immune functions.

142.

Answer: A. muramyl dipeptide

Explanation: Muramyl dipeptide is a component o f mycobacterial cell walls and it stimulates macrophage activation. They may be used as an adjuvant given with antigen or given alone as an immunostimulant.

Infectious Diseases

A man can succeed at almost anything for which he has unlimited enthusiasm.

Charles Schwab

1. Which o f the following statements is (are) TRUE? l.Anti-infective agents treat infection b> suppressing or destroying the causatm microorganisms ILAnti-infective agents derived frorr natural substances are called antibiotics. 111.Anti-infective agents produced fron synthetic substances are called anti microbials A. B. C. D. E. i f l only is correct if HI only is correct if I & II are correct if II&III are correct ifl , II, and 111 are correct

C. Susceptibility tests o f the infective microorganism D. All o f the above E. A and C are enough

5. Which of the following statements best describes the minimum inhibitory concentration in the micro dilution method o f susceptibility testing? A. It is the lowest drug concentration that prevents microbial growth after 18-24 hours o f incubation. B. It is the minimum number of bacteria that can survive after 24 hours o f incubation in anti-microbial drug susceptibility testing. C. It is the lowest concentration o f a drug that reduces bacterial density by 99.9% D. It is the concentration o f a drug that kills the lowest number o f bacteria. E. None

2. Which o f the following statements is NOT TRUE about gram staining? A. Gram staining can be done on a)ll specimens except blood cultures B. By determining if the causath agent is gram-positive or gramnegative, the test allows a bett choice o f drug therapy C. Gram-positive microorganisms stain blue or purple D. Fungi cannot be identified fey gram stain E. Gram-negative microorganisijis stain red or rose pink

6. Which o f the following statements are true about break point concentrations of antibiotics? A. They are used to characterize antibiotic activity. B. They are determined by considering pharmacokinetics, serum and tissue concentrations following normal doses o f antibiotics. C. The interpretive categories are based on break point concentrations are susceptible, moderately susceptible, and resistant. D. All o f the above E. A and B only

3. All o f the following are termed microorganisms EXCEPT: A. B. C. D. E. Bacteria Fungi Protozoa Viruses Lice

4. Which o f the following should be performed before anti-infective therapy i initiated? A. Microbiological cultures B. Gram staining

7. As compared to the microdilution method the diffusion method o f susceptibility testing is: A. Less expensive B. More expensive
C. Less reliable

D. More reliable E. A and C

8. Which o f the following may suggest the effectiveness o f a particular drug in treating a given syndrome (mostly infections)? A. B. C. D. E. Structure o f a drug Physical properties o f a drug Susceptibility testing Clinical experience C and D

12. Which of the following statements is NOT TRUE about drug therapy during pregnancy? I.Plasma drug concentrations tend to decrease in pregnant women II.Most drugs, including antibiotics, appear in the breast milk o f nursing mothers and may cause adverse effects in infants III .The m other's need for the antibiotic should be weighed against the drugs potential harm A. B. C. D. E. I only Ill only I & II II&III 1,11, and III

9. An anti-infective agent should be chosen for a particular infection based on: A. B. C. D. E. Its pharmacological properties Spectrum o f activity Various patient related factors All o f the above A and C only

13. Which o f the following class o f antibiotics may lead to toxic bilirubin accumulation in a newborns brain? A. B. C. D. E. Tetracyclines Sulfonamides Aminoglycosides Erythromycins None

10. A bactericidal agent is: A. A drug that inhibits the growth or reproduction o f a bacterium. B. A drug that rapidly destroys the bacteria C. A drug that stimulates the growth o f bacteria D. A drug that acts as food for bacteria E. None

14.Sulfonamides may cause hemolytic anemia in patients with hereditary deficiency o f the enzyme: A. B. C. D. E. Salivary amylase Glucose-6-phosphate dehydroganse Ri bose-6-phosph ate Topoisomerase None

11 .Which o f the following patient related factors affect the outcome o f anti-infective therapy? A. Impaired immunological mechanisms B. Preexisting kidney or liver damage C. Pregnancy if the patient is female D. All o f the above E. A and C only

15.Patients who rapidly metabolize drugs (i.e. rapid acetylators) may develop hepatitis when receiving the antitubercular drug: A. B. C. D. Isoniazid Streptomycin Rifamipicin Ethambutol

E. None

16. Which o f the following should be done when a serious life-threatening infection occurs? A. A broad-spectrum antibiotic should be given until the specific organism has been identified B. Any antibiotic should be given in doses higher than those used in the treatment o f less severe infections C. The antibiotic therapy should not be given until the infective organism is known D. Combination o f any antibiotics should be used E. None

II.In chronic infection treatment may require duration o f 4-6 weeks. III.Treatment o f acute infection should continue until the patient feels better. A. B. C. D. E. 1 only 111 only I&1 1 II&III I,II, and III

20.The role o f radiographic findings in monitoring therapeutic effectiveness is: A. They help in identification o f the infecting organism. B. They help indicate the locus of infection. C. They act as therapeutic agents by directly killing the infecting organism. D. They help in the management of symptoms o f acute infection. E. None

17. The disadvantages o f combination therapy o f anti-infective agents are: A. It may increase the toxic drug effects B. It may result in drug antagonism C. It is always ineffective D. A and B E. None 18. The indications for multiple-drug therapy include: A. Need for increased antibiotic effectiveness B. To prevent the proliferation o f drugresistant organisms C. Treatment o f an infection caused by multiple pathogens D. Treatment o f any infection E. A, B and C only

21 .Which o f the following statements is NOT TRUE about erythrocyte sedimentation rate? A. Large elevations in erythrocyte sedimentation rate are associated with acute or chronic infection B. Elevated erythrocyte sedimentation rate does not occur due to noninfectious cases C. Elevated sedimentation rates are common with infections such as endocarditis D. A normal erythrocyte sedimentation rate may occur in some infections E. Erythrocyte sedimentation rates are elevated with intraabdominal infections

19. Which o f the following statements is/are FALSE about the duration o f antiinfective therapy? I.In acute uncomplicated infection treatment should generally continue until the patient has been afebrile and asymptomatic for atleast 72"Rours

22. Which of the following are useful in indicating a locus o f infection? A. Radiographic findings

B. C. D. E. F.

Pain and inflammation ESR measurements White blood cell count A and B C and D

26. Which o f the following statements is NOT TRUE about perioperative antibiotic prophylaxis? A. It is a short course o f antibiotic administered before there is clinical evidence o f infection B. Initiation o f prophylaxis is done often at induction o f anesthesia C. The most commonly used route o f administration o f the drugs is the oral route D. The antibiotic should be administered in order to ensure that appropriate antibiotic levels are available at the site of contamination before the incision E. The most commonly used route o f administration o f the drugs is IV or 1M

23.A patient was admitted to a hospital for a severe infection. The physician in charge ordered proper laboratory tests for identification o f the infecting microorganism. The laboratory result was obtained and the physician ordered an antibiotic based on the laboratory result, but the patients condition didnt improve. Which o f the following may be causes o f the lack effectiveness o f the antibiotic? A. Misdiagnosis o f the infecting microorganism B. Improper drug regimen C. Inappropriate choice o f an antibiotic agent D. All o f the above E. A and B

27. First generation cephalosporins are drugs o f choice for most procedures and patients in perioperative antibiotic prophylaxis because: A. They have appropriate spectrum B. They have less frequency o f side effects C. They have favorable half-life D. They have low cost E. All o f the above

24. Which o f the following can be causes of fever? A. Infections B. Drug reactions C. Neoplasms D. All o f the above E. B and C only F. A and C only

25. Which o f the following non-infcctious conditions respond to antimicrobial agents? A. B. C. D. E. Metabolic disorders Phlebitis Arthritis Neutropenic cancer None

28. Which o f the following statements are TRUE about Aminoglycosides? I.They are primarily used in the treatment o f infections caused by gramnegative enterobacteria and in suspected sepsis II.They act as antibacterial by inhibiting protein synthesis. III.The toxic potential o f these drugs limits their use. A. B. C. D. E. i f l only is correct i f III only is correct if I & 1 1 are correct if I1&I11 are correct if I,II, and III are correct

29.An amino glycoside antibiotic most commonly used in treatment o f tuberculosis in combination with other antitubercular drugs is: A. B. C. D. E. Gentamicin Kanamycin Streptomycin Tobramcyin None

A. B. C. D. E.

Aminoglycosides Tetracycline Amikacin Penicillin None

34. Aminoglycosides can cause vestibular or auditory damage. Which o f the following Aminoglycosides are primarily associated with vestibular damage? A. B. C. D. E. Streptomycin Amikacin Netilmicin Gentamicin A and D

30.The amino glycoside antibiotic with the broadest-spectrum activity against most aerobic gram-negative bacilli as well as many anaerobic gram-negative bacterial strains that resist gentamicin and tobramycin is: A. B. C. D. E. Kanamycin Neomycin Amikacin Netilmicin None

35. All o f the following Aminoglycosides are associated with auditory damage EXCEPT: A. B. C. D. E. Amikacin Netilmicin Kanamycin Neomycin None

31.The amino glycoside antibiotic with the least ototoxic adverse effect is: A. B. C. D. E. Streptomycin Gentamicin Netilmicin Kanamycin None 36. An aminoglycoside that results in both vestibular and auditory damage is: A. B. C. D. E. Tobramycin Gentamicin Amikacin Streptomycin None

32. Which o f the following organisms are neomycin resistant? A. B. C. D. E. E.coli Klebsiella pneumoniae P.aeruginosa Streptococci C and D 37. Aminoglycosides accumulate in the proximal tubule; mild renal dysfunction develops in up to 25 % o f patients receiving these drugs. Which o f the following is the most nephrotoxic? A. B. C. D. E. Neomycin Kanamycin Amikacin Gentamicin Streptomycin

33.Streptomycin is used in the treatment of acute brucellosis in combination with:

38. The risk factors for the development o f nephrotoxicity in patients taking Aminoglycosides are: A. Preexisting renal disease B. Impaired renal flow unrelated to renal disease C. Concurrent administration of another nephrotoxic drug D. Previous or prolonged aminoglycoside therapy E. All o f the above

42.All o f the following are first generation cephalosporins EXCEPT: A. B. C. D. E. Cefadroxil Cefazolin Cephalexin Cefmetazole Cephapirin

43. Which o f the following is a fourth generation cephalosporin? A. B. C. D. E. Cefdinir Cefazolin Cefonicid Cefepime None

39. A carbapenem which should be administered with cilastatin is: A. B. C. D. E. Ertapenem Meropenem Imipenem Cefuroxime None

44. First generation cephalosporins are active against all o f the following grampositive cocci EXCEPT: A. B. C. D. E. Staphylococcus Streptococcus Pneumococci Enterococci None

40. Which one o f the following statements is FALSE about carbapenems? A. They have broader spectrum of activity than do most p-lactams B. They inhibit bacterial cell wall synthesis C. They are destroyed easily by most p-lactam ases D. They are active against gram positive cocci E. They are active against gramnegative rods and anaerobes

4 5 .Both first generation and Second generation cephalosporins are active against all of the following organisms EXCEPT: A. B. C. D. E. coli Klebsiella Pneumoniae Proteus mirabilis Haemophilis influenzae None

41. Cephalosporins are known as p-lactam antibiotics because their chemical structure consists o f a p-lactam ring adjoined to a: A. B. C. D. E. Thiazolidine ring Imidazole ring Benzene ring Tetrazole ring None

46. Which o f the following statements is not TRUE? A. Generally each generation of cephalosporin has shifted toward increased gram-negative activity but lost activity toward gram-positive organisms

B. Fourth-generation cephalosporins have improved activity toward gram-positive organisms over third generation cephalosporins C. Cephalosporins inhibit bacterial cell wall synthesis, reducing wall stability, thus causing membrane lysis. D. Cephalosporins are generally classified in four groups based mainly on structural similarity. E. None

50. Probenecid may impair the excretion o f all o f the following cephalosporins EXCEPT: A. B. C. D. E. Cephapirin Cephradine Ceftazidime Ceftriaxone None

51. Alcohol consumption may result in a disulfiram-type reaction in patients taking: 47. A second generation cephalosporin commonly administered for communityacquired pneumoniae is: A. B. C. D. E. Cefprozil Cefoxitin Cefuroxime Cefonicid None A. B. C. D. E. Cefmetazole Cefotetan Cefoperazone All o f the above B and C only

52. The ring found in the chemical structure of macrolide antibiotics is known as: A. B. C. D. E. lactone Tetrazole Thiazolidine (3-lactam None

48. Third generation cephalosporins are valuable in the treatment o f meningitis caused by meningococci, pneumococci and H. influenzae because: A. They penetrate the cerebrospinal fluid B. They are resistant to destruction by p-lactamases produced by these organisms. C. They have the broadest spectrum o f activity as compared to other generation o f cephalosporins. D. They are administered only orally. E. None

53. Which o f the following erythromycin salts are given parenterally? A. B. C. D. E. Erythromycin Erythromycin Erythromycin Erythromycin C and D estolate ethylsuccinate lactobionate gluceptate

49. All o f the following cephalosporins are eliminated renally EXCEPT: A. B. C. D. E. Cephalexin Cefproxil Cefoperazone Cefixime None

54.The erythromycin salt commonly associated with cholestatic hepatitis is: A. B. C. D. E. erythromycin erythromycin erythromycin erythromycin None gluceptate estolate ethylsuccinate lactobionate

55. Which of the following macrolide antibiotics increase the plasma concentration o f terfenadine and astemizole? A. B. C. D. E. Erythromycin Azithromycin Dirithromycin Clarithromycin A and D

A. Macrolide antibiotics act by binding to the 50S ribosomal subunit, inhibiting bacterial protein synthesis B. Gastrointestinal distress may occur with all forms o f erythromycin. C. Azithromycin is more effective than erythromycin against gram-positive cocci. D. Clarithromycin is less active than erythromycin against staphylococci and streptococci. E. C and D

56. Coadministration o f one o f the follwing is contrainidacted with an ongoing pimozide therapy. A. B. C. D. E. Erythromycin Clarithromycin Dirithromcyin Azithromycin None

60.A macrolide antibiotic known to concentrate itself within cells and its tissue levels are higher than serum levels is: A. B. C. D. E. Troleandomycin Clarithromycin Azithromycin Erythromycin None

57. The advantages o f the semi-synthetic macrolide antibiotics as compared to erythromycin are: A. B. C. D. E. they are cheap : they are well tolerated they are administered once daily All o f the above B and C only

61 .Which o f the following natural penicllins are repository drug forms administered intramuscularly? A. B. C. D. E. Penicillin G Penicillin G procaine Penicillin V Penicillin G benzathine B and D

58. A semi-synthetic macrolide antibiotic used in combination with omeprazole or lansoprazole for helicobacter pylori eradication is: A. B. C. D. E. Azithromycin Dirithromcyin Clarithromycin Erythromycin None

62.How many times is Penicillin G more active than penicillin V against gramnegative organisms and some anaerobic organisms. A. B. C. D. E. 5-10 times 30-40 times 40-50 times 50-60 times None

59. Which o f the following statements are not TRUE?

63.Resistance is emerging to penicillin G by S.pneumoniae. The alternative drug for such organisms is:

A. B. C. D. E.

Vancomycin Penicillin V Penicillin G procaine Penicillin G benzathine None

A. B. C. D. E.

Cloxacillin Dicloxacillin Oxacillin Methicillin A,B,C

64. Which o f the following statements is NOT TRUE about hypersensitivity reactions associated with penicillin therapy? A. They occur in up to 10% o f patients receiving penicillin B. They do not occur in patients with a negative history o f penicillin allergy C. A life-threatening anaphylaxis occurs with parenteral administration o f penicillins D. A positive history places the patient at a heightened risk for a subsequent reaction E. Manifestaions range from mild rash to anaphylaxis

68. A penicillinase resistant penicillin excreted by the liver and thus may be useful in treating staphylococcal infections in patients with renal impairment is: A. B. C. D. E. Methicillin Nafcillin Cloxacillin Dicloxacillin None

69. Which o f the following penicillinase resistant penicillins are most valuable in long-term therapy o f serious staphylococcal infections such as endocarditis and osteomyelitis. A. B. C. D. E. Oxacillin Cloxacillin Dicloxacillin All o f the above B and C only

65 .A severe adverse effect that most commonly occurs in patients taking highdose penicillin is: A. B. C. D. E. Vomiting Depression Seizures Diarrhea None

70. Which o f the following statements is FALSE about aminopenicillins? A. They are also known as broadspectrum penicillins. B. They have a spectrum o f activity broader than that o f natural penicllins. C. Their spectrum o f activity is narrower than that of penicillinase resistant penicillins. D. They are easily destroyed by staphylococcal penicillinases. E. None

66. Antibiotic antagonism occurs when penicillin is given within 1 hour o f the administration of: A. B. C. D. E. Erythromycins Tetracyclines Chloramphenicol All o f the above A and C only

67. Penicillinase resistant isoxazolyl penicillin(s) is/are

71. All o f the following drugs are aminopenicillins EXCEPT:

A. B. C. D. E.

Bacampicillin Cyclacillin Ampicillin Amoxicillin Penicillin

72. For infections resulting from penicillinresistant organisms, ampicillin may be given in combination with: A. B. C. D. E. Ampicillin Penicillin G potassium Sulbactam Bacampicillin None

B. Carbenicillin is active against ampicillin-resistant proteus strains and other gram-negative organisms. C. Carbenicillin is two to four times more active than Ticaricillin against P.aeruginosa. D. Piperacillin is 10 times as active as carbenicillin against Pseudomonas organisms. E. None

76. All of the following organisms are sensitive to a combination o f Tazobactam with piperacillin EXCEPT: A. B. C. D. E. Haemophilis Enterobacteriaceae Bacteroides Pseudomonas None

73.Amoxicillin is more effective against S.aureus, Klebsiella and bactcroides fragilis when given in combination with clavulanic acid because: A. Clavulanic acid inactivates penicillinases B. Clavulanic acid enhances the absorption o f an orally administered amoxicillin C. Clavulanic acid inhibits the renal elimination o f amoxicillin D. Clavulanic has a bactericidal effect. E. None

77. The extended spectrum penicillins which may cause hypokalemia are: A. B. C. D. E. Mezlocillin Ticaricillin Carbenicillin All o f the above B and C

78.The mechanism o f antibacterial action o f sulfonamides is: 74. Which o f the following extendedspectrum penicillins are Ureidopencillins? A. B. C. D. E. Carbenicillin Ticaricillin Mezlocillin Piperacillin C and D A. They suppress bacterial growth by triggering a mechanism that blocks folic acid synthesis. B. They inhibit bacterial cell wall synthesis. C. They damage the bacteria] DNA. D. They inhibit an enzyme involved in the detoxification o f bacteria] metabolites. E. None

75.All o f the following statements are true EXCEPT A. Amoxicillin is more effective than ampicillin against shigellosis.

79. Sulphonamides may cause blood dyscrasias in patients with hereditary deficiency of the enzyme:

A. Pyruvate dehydrogenase B. Glucose-6-phosphate dehydrogenase C. Aminotransferase D. Serum glutamic-pyruvic transaminase E. None

84. Doxycycline is the safest tetracycline for the treatment o f extrarenal infections in patients with renal impairment because: A. B. C. D. it is excreted by the renal route it is excreted mainly in the feces it is concentrated in the kidney it is metabolized by gastrointestinal enzymes E. None

80. All o f the following antibacterial agents have bactericidal property EXCEPT A. B. C. D. E. Aminoglycosides Cephalosporins Penicillins Sulfonamides None

85.The tetracycline commonly used as an adjunctive agent to treat the syndrome o f inappropriate antidiuretic hormone secretion is: A. B. C. D. E. Chlortetracycline Methacycline Minocycline Demeclocycline None

81 .A sulfonamide used in combination with erythromycin ethylsuccinate to treat acute otitis media (caused by H. influenzae) and in combination with phenazopyridine for relief o f symptoms o f pain and burning in urinary tract infections is: A. B. C. D. E. Sulfamethoxazole Sulfisoxazole Sulfamethizole Sulfacytine None

86.Phototoxic reactions (reactions which develop upon exposure to sunlight) are common in patients taking: A. B. C. D. E. Demeclocycline Minocycline Doxycycline Methacycline A and C

82. All o f the following organisms are susceptible to tetracyclines EXCEPT: A. B. C. D. E. Mycoplasma Chlamydial organisms Rickettsial organisms Pseudomonas Spirochetes

87. Member o f the tetracycline group which can cause vestibular toxicity is: A. B. C. D. E. Demeclocycline Chlortetracycline Minocycline Methacycline None

83. A tetracycline highly effective in the prophylaxis o f travelers diarrhea is: A. B. C. XT. Demeclocycline Methacycline Doxycycline Chlortetracycline

88. Which o f the following statements is NOT TRUE about tetracyclines?

A. Tetracyclines are useful alternatives to penicillin in the treatment o f anthrax, syphilis, gonorrhea, and H.influenzae infections B. The gastrointestinal distress associated with tetracyclines can be minimized by administering them with food C. Tetracyclines may induce permanent tooth discoloration D. Members o f the tetracycline group do not have cross-sensitivity among themselves. E. None

D. Ofloxacin E. None

92. All o f the following are first generation quinolones EXCEPT: A. B. C. D. E. Sparfloxacin Cinoxacin Enoxacin Norfloxacin Nalidixic acid

93. A fluoroquinolone that has been associated with serious liver injury leading to liver transplantation or death is: A. B. C. D. E. Gatifloxacin Grepafloxacin Trovafloxacin Levofloxacin None

89. Iron preparations, antacids, magnesium containing laxatives reduce the absorption o f tetracyclines. The only exception is: A. B. C. D. E. Minocycline Methacycline Chlortetracycline Doxycycline None

94.The blood level o f one antiasthmatic drug is increased when it is administered with ciprofloxacin. The drug is most likely: A. B. C. D. E. Bitolterol Terbutaline Epinephrine Theophylline None

90. The mechanism o f action o f fluoroquinolone antibacterials is: A. They inhibit bacterial cell wall synthesis. B. They inhibit the enzyme DNA gyrase C. They inhibit bacteria] cell wall synthesis by binding to the 30S ribosomal subunit. D. They inhibit bacterial cell wall synthesis by binding to the 50S ribosomal subunit. E. None

95. Which o f the following fluoroquinolones should be avoided in patients with known prolongation o f QTC interval? A. B. C. D. E. Gatifloxacin Moxifloxacin G repatof! oxacin Enoxacin A and B

91. Which o f the following fluoroquinolones has the greatest activity against Chlamydia? A. Ciprofloxacin B. Trovafloxacin C. Norfloxacin

96. Which o f the following statements is/are TRUE about urinary tract antiseptics?

I .They get concentrated in the renal tubules and bladder, exerting local antibacterial effects. Il.M ost o f them do not achieve blood levels high enough to treat systemic infections. Ill .All urinary tract antiseptics have the same mechanism o f action. A. B. C. D. E. i f l only is correct if III only is correct if I & II are correct if II&III are correct if I,II, and III are correct

100. A urinary antiseptic indicated for the treatment o f uncomplicated urinary tract infection (acute cystitis) in women caused by susceptible strains o f E.coli and E.faecalis is: A. B. C. D. E. Cinoxacin Enoxacin Fosfomycin Nalidixic acid None

101. Which o f the following agents are likely to antagonize the effects o f methenamine? A. B. C. D. E. Aspirin Acetozolamide Sodium bicarbonate All o f the above B and C only

97.The mechanism as to how methenamine acts as a urinary antiseptic is that it hydrolyses in acidic urine into: A. Ammonia and formaldehyde B. Carbonic acid and bicarbonate. C. Ammonium hydroxide and Sulphuric acid. D. Nalidixic acid and ammonium chloride E. None

102. Which o f the following anti-gout drugs increase the blood level and decrease the urine level o f nitrofurantoin? A. Probenecid B .Sulfinpyrazone C.Colchicine D.Allopurinol E.A and B

98. Fosfomycin tromethamine acts as antibacterial by inactivation o f the enzyme: A. Enolylpyruvyl transferase B. Glucose-6-phosphate dehydrogenase C. Topoisomerase II D. DNA gyrase E. None

103. All o f the following statements are true about aztreonam EXCEPT: A. It is a monocyclic fi-lactam compound B. It resembles the Aminoglycosides in its efficacy against many gramnegative organisms, and its ototoxic and nephrotoxic adverse effects. C. It is active against many gentamicin resistant organisms. D. It lacks cross-allergenicity with penicillin. E. It preserves the bodys normal gram-positive and anaerobic flora

99.Nalidixic acid and oxolinic acid are active against all o f the following organisms EXCEPT: A. B. C. D. E. Proteus mirabilis Escherichia Coli Pseudomonas Klebsiella Enterobacter organisms

104.

Chloramphenicol is chemically: 108. The anti-epileptic drug whose metabolism is inhibited by chloramphenicol is: A. B. C. D. E. Zonisamide Carbamazepine Lamotrigine Phenytoin None

A. a nitrobenzene derivative B. a phenyl alkyl derivative C. a naphthalene derivative D.an imidazole derivative E. None

105. Which o f the following drugs are active against Rickettsial infections? A. B. C. D. E. Chloramphenicol Tetracycline Amoxicillin Cefaclor A and B

109. Which o f the following analgesic drugs elevates the levels of chloramphenicol? A. Aspirin B. Acetaminophen C. Naproxen D..Ibuprofen E. None

106. Which o f the following statements is FALSE about Chloramphenicol? A. It is primarily a bacteriostatic drug B. Because o f its toxic side effects, it is used only to suppress infections that cannot be treated effectively with other antibiotics C. The bone marrow suppression associated with Chloramphenicol is not dose-related D. Severe Hypersensitivity reactions due to Chloramphenicol include angioedcma or anaphylaxis E. Chloramphenicol therapy may lead to gray baby syndrome in neonates

110. Clindamycin is used only against infections for which it has proven to be most effective drug. It is most commonly used in the treatment o f abdominal and female genitourinary tract infections caused by: A. B. C. D. E. Bacillus fragilis Escherichia Coli Staphylococcus aureus Salmonella typhi None

107. The gray baby syndrome which occurs in neonates taking Chloramphenicol is due to: A. Inadequate liver detoxification o f chloramphenicol B. Interaction o f chloramphenicol with plasma proteins C. Necrotic effects of chloramphenicol on renal tissues D Inadequate absorption of chloramphenicol from the gastrointestinal tract

111. Dapsone is a member o f which class o f antibiotics A. B. C. D. E. Sulfone Penicillin Aminoglycoside Cephalosporin None

112. All o f the following drugs have bacteriostatic action EXCEPT:

A. B. C. D. E.

Dapsone Clindamycin Chloramphenicol Cefonicid tetracyclines

A. Patients taking adrenergic agents B. Patients taking serotonergic agents C. Patients consuming more than 100 mg o f tyramine a day D. All o f the above E. B and C only

3. Dapsone is active against I.P.carinii II.Plasmodium III.Mycobacterium leprae A. B. C. D. E. if l only is correct if III only is correct if I & II are correct if II&III are correct if I,II, and III are correct

118. to: A. B. C. D. E.

Spectinomycin is related structurally

Penicillins Cephalosporins Aminoglycosides Sulfonamides None

114. Maloprim is a combination product containing dapsone and: A. B. C. D. E. Pyrimethamine Trimethoprim Procaine penicillin Erythromycin None

119. route o f administration o f Spectinomycin is A. B. C. D. E. IM IV Oral Subcutaneous Sublingual

115.

Linezolid is chemically a synthetic:

120. Trimethoprim is chemically a substituted: A. B. C. D. E. Purine Pyrimidine Sugar Amino acid None

A. Oxazolidine B. Imidazole C. Tetrazole D. P-lactam E. None

116. Linezolid has bactericidal action against: A. B. C. D. E. Enterococci Streptococci Staphylococci A and C All the above

121. Trimethoprim acts as antibacterial by inhibiting the enzyme: A. Lactate dehydrogenase B. Dihydrofolate reductase C. Glucose-6-phosphate dehydrogenase D. Topoisomerase 11 E. None

117. In which of the following cases is enhanced effect o f the antibiotic linezolid expected?

122. When a combination o f Trimethoprim and sulfamethoxazole is used; many organisms resistant to one component are susceptible to the combination. This effect is known as; A. B. C. D. E. synergism antagonism agonism synchronism None

II.lt is prim arily active against


cryptococcus and Candida

III.Use o f Flucytosine alone is recommended A. B. C. D. E. if l only is correct if 111 only is correct i f l & II are correct if 1I&I11 are correct if 1,11, and III are correct

123. All o f the following drugs result in an increase in the clearance o f caspofungin EXCEPT: A. B. C. D. E. 124. A. B. C. D. E. Nelfinavir Phenytoin Rifamipicin Cyclosporine None Flucytosine is chemically a: Fluorinated Fluorinated Fluorinated Fluorinated None pyrimidine purine amino acid sugar

127. Which o f the following drugs have demonstrated synergy with Flucytosine against cryptococcus and Candida? A. B. C. D. E. Griseofulvin Amphotericin B Fluconazole Nyastatin B and C

128. A. B. C. D. E.

Griseofulvin is produced from: Penicillium griseofulvum dierckx Cryptococcus species Apsergillus species Candida albicans None

125. The mechanism o f action of Flucytosine is: A. It inhibits DNA synthesis B. It inhibits bacterial cell wall synthesis C. It is converted to fluorouracil, which results in defective protein synthesis. D. It inhibits an enzyme involved in fatty acid synthesis. E. None

129. Griseofulvin is active against which o f the following fungal species A. B. C. D. E. Microsporum Epidermophyton Trichophyton Aspergillus A, B and C

130. Which o f the following statements is TRUE about the therapeutic uses of griseofulvin? A. It is effective against tinea infections o f the skin, hair, and nails caused by microsporum, epidermophyton and trichophyton.

126. Which o f the following statements is TRUE about Flucytosine? I. It is usually given in combination with amphotericin B

B. Generally it is given only for infections that do not respond to topical antifungal agents. C. It may used in the treatment of Raynauds diseases D. It may be used in the treatment o f gout. E. All o f the above

135. Which o f the following statements best describes the mechanism o f action o f imidazole antifungals? A. They inhibit the synthesis of proteins involved in membrane transport B. They inhibit sterol synthesis in fungal cell membranes and increase cell wall permeability. C. They result in the synthesis o f defective fungal DNA. D. They bind to 30 S ribosomal subunit o f fungal cells and inhibits protein synthesis. E. None

131. The mechanism o f action of griseofulvin is similar to: A. B. C. D. E. Amphotericin B Caspofungin Flucytosine Colchicine None

132. Which o f the following adverse effects associated with griseofulvin is classified as rare? A. B. C. D. E. Headache Leukopenia Hepatotoxicity Confusion None

136. Which o f the following are susceptible to imidazole antifungal agents? A. B. C. D. E. Dermatophytes Actinomycetes Phycomycetes Yeasts All o f the above

133. The dosage o f griseofulvin is dependent on: A. The particle size o f the product B. The color of the product C. The bioequivalence of the product with other standard product. D. The solubility o f the product in water E. None

137. Ketoconazole is less effective than other antifungal agents for the treatment o f severe and acute systemic infections because: A. B. C. D. E. it is not distributed well on our body it is only given topically it is slow-acting it requires a long duration o f therapy C and D

134. Which of the following drugs result in tachycardia and flushing when given with griseofulvin? A. B. C. D. Barbiturates Alcohols Cimetidine Warfarin

138. Which o f the following statements are NOT TRUE about miconazole? A. It is available for topical application only. B. It is available in parenteral form only.

C. Topical miconazole is highly effective in vulvovaginal candidiasis. D. Parenteral miconazole therapy is associated with CNS toxicity. E. A and B

C. Amphotericin is not available in the market D. Itraconazole has broader spectrum E. None

139. Which o f the following statements are true about parenteral miconazole: LAs a first line therapy II.When other antifungal drugs are ineffective III. When other antifungal drugs cannot be tolerated. A. B. C. D. E. if I only is correct if III only is correct if I & II are correct if II&III are correct if 1,11, and III are correct

143. Which o f the following adverse effects are common to all imidazole antifungal agents? A. B. C. D. E. Nausea Vomiting Hepatotoxicity CNS toxicity A and B

144. Antacids, H2-blockers, or proton pump inhibitors should not be co-administered with ketoconazole and itraconazole because: A. They decrease the absorption of ketoconazole and itraconazole B. They decrease the level o f gastric acidity, which is necessary for ketoconazole and itraconazole to act. C. They increase the enzymatic degradation o f ketoconazole and itraconazole. D. They increase the urinary elimination o f ketoconazole and itraconazole E. None

140. An imidazole antifungal drug used in the treatment o f CNS infections involving Cryptococcus and Candida is: A. B. C. D. E. Miconazole Ketoconazole Itraconazole Voriconazole Fluconazole

141. Which o f the following infections is/are susceptible to itraconazole? A. B. C. D. E. Blastomycosis Coccidioidomycosis Cryptococcosis Histoplasmosis All o f the above

145. Ketoconazole may antagonize the antibiotic effects of: A. B. C. D. E. Nyastatin Flucytosine Caspofungin Amphotericin B None

142. Itraconazole is preferred to amphotericin B against systemic and invasive pulmonary aspergillosis because: A. Amphotcricin B is less effective B. Amphotericin B is associated with hematological toxicity

146. The blood level o f which o f the following drugs is elevated by fluconazole?

B. C. D. E.

Cyclosporine Warfarin Sulfonylureas All o f the above

151. as: A. B. C. D. E. 3% cream Lotion Oral suspension All o f the above A and C only

147. Which o f the following enzyme systems are inhibited by Voriconazole? A. B. C. D. E. Cytochrome P4502C19 Cytochrome C Y P2C19 Cytochrome CYP3A4 All o f the above A and B

152. Which o f the following adverse effects are likely to occur with lotion and cream dosage forms o f amphotericin B? A. B. C. D. E. Pruritis Local irritation Nausea Vomiting A and B

148. A. B. C. D. E.

Nyastatin is related chemically to: Voriconazole Itraconazole Amphotericin B Ketoconazole None

153. Which o f the following statements is FALSE about butenafine? A. It interferes with sterol biosynthesis B. It may be fungicidal in certain concentrations against susceptible organisms such as dermatophytes. C. It alters fungal membrane permeability D. It is ineffective against Candida species E. It is effective against Trichophyton rubrum

149. A. B. C. D. E.

Nyastatin is primarily active against: Aspergillus Candida Fusarium Cryptococcus None

150. Which o f the following statements is FALSE about terbinafine? A. It is a synthetic allylamine B. It possesses some activity against yeasts C. It is useful in patients who may not tolerate the adverse effect profile of imidazole antifungals. D. It has been shown to be ineffective against tinea capitis and tinea corporis E. Oral terbinafine iws useful in treating toe nail and finger nail infections 154. In the treatment o f dermatophytes, butenafine is used as: A. B. C. D. E. 10 % lotion 10 % cream 10 % solution 1 % cream None

155. An azole antifungal available as a cream for vaginal use is: A. Miconazole B. Fluconazole

C. Ketoconazole D. Butoconazole E. None

bacteria. Which o f the following bacteria are susceptible to clotrimazole A. B. C. D. E. S.aureus S.pyogenes Proteus vulgaris Salmonella All o f the above

156. Butoconazole is effective against which of the following bacteria I. S.aureus II. S.pyrogenes III. E. Faecalis A. B. C. D. E. if l only is correct if III only is correct if I & II are correct if II&III are correct if 1,11, and III are correct

161. Clotrimazole may be available in all o f the following dosage forms EXCEPT: A. B. C. D. E. Lozenges Parenteral solutions Creams Lotion None

157. Which o f the following drugs has different mechanism o f action from the other? A. B. C. D. E. Terbinafine Naftifme Ciclopirox Butoconazole Nystatin

162. Which o f the following statements are NOT TRUE about clotrimazole? A. Below normal liver enzyme levels has occurred in patients taking clotrimazole lozenges. B. Abnormal liver function tests have occurred in patients taking topical clotrimazole formulations. C. Vaginal clotrimazole tablets are associated with mild burning, skin rash, and itching. D. Cross-sensitization occurs with imidazole antifungals. E. A and B F. C and D

158. Clioquinol is a topical antifungal agent that is most commonly used ointment form in combination with: A. B. C. D. E. Hydrocortisone Griseofulvin Voriconazole Ketoconazole None

163. 159. Clotrimazole alters fungal cell membrane permeability by binding with A. B. C. D. E. Sterols in membrane Phospholipids in membrane Amino acids Calcium ions None

Gentian violet is:

A. A dye B. An antibiotic derived from fungal cultures. C. A synthetic antifungal antibiotic D. It an antibiotic derived from

160. At higher concentrations, clotrimazole inhibits some strains o f

164. Which o f the following formulations of ketoconazole is used in the treatment of fungal keratitis?

A. B. C. D. E.

Ophthalmic suspension 2% shampoo 2% topical cream Oral tablets None

C. Vaginal suppositories worsen the hypersensitivity reactions caused by latex products D. Drugs given in the form o f vaginal suppositories have anti-infertility effects. E. None

165. Ketoconazole when comibined with one o f the follwoing is useful in treating dermatitis, diaper rash, impetigo, and psoriasis. A. B. C. D. E. Gentian violet Clioquinol Steroids Butenafine None

169. Which o f the following statements is FALSE about naftifine? A. It is a synthetic allylamine B. It acts by interfering with fungal protein synthesis C. It is active against aspergillus flavus and aspergillus fumigatus in vitro D. It possesses some local anti inflammatory activity E. None

166. Topical dosage form(s) o f Miconazole is/are A. B. C. D. E. Aerosol powder Cream Tincture Vaginal suppositories All o f the above

170. All o f the following antifungal agents may be fungistatic or fungicidal depending on concentration EXCEPT: A. B. C. D. E. Amphotericin B Griseofulvin Terbinafine Nyastatin None

167. Miconazole is advantageous over other agents such as Nyastatin and tolnaftate in that its activity covers: A. B. C. D. E. T. mentagrophytes T. rubrum Candia species All o f the above A and C only

171. The antibacterial mechanism of action o f sulconazole is: A. It has a direct physicochemical effect on the destruction of unsaturated fatty acids present in fungal cell membranes. B. It damages bacterial DNA. C. It inhibits bacterial protein synthesis D. It inhibits an enzyme involved in protein synthesis. E. None

168. Use o f condoms and diaphragms concurrently with vaginal suppositories (e.g vaginal tablets o f miconazole) is contraindicated because: A. Condoms antagonize the antifungal activity o f any drug B. Vaginal suppositories are manufactured from a vegetable oil base that may interact with latex products "

172. All o f the following antifungal agents are active against M furfur EXCEPT:

A. B. C. D. E.

Miconazole Ketoconazole Nyastatin Sulconazole Oxiconazole

A. B. C. D. E.

Chloroquine Hydroxychloroquine Fansidar Mefloquine None

173. Which of the following antifungal agents have antibacterial activity? A. Sulconazole B. Tetraconazole C. Econazole D. Miconazole E. A and B 174. Malaria results from infection by any o f four species o f the protozoal genus: A. B. C. D. E. Plasmodium Amoeba Isoporidium Microsporidia None

178. Which o f the following anti-malarial drugs is active against liver forms of P. Vivax and P. Ovale? A. B. C. D. E. Primaquine Mefloquine Chloroquine Fansidar None

179. An antimalarial drug now used almost exclusively in combination with a sulfonamide or sulfone is: A. B. C. D. E. Quinine Pyrimethamine Mefloquine Chloroquine None

175. Which o f the following antimalarial agents bind to and alter the properties o f microbial and mammalian DNA? A. B. C. D. E. Chloroquine Hydroxychloroquine Primaquine Mefloquine A and B

180. A Parenteral form of quinine used in severe cases o f chloroquine-resistant malaria is: A. B. C. D. E. Quinine dihydrochloride Quinine sulfate Quinine carbonate Quinine None

176. All o f the following have blood schizonticidal activity (kill the schizont forms o f plasmodium) EXCEPT: A. B. C. D. E. Chloroquine Fansidar Mefloquine Primaquine None

181. Fansidar is used in the prophylaxis o f an infection in AIDS patients unable to tolerate co-trimoxazole. The infective agent is: A. B. C. D. E. Plasmodium falciparum Pneumocystis carinii Toxoplamsa Gondii Plasmodium vivax None

177. A schizonticidal antimalarial drug active against erythrocytic forms of susceptible plasmodium and toxoplamsa Gondii is:

182. Which o f the following antimalarial drugs are contraindicated in patients with hereditary deficiency o f the enzyme glucose-6-phosphate dehydrogenase? A. B. C. D. E. Chloroquine Quinine Mefloquine Primaquine B and D

D. Paromomycin E. Emetine

187. Paromomycin is not effective in extra-intestinal amoebiasis because: A. It is absorbed very quickly B. It is poorly absorbed C. It is always given in solid dosage forms D. It is an amino-glycoside antibiotic E. None

183. Which o f the following antibacterial agents are contraindicated in patients taking primaquine? A. B. C. D. E. Penicillins Aminoglycosides Sulfonamides Cephlosporins None

188. Which o f the following drugs have a mechanism o f action related to DNA? A. Metronidazole B. Paromomycin C. Emetine D. Quinacrine E. A and D

184. Fansidar is a combination containing sulfadoxine and: A. pyrimethamine. B. chloroquine C. primaquine D. Mefloquine E. None

189. Which o f the following amebicidal drugs is effective in giardiasis, trichomoniasis and against bacterial anaerobes? A. B. C. D. E. Diloxanide Quinacrine Emetine Metronidazole None

185. Concomitant use o f Mefloquine with one o f the following may increase the risk o f convulsions. A. B. C. D. E. Primaquine Fansidar Pyrimethamine Chloroquine None

190. Quinacrine is useful in the treatment of: A. B. C. D. E. Giardiasis Tapeworm infection Malaria A and B only B and C only

186. Which one o f the following drugs is an alkaloid? A. Diloxanide B. Quinacrine C. Metronidazole 191. Which o f the fol lowing is known for its cardiovascular toxicity? A. Paromomycin

B. C. D. E.

Diloxanide Emetine Quinacrine None

C. A dichloroacetamide D. An aminoquinoline E. None

192. Concomitant use o f alcohol v^ith one o f the following drugs results in a typical disulfiram like reaction : A. B. C. D. E. Iodoquinol Metronidazole Quinacrine Diloxanide None

197. After initial administration of intravenous pentamidine the blood sugar level: A. B. C. D. E. Increases Decreases Does not change All o f the above None

193. Which o f the following drugs may produce optic neuritis or peripheral neuropathy with high doses? A. B. C. D. E. Emetine Quinacrine Iodoquinol Metronidazole None

198. Atovaquone acts as antiprotozoal by blocking mitochondrial electron transport o f complex III o f the respiratory chain of protozoa, resulting in inhibition of: A. B. C. D. E. Pyrimidine synthesis Purine synthesis Amino acid synthesis Protein synthesis None

194. Pentamidine can be administered by which route? A. B. C. D. E. Intra-muscular route Intravenous route Inhalation A, B&C A& B only

199. Which o f the following statements are NOT TRUE about Atovaquone? A. It is highly protein bound (99%) B. It is a second line drug in the treatment o f P.carinii pneumonia in patients intlerant of co-trimoxazole or other sulfonamides. C. Its oral absorption is decreased when administered with food. D. It results in elevated liver function tests. E. None

195. Pentamidine is indicated for the prevention and treatment of: A. B. C. D. E. Infections due to P. carinii Trypanosomiasis Visceral leishmaniasis Babesiosis None

200. Eflomithine HC1 is an antiprotozoal drug given through the: A. B. C. D. E. Intravenous route Intravenous rote Inhalational route Oral route None

196.

Pentamidine is chemically:

A. An aromatic diamide B. A hydroxyquinoline

201. The mechanism o f antiprotozoal action ofEflom ithine is: A. It inhibits the enzyme glucose-6phosphate dehydrogenase. B. It inhibits the enzyme ornithine decarboxylase C. It inhibits protozoal protein synthesis D. It inhibits protozoal cell wall synthesis. E. None

B. Ethambutol, streptomycin, Isoniazid C. Pyrazinamide, streptomycin, Isoniazid D. Ethambutol, ethionamide, capreomycin E. None

206. In the treatment o f tuberculosis combination therapy is recommended: A. In order to overcome resistance B. Tn order to minimize the incidence o f adverse effects. C. In order to decrease the overall cost o f a drug therapy. D. B and C E. None

202. Organisms susceptible to atovaquone is/are: A. B. C. D. E. T.Gondii P.Carinii Microsporidia P.falciparum All o f the above

207. Ethambutol is used in combination with which of the following in the treatment of mycobacterium avium complex. A. B. C. D. E. Clarithromycin Azithromycin Isoniazid Pyrazinamide A and B

203. The most frequent serious side effect of Eflomithine is: A. B. C. D. E. Nausea Vomiting Myelosuppression Hearing impairment None

208. Which o f the following statements is NOT TRUE about Isoniazid? A. It is a hydrazide o f isonicotinic acid. B. It i