Clinical Pharmacology and Therapeutics Questions For Self Assessment Third Edition CRC Press 2008
Clinical Pharmacology and Therapeutics Questions For Self Assessment Third Edition CRC Press 2008
Clinical Pharmacology and Therapeutics Questions For Self Assessment Third Edition CRC Press 2008
and Therapeutics:
Questions for
Self Assessment
THIRD EDITION
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© 2008 Timothy GK Mant, Lionel D Lewis, James M Ritter and Albert Ferro
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CONTENTS
Multiple choice, extended matching, best of five and problem solving ques-
tions are now ubiquitous in medical graduate and postgraduate examina-
tions. They provide a rapid method for testing a wide range of knowledge
and marking is objective. The authors of this book, who are all practising
physicians who have taught clinical pharmacology and therapeutics for many
years, have based it on the fifth edition of Textbook of Clinical Pharmacology and
Therapeutics not only to prepare students for their exams but also to empha-
size the principles and facts that are the key to safe and effective prescribing.
Although this book can ‘stand alone’, we recommend that students will read a
section of the main textbook and then reinforce and revise their knowledge by
self testing using the self assessment book. At the end of the book is a practice
examination of 50 ‘Best one correct answer of five’ questions, the type currently
most favoured in medical examinations, followed by five problem solving
questions. This examination covers the spectrum of topics that may be encoun-
tered in a final MB (medical degree) examination or even in some postgraduate
examinations (e.g. American Board of Clinical Pharmacology, Inc.). We suggest
that students use this as a ‘practice run’ after finishing their revision of the sub-
ject as a whole. It is best to do it ‘blind’ at one sitting lasting not more than 60
minutes.
Timothy Mant
Lionel Lewis
James Ritter
Albert Ferro
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CHAPTER ONE
GENERAL PRINCIPLES
32 Cardiac failure:
a) Increases the bioavailability of oral thiazide diuretics
b) Increases the volume of distribution of lidocaine
c) Has little effect on the volume of distribution of
furosemide
d) Decreases the elimination half-life of lidocaine
e) Decreases the elimination half-life of
gentamicin
MULTIPLE CHOICE QUESTIONS 7
68 Abnormal pseudocholinesterase:
a) Is typically inherited as a Mendelian dominant condition
b) Results in malignant hyperthermia following exposure to
suxamethonium
c) Causes warfarin resistance
d) Leads to prolonged paralysis following suxamethonium
e) Is associated with treatment failure with donepezil for Alzheimer’s
disease
70 The MHRA:
a) Is an independent group of clinicians, clinical pharmacologists,
toxicologists, pathologists and others who advise the drug licensing
authority
b) Is financed directly by the pharmaceutical industry
c) Considers the quality, safety and efficacy of medicinal
products
d) Considers the investigation, monitoring and response to adverse
reactions once a drug has been licensed
e) Appoints the committees on ethical practice, which assess drug trials
73 PHARMACODYNAMICS
A Omeprazole F Atenolol
B Clopidogrel G Dobutamine
C Morphine H Warfarin
D Glucagon I Magnesium trisilicate
E Fluoxetine J Insulin
Select the drug that causes the pharmacodynamic effect described below:
1 Prolongation of prothrombin time
2 Reduction in blood glucose
3 Reduction in exercise-induced increase in heart rate
4 Pupil constriction
5 Inhibition of gastric acid secretion
74 PHARMACOKINETICS
A Prednisolone F Metoprolol
B Amiodarone G Simvastatin
C Carbamazepine H Paracetamol
D Lithium I Gentamicin
E Enalapril J Bendroflumethiazide
Choose the drug from the list above which is a good example for the pharma-
cokinetic characteristics listed below:
1 Absorption into the systemic circulation following oral administration
is minimal
2 The mean elimination half-life is greater than 28 days in someone with
normal hepatic and renal function
3 Is a prodrug which is hydrolysed to its active metabolite
4 Induces its own metabolism such that plasma concentrations may
reduce significantly on repeated dosing
5 Undergoes active tubular reabsorption
16 CHAPTER 1 GENERAL PRINCIPLES
75 PHARMACOGENETICS
A Warfarin F Sildenafil
B Digoxin G Suxamethonium
C Omeprazole H Isoniazid
D Cefuroxime I Heparin
E Fluconazole J Codeine
Match the drug from the above list whose metabolism is most affected by the
enzyme genetic polymorphism below:
1 CYP2D6
2 CYP2C9
3 N-Acetyltransferase
4 Pseudocholinesterase
5 CYP2CI9
77 DRUG METABOLISM
A Azathioprine F Rimonabant
B Irinotecan G Midazolam
C Clozapine H Amoxicillin
D Dalteparin I Isoniazid
E Phenylephrine J Warfarin
Choose the drug from the list above which is significantly affected by the
enzyme below:
1 Monoamine oxidase
2 CYP1A2
3 CYP3A4
4 Uridine diphosphoglucuronyl transferase (UGT1AI)
5 Thiopurine methyltransferase (TPMT)
EXTENDED MATCHING QUESTIONS 17
78 RENAL ELIMINATION
A Clarithromycin F Lithium
B Para-aminohippuric acid G Gentamicin
C Probenecid H Senna
D Salicylate I Thyroxine
E Atorvastatin J Orlistat
79 RENAL TRACT
A Sildenafil F Acetazolamide
B Finasteride G Bendroflumethiazide
C Furosemide H Eplerenone
D Oxybutinin I Desmopressin
E Spironolactone J Tamsulosin
81 MONOCLONAL ANTIBODIES
A Infliximab F Abciximab
B Bevacizumab G Omalizumab
C Basilixumab H Alemtuzumab
D Anti-D (Rh) immunoglobulin I Rituximab
E Natalizumab J Palivizumab
Match the monoclonal antibody with the mode of action described below:
1 Binds to respiratory syncytial virus
2 Anti IgE
3 Anti-tumour necrosis factor alpha (TNF-α)
4 Inhibition of vascular endothelial growth factor (VEGF)
5 Inhibition of glycoprotein IIb–IIIa
ANSWERS: see pages 33–38
MCQ ANSWERS 19
ANSWERS
MCQ ANSWERS
c) True
d) True – Anticholinergic properties reduce gastro-intestinal
motility
e) False – Metoclopramide accelerates gastric emptying
32 a) False – The absorption of thiazides is reduced
b) False – The volume of distribution of lidocaine is reduced
probably because of decreased tissue perfusion
c) True – The distribution volume of furosemide is largely confined
to the vascular compartment
d) False – Is prolonged predominantly due to decreased hepatic
perfusion
e) False – Glomerular filtration is reduced in cardiac failure and
hence the elimination half-life of gentamicin is prolonged
(i.e. not decreased)
33 a) False – Gastric pH increases
b) True – The ratio of unbound:bound phenytoin rises in renal
failure. It is the unbound drug which is active and the
laboratory assay for phenytoin measures total blood
concentration (bound and unbound)
c) True – The blood–brain barrier becomes functionally less of a
barrier to drug distribution in severe renal failure.
This may be the reason for the increased incidence of
confusion associated with cimetidine and famotidine in
renal failure
d) True
e) False
35 a) False
b) False – But reduce dose; rashes more common
c) False – May need very high doses for any diuretic effect
d) True – Increased risk of lactic acidosis
e) True – Direct nephrotoxicity, anti-anabolic, increases
blood urea
36 a) True NSAIDs cause salt and water retention and reduce renal
b) False blood flow by inhibition of prostacyclin and prostaglandin
E2 synthesis in patients with renal compromise. This
disrupts autoregulation of renal blood flow and GFR thus
preventing the normal physiological mechanism which
26 CHAPTER 1 GENERAL PRINCIPLES
42 a) True
b) True
c) False – Minimal experience, animal data discouraging
d) False – The fetal VIIIth nerve is more sensitive to aminoglycoside
toxicity
e) False – Ribavirin inhibits a wide range of DNA and RNA viruses.
It is used by inhalation to treat severe respiratory syncytial
virus (RSV) bronchiolitis in children and is used in
combination with interferon alfa to treat chronic hepatitis C
infection. It is a very potent teratogen in animal models.
28 CHAPTER 1 GENERAL PRINCIPLES
44 a) True – This is also true for the low molecular weight heparins
(which are often the anticoagulants of choice in
pregnancy)
b) False – Warfarin is a teratogen and is associated with a high
incidence of haemorrhagic complications in late
pregnancy
c) False
d) False
e) False – Pethidine, which is commonly used as an analgesic during
delivery, can cause apnoea of the newborn which is
reversed with naloxone
Amiodarone
Aspirin
Benzodiazepines
Chloramphenicol
Ciclosporin
Ciprofloxacin
Cocaine
Combined oral contraceptives
Cytotoxics
Ergotamine
Octreotide
Stimulant laxatives (senna)
Sulfonylureas
Thiazide diuretics
Vitamin A/retinoid analogues
d) True
e) True
69 a) True
b) False – Placebo is the usual control
c) False
d) False
e) False – Phase 1 studies are usually performed in healthy male
adults aged 18–35 years
70 a) False The MHRA is the regulatory review board of the UK who
b) False advise when certificates to perform clinical trials should be
c) True issued to pharmaceutical companies and advise, following
d) True review of all the data from a submission, on the granting of
e) False a product licence which will allow the company to market
the drug
71 a) True See Textbook of Clinical Pharmacology and Therapeutics,
b) True Chapter 12
c) True
d) True
e) True
72 a) True The production of human proteins using recombinant
b) True DNA/RNA technology not only produces large quantities
c) True of natural human proteins but also minimizes the risk
d) True of blood-borne viral infection such as hepatitis B and C
e) True and HIV
EMQ ANSWERS
73 PHARMACODYNAMICS
Pharmacodynamics is the study of the effects of drugs on biological processes.
1 H Warfarin prolongs the prothrombin time and is the most commonly
prescribed oral anticoagulant. It is a vitamin K antagonist. The onset of
action is at least 48–72 hours after initiation of treatment following a
loading dose. There is wide variability in drug response related to
genetics, hepatic function, drug and alcohol interactions. Monitoring
of treatment through measurement of INR (international normalized
ratio) calculated from the prothrombin time is essential. Prolongation
of INR predisposes to haemorrhage.
2 J Insulin controls the metabolic disposition of carbohydrate, fats and
amino acids. Insulin is inactivated by gastrointestinal enzymes, hence
administration is by injection or occasionally by inhalation. Excess
insulin causes hypoglycaemia.
3 F Atenolol is one of the many beta-adrenoceptor blocking drugs
available. Indications include hypertension and angina.
34 CHAPTER 1 GENERAL PRINCIPLES
74 PHARMACOKINETICS
Pharmacokinetics is defined as the study of the time-course of drug absorp-
tion, distribution, metabolism and excretion.
1 I The absorption of gentamicin (and other aminoglycoside antibacterial
drugs) following oral administration is minimal. Hence gentamicin is
used by injection (intramuscular and intravenous) and topically.
2 B Amiodarone, an effective antidysrhythmic drug, is only slowly
eliminated by the liver, with a mean elimination half-life of 53 days.
Hence effects may continue for several months after dosing has ceased.
3 E Enalapril is hydrolysed to its active metabolite, enalaprilat, which is an
ACE inhibitor.
4 C Carbamazepine, an antiepileptic, induces its own metabolism such
that plasma concentrations reduce significantly on repeated dosing. It
has an elimination half-life of 25–60 hours following a single dose, but
approximately 10 hours after repeated dosing.
5 D Lithium undergoes active tubular reabsorption. It mimics sodium on
the proximal tubular sodium ion reabsorption mechanism, hence co-
administration of thiazides prolongs the half-life of lithium and
predisposes to toxicity.
75 PHARMACOGENETICS
Pharmacogenetics is the study of variation in drug responses under hereditary
control.
1 J Approximately 70 polymorphic variants of CYP2D6 have been defined
in humans. CYP2D6 enzyme is ‘deficient’ in about 7–10 per cent of the
UK white population. Drugs affected include codeine (minimal
analgesia as poor metabolizers convert little to morphine),
EMQ ANSWERS 35
77 DRUG METABOLISM
Drug metabolism is one of the primary mechanisms by which drugs are inac-
tivated. However, drug metabolism in certain cases leads to increased drug
activity, e.g. activation of prodrugs.
1 E Phenylephrine, an indirectly acting sympathomimetic, may cause a
hypertensive crisis if taken by a patient on an MAO inhibitor.
78 RENAL ELIMINATION
The kidneys are involved in the elimination of virtually every drug or drug
metabolite.
1 G Gentamicin, an aminoglycoside antibacterial drug with a low
therapeutic index, is predominantly eliminated via the kidney.
2 C Probenecid competes for the proximal tubule active secretion of organic
anions hence reduces the tubular secretion of penicillin and methotrexate.
3 D Urinary alkalinization enhances the excretion of salicylate reducing
toxicity after salicylate/aspirin overdose.
4 F Hence salt depletion which causes increased proximal tubular sodium
ion reabsorption causes lithium toxicity unless the dose of lithium is
reduced.
5 B Para-aminohippuric acid is excreted so efficiently that it is completely
extracted from the renal plasma in a single pass through the kidney.
79 RENAL TRACT
81 MONOCLONAL ANTIBODIES
Monoclonal antibodies are highly specific antibodies derived from one class
of cells which recognize one antigen. Receptor affinity is high and toxicity is
likely to be due to exaggerated pharmacological action or hypersensitivity.
1 J Palivizumab (Synagis®) is used in ‘at-risk’ infants to prevent serious
lower respiratory-tract disease caused by RSV. At-risk infants includes
those with serious congenital heart disease.
38 CHAPTER 1 GENERAL PRINCIPLES
NERVOUS SYSTEM
82 Benzodiazepines:
a) Potentiate the sedative effects of alcohol
b) Should only be used as hypnotics for a maximum of 2–4 weeks
c) Suppress rapid eye movement (REM) sleep
d) Act by binding to the gamma-aminobutyric acid (GABA)
receptor–chloride channel complex and facilitate the opening of the
channel in the presence of GABA
e) Are anxiolytic
83 Benzodiazepine dependence and withdrawal syndrome:
a) Benzodiazepine withdrawal symptoms should be treated with
buspirone
b) Fits can occur in the first week after withdrawal
c) The full withdrawal picture usually appears after an interval of 3–8
weeks
d) Perceptual distortions are characteristic
e) Shorter-acting benzodiazepines are less likely to cause dependence
and should be substituted for long-acting benzodiazepines when
withdrawing a patient from benzodiazepines
84 Diazepam:
a) Has a half-life of less than 20 hours
b) Can cause anterograde amnesia
c) Is effective in terminating acute dystonia caused by metoclopramide
d) Never causes fatal overdose
e) The major site of metabolism is the liver
85 Temazepam:
a) Has a shorter half-life than diazepam
b) Potentiates the effects of alcohol
c) Causes no ‘hangover’ effect 10 hours post dosing
d) Is not addictive
e) Is more potent than lorazepam
40 CHAPTER 2 NERVOUS SYSTEM
86 Clomethiazole (chlormethiazole):
a) Is not absorbed orally
b) Has a half-life of approximately 10 hours
c) In cirrhosis the bioavailability is increased about 10-fold
d) High doses cause cardiovascular and respiratory depression
e) Is antagonized by ethanol
87 Promethazine:
a) Is a GABA agonist
b) Is available without prescription
c) Causes dry mouth, constipation and reduced sweating
d) Liver failure is an absolute contraindication
e) May cause hallucinations
88 Zopiclone:
a) Is an ultra short-acting benzodiazepine
b) Is the hypnotic of choice in a breastfeeding mother
c) Is a more effective anticonvulsant than clonazepam
d) Is associated with drug dependence
e) Can cause confusion
89 The following drugs may mimic some of the common clinical features
of schizophrenia:
a) Levodopa
b) Salbutamol
c) LSD
d) Diamorphine
e) Methylenedioxymethylamphetamine (MDMA, ecstasy)
90 Blockade of central D2 receptors:
a) Parallels the clinical efficacy of the conventional antipsychotic drugs
such as chlorpromazine and haloperidol
b) Induces extrapyramidal effects
c) Repeated administration of D2 antagonists causes a reduction in D2
agonist sensitivity due to an increase in abundance of these
receptors
d) Repeated administration of D2 antagonists may lead to tardive
dyskinesia
e) Causes a decrease in cardiac output
91 Adverse effects associated with phenothiazines include:
a) Dry mouth
b) Blurred vision
c) Postural hypotension
d) Impaired temperature control
e) Jaundice
MULTIPLE CHOICE QUESTIONS 41
92 Chlorpromazine:
a) Is the first-line treatment for malignant neuroleptic syndrome
b) Has a low volume of distribution (approx. 100 mL/kg)
c) Is predominantly eliminated via the kidneys as unchanged
chlorpromazine
d) Of the chlorpromazine in plasma, 90–95 per cent is bound to plasma
proteins
e) Usually once-daily administration is adequate
93 Flupentixol:
a) Is particularly effective in mania
b) May be given once every 2–4 weeks via the intramuscular route for
chronic schizophrenia
c) Is less sedating than chlorpromazine
d) Is more prone than chlorpromazine to produce extrapyramidal
toxicity
e) Should not be used in patients with porphyria
94 Clozapine:
a) Has weak D2-blocking activity
b) Is effective in up to 60 per cent of patients who have not responded
to phenothiazines
c) Is effective against negative as well as positive symptoms
d) Rarely causes tardive dyskinesia
e) Causes blood dyscrasias more commonly than most antipsychotics
95 Newer atypical drugs such as olanzapine and risperidone:
a) Are less effective than traditional antipsychotic drugs against the
negative symptoms of schizophrenia
b) Are associated with weight loss
c) Bind irreversibly to D2 receptors
d) Are associated with an increased incidence of stroke in elderly
patients with dementia
e) Are virtually free from extrapyramidal side-effects at standard doses
96 The following drugs raise synaptic and/or total brain monoamines:
a) Cocaine
b) Amitriptyline
c) Imipramine
d) Phenelzine
e) Amphetamine
42 CHAPTER 2 NERVOUS SYSTEM
97 Tricyclic antidepressants:
a) Are more effective in endogenous rather than reactive depression
b) Are particularly effective when the depression is associated with
psychomotor and physiological changes
c) Onset of therapeutic action is approximately two weeks after
starting therapy
d) Are effective in the management of panic disorder
e) Are used for the treatment of nocturnal enuresis in children
98 Antidepressants with sedative properties include:
a) Amitriptyline
b) Dosulepin
c) Citalopram
d) Paroxetine
e) Sertraline
99 The following are consistent with tricyclic antidepressant overdose:
a) Dilated pupils
b) Hyperreflexia
c) Sinus tachycardia
d) Widened QRS on the ECG
e) Convulsions
100 Amitriptyline:
a) Is highly lipid soluble
b) Is highly protein bound
c) Has a low volume of distribution (approx. 100 mL/kg body weight)
d) Blocks uptake of monoamines into cerebral and other neurons
e) Delays gastric emptying
101 Fluvoxamine:
a) Inhibits monoamine oxidase (MAO)
b) Is a powerful anticholinergic agent
c) Is less sedative than trazodone
d) Inhibits a CYP450 isoenzyme
e) During therapy the blood count should be monitored weekly
102 Fluoxetine:
a) Selectively blocks neuronal uptake of noradrenaline
b) Is more cardiotoxic than imipramine
c) Is less sedative than amitriptyline
d) Is associated with nausea and dyspepsia
e) Has a short elimination half-life of 1–2 hours
MULTIPLE CHOICE QUESTIONS 43
103 Phenelzine:
a) Is a reversible selective inhibitor of MAO-B
b) Onset of therapeutic effect is usually within one week
c) Is ineffective if used alone in the treatment of depression
d) Is sometimes effective in reducing hypochondriacal and hysterical
symptoms
e) Is more likely to cause a hypertensive crisis when an indirectly
acting sympathomimetic (e.g. ephedrine) is given concurrently
rather than a directly acting sympathomimetic (e.g. adrenaline
combined with local anaesthetic)
104 Moclobemide:
a) Is a reversible selective inhibitor of MAO-A
b) Is effective adjunct therapy in Parkinson’s disease
c) Has a longer duration of MAO inhibition compared to phenelzine
after stopping therapy
d) Causes dry mouth in over 50 per cent of patients
e) Is less likely than phenelzine to cause a food (tyramine) interaction
105 The following foodstuffs can cause a hypertensive/hyperthermic
reaction during non-selective MAO inhibitor therapy:
a) Cheese
b) Yoghurt
c) Beer
d) Marmite
e) Grouse
106 Lithium toxicity can be precipitated by:
a) Sodium depletion
b) Thiazide therapy
c) Angiotensin-converting enzyme (ACE) inhibitors
d) Non-steroidal anti-inflammatory drugs (NSAIDs)
e) Atenolol
107 Tricyclic antidepressant therapy should not be started within 14 days of
therapy with:
a) Citalopram
b) lsocarboxazid
c) Tranylcypromine
d) Moclobemide
e) St John’s wort
44 CHAPTER 2 NERVOUS SYSTEM
114 The following drugs reduce spasticity in patients with upper motor
neuron lesions:
a) Donepezil
b) Riluzole
c) Diazepam
d) Baclofen
e) Dantrolene
115 Tardive dyskinesia:
a) Occurs in about 15 per cent of patients treated with phenothiazines
for over 2 years
b) Stopping treatment results in slow improvement in approximately
40 per cent of patients
c) Dyskinesia may initially worsen after discontinuing treatment
d) Consists of rapid involuntary movements of the limbs
e) Is treated with botulinum toxin A
119 The following drugs are effective in partial seizures with or without
secondary generalized tonic clonic seizures:
a) Carbamazepine
b) Valproate
c) Topiramate
d) Lamotrigine
e) Ethosuximide
120 The following adverse effects are associated with sodium valproate
therapy:
a) Tremor
b) Nausea, vomiting and abdominal pain
c) Ventricular tachycardia
d) Thrombocytosis
e) Hair loss (temporary)
121 The following are recognized adverse effects associated with phenytoin
therapy:
a) Ataxia
b) Dysarthria
c) Acne
d) Hyperkalaemia
e) Macrocytic anaemia
122 The pharmacokinetics of phenytoin are characterized by:
a) Wide interindividual variation
b) Less than 10 per cent systemic bioavailability if taken by mouth
with food
c) Two populations – fast and slow acetylators
d) The half-life is not affected by dose
e) Once-daily dosing is adequate
123 Carbamazepine:
a) Inhibits GABA transaminase
b) Inhibits its own metabolism
c) Is effective in temporal lobe epilepsy
d) Inhibits the metabolism of warfarin
e) Modified-release tablets significantly lessen the incidence of dose-
related side-effects
124 The following adverse effects are associated with carbamazepine therapy:
a) Trigeminal neuralgia
b) Sedation
c) Dizziness
d) Diplopia
e) Hyponatraemia
MULTIPLE CHOICE QUESTIONS 47
153 Buprenorphine:
a) Is a partial agonist on opioid receptors
b) Occupies a much larger fraction of opioid receptors to produce its
analgesic effect than does morphine
c) Should only be used to treat acute pain
d) Is subject to prescription requirements under the Misuse of Drugs
Act
e) May be administered sublingually
154 Naloxone:
a) Binds to opioid μ receptors
b) Acts as a partial opioid agonist
c) Has little effect on a healthy person who has not taken opioid drugs
d) Has an elimination half-life of approximately 12 hours
e) Is contraindicated in young children
Answers: see pages 55–66
EXTENDED MATCHING QUESTIONS 53
For each clinical scenario below, suggest the most appropriate therapy:
1 Acute migraine in a 20-year-old woman, which is unresponsive to
paracetamol, ibuprofen and metoclopramide
2 A 40-year-old man with troublesome myoclonic jerks
3 A 70-year-old man with schizophrenia, who has developed
incapacitating tardive dyskinesia on his maintenance therapy of oral
chlorpromazine
4 A 40-year-old man with endogenous depression
5 Severe disabling insomnia
156 DRUG-INDUCED MOVEMENT DISORDERS
A Interferon beta F Esmolol
B Ciprofloxacin G Prednisolone
C Salbutamol H Pioglitazone
D Doxazosin I Phenytoin
E Gentamicin J Ranitidine
Select the drug from the list above that is most likely to be the cause of the
effect below:
1 Tremor
2 ‘Cerebellar’ ataxia
3 Vestibular toxicity causing loss of balance
4 Proximal myopathy
5 Tenosynovitis
54 CHAPTER 2 NERVOUS SYSTEM
Select the drug from the above list which is licensed for the indication below:
1 Idiopathic Parkinson’s disease
2 Hemifacial spasm
3 Myasthenia
4 Fluphenazine-induced dystonia
5 Alzheimer’s disease
158 ANALGESICS/PAIN
A Fentanyl F Indometacin
B Aspirin G Morphine
C Nefopam H Paracetamol
D Allopurinol I Metoclopramide
E Pregabalin J Ephedrine
ANSWERS
MCQ ANSWERS
Note: Other antiepileptics not listed above may be useful. Refer to National Institute for
Health and Clinical Excellence (NICE) guidelines.
120 a) True Tremor, ataxia and incoordination are dose related. The
b) True gastrointestinal effects can be reduced by the use of an
c) False enteric coated formulation
d) False
e) True
121 a) True High blood concentrations of phenytoin produce a
b) True cerebellar syndrome, involuntary movements and sedation.
c) True Macrocytic anaemia which responds to folate is common.
d) False Rashes, fever, hepatitis, gum hypertrophy, hirsutism and
e) True lymphadenopathy are all well-recognized adverse effects
of phenytoin
122 a) True Age, body weight, sex and, in particular, saturable
b) False metabolism which is under polygenic control, contribute to
c) False the wide variation in handling of phenytoin
d) False
e) True
62 CHAPTER 2 NERVOUS SYSTEM
c) True
d) True
e) False
150 a) False Morphine increases smooth muscle tone throughout the
b) True gastrointestinal tract and in addition reduces peristalsis
c) True through an action on the receptors in the ganglion plexus
d) True in the gut wall which results in constipation. Diamorphine
e) False is diacetylmorphine. Its actions are similar to those of
morphine but is more potent as an analgesic when given by
injection. It is more soluble than morphine. Diamorphine
and 6-acetylmorphine enter the brain more rapidly than
morphine
151 a) False Pethidine causes similar respiratory depression and
b) False vomiting to morphine, but does not release histamine or
c) False suppress cough and only uncommonly produces pupillary
d) False constriction to the same extent as morphine
e) False
EMQ ANSWERS
158 ANALGESICS/PAIN
1 H Paracetamol is a mild analgesic and antipyretic which, unlike aspirin,
is not associated with Reye’s syndrome. Therapeutic doses are
extremely well tolerated but overdose can be fatal usually through
hepatic failure.
2 F Indometacin, an NSAID, is effective in acute gout.
3 G Patient-controlled analgesia using morphine is especially valuable in
the management of post-operative visceral pain.
4 B Aspirin overdose is associated with tinnitus.
5 A Fentanyl, a potent synthetic opioid, is available as a transdermal patch
which can provide analgesia for up to 72 hours.
CHAPTER THREE
MUSCULOSKELETAL SYSTEM
168 ARTHRITIS
A Colchicine F Methylprednisolone
B Azathioprine G Hydroxychloroquine
C Allopurinol H Naproxen
D Gold injections I D-penicillamine
E Methotrexate J Etanercept
ANSWERS
MCQ ANSWERS
164 a) False Uric acid is the end product of purine metabolism in humans,
b) True and gives rise to problems because of its limited solubility.
c) True Cytosine arabinoside causes massive cell death and increased
d) True uric acid production. Diuretics, low-dose salicylates and
e) False pyrazinamide inhibit tubular excretion of uric acid
166 a) True
b) False – NSAIDs are probably one of the most widely used
c) False treatments although paracetamol, because of its superior
d) False tolerance in the elderly, should be tried first
e) False – Raloxifene is used in the treatment and prevention of
postmenopausal osteoporosis
EMQ ANSWERS
168 ARTHRITIS
CARDIOVASCULAR SYSTEM
169 The following are modifiable risk factors for the genesis of
atheromatous plaque:
a) Smoking
b) Obesity
c) Dyslipidaemia
d) Glucose intolerance
e) Hypertension
170 Colestyramine:
a) Causes a fall in plasma cholesterol
b) Increases fecal excretion of bile acids
c) Reduces absorption of folic acid
d) Causes diarrhoea in diabetic autonomic neuropathy
e) Reduces pruritus in incomplete biliary obstruction
171 Bezafibrate:
a) Lowers plasma triglyceride
b) Is ineffective post cholecystectomy
c) Inhibits lipoprotein lipase
d) Is indicated in alcohol-induced hyperlipidaemia
e) Potentiates the effects of warfarin
172 Simvastatin, an HMG-CoA (3-hydroxy-3-methyl-glutaryl-CoA)
reductase inhibitor:
a) Lowers low-density lipoprotein (LDL) cholesterol
b) Is particularly useful in heterozygous familial
hypercholesterolaemia
c) Acts locally on HMG-CoA reductase in the intestine
d) Is associated with myositis/myopathy
e) Is ineffective if prescribed with ezetimibe
76 CHAPTER 4 CARDIOVASCULAR SYSTEM
185 The following drug effects have been correctly paired with the named
drug:
a) Hydralazine – drug-induced systemic lupus erythematosus (SLE)
b) Minoxidil – hirsutism
c) Captopril – first-dose hypotension
d) Atenolol – tremor
e) Candesartan – cough
186 Management of acute ST elevation myocardial infarction (STEMI)
should usually include:
a) 24 per cent oxygen
b) Intravenous opiate with an antiemetic
c) Aspirin
d) Some measure to open the coronary atery (e.g. angioplasty)
e) Lidocaine (lignocaine)
187 The management of unstable angina usually includes:
a) Aspirin
b) Glyceryl trinitrate (GTN)
c) Low molecular weight heparin
d) Salbutamol
e) Beta-adrenoceptor antagonist
188 GTN:
a) Relaxes vascular smooth muscle
b) Is associated with tolerance more commonly with transdermal GTN
patches than sublingual GTN
c) Is volatile
d) Is more selective for arteriolar than for venous smooth muscle
e) May relieve the pain of oesophageal spasm
189 Beta-adrenoceptor antagonists:
a) Increase cardiac tissue cyclic adenosine monophosphate (cAMP)
b) Competitively antagonize the β receptor-mediated effects of
adrenaline and noradrenaline
c) Non-competitively antagonize several of the actions of thyroxine
d) Decrease peripheral vascular resistance
e) Reduce renin secretion
190 The following drugs may reduce the risk of recurrence or death post
myocardial infarction:
a) Aspirin
b) Beta blockers
c) Dexfenfluramine
d) Sildenafil
e) Statins
MULTIPLE CHOICE QUESTIONS 79
193 Aspirin:
a) Reduces the risk of stroke in patients with transient ischaemic
attacks
b) Predisposes to peptic ulceration
c) Irreversibly inhibits fatty acid cyclo-oxygenase
d) Has no effect on bleeding time
e) Needs to be given twice daily to prevent platelet cyclo-oxygenase
resynthesis within the dose interval
194 Streptokinase:
a) Is derived from streptococci
b) Reduces the acute mortality of myocardial infarction
only if administered within 4 hours of the onset of
chest pain
c) Is contraindicated if the patient is taking regular NSAID
therapy
d) Is administered by intravenous infusion
e) Should not be given to patients over the age of 60 years
195 Alteplase:
a) Is a prodrug that liberates streptokinase
b) Heparin must not be administered within 24 hours of alteplase
infusion
c) Should only be administered if pulmonary artery pressure can be
measured
d) Is indicated in the treatment of pulmonary embolism
e) Is contraindicated if aspirin has been administered in the last
24 hours
80 CHAPTER 4 CARDIOVASCULAR SYSTEM
201 Warfarin:
a) Prevents the hepatic synthesis of the vitamin K-dependent
coagulation factors II, VII, IX and X
b) Is structurally closely related to vitamin K
c) Should initially be given as a subcutaneous loading dose
d) During life-threatening bleeding can be reversed by vitamin K and
fresh frozen plasma
e) Anticoagulant effect is monitored by measurement of the
prothrombin time/international normalized ratio (INR)
202 The following are relative or absolute contraindications to warfarin
therapy:
a) First trimester of pregnancy
b) Prosthetic heart valves
c) Space-occupying CNS lesion
d) Concurrent digoxin therapy
e) Glucose 6-phosphate dehydrogenase (G6PD) deficiency
203 The following inhibit the metabolism of warfarin:
a) Cimetidine
b) Fluvoxamine
c) St John’s wort
d) Carbamazepine
e) Smoking
204 The following inhibit platelet activation and/or aggregation:
a) Warfarin
b) Heparin
c) Thromboxane A2
d) Prostacyclin (epoprostenol)
e) Dipyridamole
205 Clopidogrel:
a) Is a direct inhibitor of glycoprotein IIb and IIIa
b) The antiplatelet effect lasts the life of the platelet
c) Is usually given by intravenous bolus in acute coronary syndrome
d) Is a prodrug, requiring conversion in the liver to its active metabolite
e) Prolongs the QTc (QT interval on the ECG corrected for heart rate)
predisposing to ventricular tachycardia
206 Prostacyclin (epoprostenol):
a) Relaxes pulmonary and systemic vasculature
b) Is the principal endogenous prostaglandin of large- and medium-
sized blood vessels
c) Is an effective anticoagulant
d) Is contraindicated in haemodialysis
e) Increases diastolic pressure
82 CHAPTER 4 CARDIOVASCULAR SYSTEM
207 The principal beneficial effect in heart failure of the following drugs is
to reduce preload (left ventricular filling pressure):
a) Digoxin
b) Furosemide
c) Dobutamine
d) GTN
e) Sodium nitroprusside
208 The following drugs at standard therapeutic doses aggravate heart failure:
a) Imatinib (a tyrosine kinase inhibitor)
b) Verapamil
c) Daunorubicin
d) Ibuprofen
e) Bendroflumethiazide
209 In acute pulmonary oedema the following are usually appropriate:
a) Sublingual nifedipine
b) Lie the patient supine
c) Oxygen
d) Intravenous loop diuretic
e) Intravenous morphine
210 Intravenous furosemide:
a) Causes natriuresis
b) Causes kaliuresis
c) Has an indirect vasodilator effect
d) Diuresis begins 10–20 minutes after an intravenous dose
e) High doses are ototoxic
211 ACE inhibitors:
a) Are positive inotropes
b) Increase afterload
c) Increase preload
d) May cause cough
e) Should be given parenterally in acute heart failure
212 The following statements concerning drugs in heart failure are correct:
a) The combination of furosemide (a loop diuretic) and ramipril (an
ACE inhibitor) should be avoided
b) Candesartan (an angiotensin-II receptor antagonist) is generally
better tolerated than captopril (an ACE inhibitor)
c) Beta blockers are contraindicated in heart failure
d) The combination of loop diuretic, ACE inhibitor and spironolactone
must always be avoided because of the risk of hyperkalaemia
e) The combination of hydralazine and nitrates is of demonstrated
efficacy in African-origin patients
MULTIPLE CHOICE QUESTIONS 83
213 Dobutamine:
a) Is a sympathomimetic amine
b) Is predominantly a β1-receptor agonist
c) Increases blood pressure via vasoconstriction
d) Should not be given at the same time as loop diuretics
e) Increases myocardial oxygen consumption
214 The following drugs can cause sinus tachycardia:
a) Esmolol
b) Theophylline
c) Ephedrine
d) Amphetamine
e) Verapamil
215 Lidocaine:
a) Is a class 1b agent that blocks cardiac Na channels, reducing the
rate of rise of the cardiac action potential and increasing the
effective refractory period
b) Is epileptogenic
c) Is a positive inotrope
d) Is usually administered as an intravenous bolus followed by
infusion
e) Is the drug of first choice for supraventricular tachycardia
216 The following drugs prolong the QT interval and/or cause torsades de
pointes:
a) Erythromycin
b) Pimozide
c) Foscarnet
d) Tacrolimus
e) Disopyramide
217 Amiodarone:
a) Is effective in resistant atrial fibrillation or flutter
b) Is effective in preventing recurrent ventricular fibrillation
c) Is contraindicated in Wolff–Parkinson–White (WPW)
syndrome
d) May be given intravenously via a central line
e) Prolongs the QT interval
218 The following adverse effects are associated with amiodarone:
a) Visual disturbances (e.g. coloured halos)
b) Hyperthyroidism
c) Hypothyroidism
d) Pulmonary fibrosis
e) Photosensitivity
84 CHAPTER 4 CARDIOVASCULAR SYSTEM
219 Amiodarone:
a) Is highly lipid soluble
b) Has an apparent volume of distribution of approximately 5000 L
c) Is predominantly eliminated by the kidney
d) Accumulates in the heart
e) Has a half-life of 3 weeks
220 Sotalol:
a) Is effective in supraventricular and ventricular dysrhythmias
b) Is not effective when given by mouth
c) The dose should be reduced in renal impairment
d) May cause torsade de pointes
e) Is a less potent negative inotrope than amiodarone
221 Intravenous verapamil:
a) May terminate supraventricular tachycardia
b) Must not be given to patients receiving beta blockers
c) Reduces digoxin excretion
d) One must delay DC cardioversion at least 2 hours after a dose
e) Shortens the PR interval on the ECG
222 Adenosine:
a) Is used to terminate ventricular tachycardia
b) Is contraindicated in regular broad complex tachycardia
c) Dilates bronchial smooth muscle
d) Is associated with chest pain
e) Circulatory effects last 20–30 seconds
223 Digoxin:
a) Reduces the ventricular rate in atrial fibrillation
b) Is contraindicated in second-degree heart block
c) Is the treatment of choice in atrial fibrillation in a patient with WPW
syndrome
d) Induced dysrhythmias may be terminated by magnesium
e) 80 per cent of administered digoxin is excreted unchanged in the
bile
224 A 70-year-old woman has recurrent, symptomatic ventricular
tachycardia following an acute myocardial infarction in spite of DC
conversion and lidocaine. The following may be effective:
a) Amiodarone
b) Atropine
c) Verapamil
d) Adenosine
e) Isoprenaline
MULTIPLE CHOICE QUESTIONS 85
228 HYPERTENSION
A Labetalol F Spironolactone
B Minoxidil G Candesartan
C Doxazosin H Trandolapril
D Methyldopa I Bendroflumethiazide
E Atenolol J Amlodipine
Select the drug from the list above most appropriate to prescribe to the patients
described below. In each patient the current blood pressure is above ‘target’.
1 A 40-year-old Afro-Caribbean man who has poorly controlled
hypertension having stopped bendroflumethiazide, which caused
impotence
2 A 70-year-old white man who takes losartan and amlodipine and who
has symptoms from prostatic hyperplasia
3 A 50-year-old hypertensive man who has hyperaldosteronism due to
bilateral adrenal hyperplasia who is currently on no therapy
4 A 50-year-old white man who has type II diabetes and asthma. He
currently takes gliclazide, simvastatin and inhaled beclomethasone. He
was on trandolapril, but this was associated with a troublesome cough
5 A 50-year-old Afro-Caribbean woman who developed marked lower
limb oedema on amlodipine
EXTENDED MATCHING QUESTIONS 87
Which of the above drugs is useful in each of the following clinical situations?
1 Acute treatment of an angina attack in a 65-year-old man with
ischaemic chest pain following exertion
2 Acute treatment of anterior ST-elevation myocardial infarction in a
previously healthy 60-year-old man
3 Long-term treatment of left ventricular dysfunction in a 65-year-old
woman post myocardial infarction
4 Long-term prevention of cardiac events in an asymptomatic 67-year-old
woman with a 10-year history of type 2 diabetes and a total cholesterol
of 5.0 mmol/L
5 Prevention of angina in a 78-year-old man with widespread diffuse
coronary artery disease, not amenable to percutaneous coronary
intervention or surgery, who is having troublesome exertional angina
despite combination treatment with a long-acting nitrate, beta blocker
and calcium antagonist
ANSWERS
MCQ ANSWERS
207 a) False The major influences on preload are blood volume and
b) True capacitance vessel tone
c) False
d) True
e) False
208 a) True Negative inotropes, direct cardiac toxins (e.g. daunorubicin)
b) True and drugs that cause salt retention (e.g. NSAIDs) aggravate
c) True heart failure. Excessive tachycardia does not allow
d) True sufficient time for the ventricle to fill in diastole
e) False
209 a) False In addition to helping relieve the acute anxiety and
b) False discomfort associated with acute pulmonary oedema, opioids
MCQ ANSWERS 95
218 a) True Adverse effects are many and varied and are common
b) True when plasma amiodarone concentration exceeds 2.5 mg/L.
c) True Most are reversible on stopping treatment, but this is not true
d) True of pulmonary fibrosis
e) True
225 a) False Bradycardia and first-degree heart block are common post
b) False inferior myocardial infarction. If the bradycardia causes
c) False symptoms 0.6 mg atropine intravenously is usually effective
d) False
e) True
EMQ ANSWERS
227 ATHEROMA AND THROMBOSIS
228 HYPERTENSION
See Textbook of Clinical Pharmacology and Therapeutics, Chapter 28.
1 J Thiazide diuretics are associated with erectile dysfunction which
is reversible on stopping the thiazide. Calcium channel blockers
(e.g. amlodipine) and thiazide diuretics are the antihypertensives
of first choice in Afro-Caribbean patients.
2 C Doxazosin has postsynaptic α1-blocking activity and is an effective
hypotensive agent. First-dose hypotension is a potential problem.
It relaxes smooth muscle in benign prostatic hyperplasia improving
flow rate and reducing obstructive symptoms.
3 F Spironolactone competes with aldosterone for its intracellular
receptors. Its indications include Conn’s syndrome, secondary
hyperaldosteronism in ascites and resistant, low renin hypertension.
Hyperkalaemia is a potential problem, particularly if on another
potassium-sparing drug (e.g. an ACE inhibitor such as trandolapril),
or if there is renal impairment.
4 G Candesartan is an angiotensin II blocker. Unlike ACE inhibitors it does
not inhibit the breakdown of bradykinin, the likely cause of an ACE
inhibitor-induced cough.
5 I Although not sinister, ankle oedema is a troublesome adverse effect of
calcium channel blockers (less common with verapamil). Thiazides are
often effective in Afro-Caribbean patients. Metabolic adverse effects
include hypokalaemia, hyperglycaemia, hypercalcaemia and
hyperuricaemia.
RESPIRATORY SYSTEM
242 Montelukast:
a) Is a competitive antagonist at the Cys LT1 receptor
b) Can be given orally
c) Is usually taken once daily at bedtime
d) May be associated with Churg–Strauss syndrome
e) Is not beneficial to patients with antigen-induced asthma
243 The following drugs can produce pulmonary fibrosis:
a) Methotrexate
b) Bleomycin
c) Busulphan
d) Lisinopril
e) Amiodarone
244 Pulmonary eosinophilia is caused by the following drugs:
a) Methysergide
b) Aspirin
c) Nitrofurantoin
d) Carmustine (BCNU)
e) Sulfasalazine
245 The following agents if given to an asthmatic are likely to cause
catastrophic bronchospasm:
a) Carvedilol
b) Losartan
c) Adenosine
d) Lidocaine (lignocaine)
e) Bethanecol
246 The following drugs are used as ‘standard of care’ when treating a
patient with type II (hypoxic–hypercanic) respiratory failure:
a) 35 per cent oxygen
b) Doxapram
c) Salbutamol
d) Methylprednisolone
e) Dantrolene
Answers: see pages 105–107
104 CHAPTER 5 RESPIRATORY SYSTEM
Select the drugs most frequently associated with the adverse effects described
below:
1 Seizures
2 Apnoea
3 QTc prolongation
4 Hypertension
5 Anaphylaxis
ANSWERS: see page 108
MCQ ANSWERS 105
ANSWERS
MCQ ANSWERS
239 a) True Objective improvement does not occur until 6 hours and is
b) False maximal 13 hours after the start of intravenous glucocorti-
c) False costeroid treatment in asthma. This delay is due to the
d) False pharmacodynamics of glucocorticoids which work via
e) False modifying transcription of certain genes and thus affecting
their protein synthesis. They should be administered early
in acute asthma
240 a) True Systemic adverse events are rarely significant with inhaled
b) True glucocorticoids unless the dose exceeds e.g. 1000 μg of
c) False fluticasone or its equivalent. They are invaluable in the
d) False prophylaxis of asthma and have been shown to reduce
e) True asthma deaths and exacerbations in patients with chronic
obstructive pulmonary disease (COPD)
246 a) False – Use low FiO2 (e.g. 22–24 per cent) and titrate upwards
based on blood gas response/clinical response
b) False – Analeptics are no longer used unless mechanical
ventilation is unavailable or contraindicated
c) True
d) True
e) False – Dantrolene is a muscle relaxant; this would worsen
respiratory failure
108 CHAPTER 5 RESPIRATORY SYSTEM
EMQ ANSWERS
247 RESPIRATORY DRUGS – MECHANISM OF ACTION
1 D Corticosteroids bind to its receptor in the cytoplasm, which then
moves to the nucleus where it binds to DNA suppressing the
transcription of certain genes such as interleukins and tumour necrosis
factor (TNF) and enhancing transcription of beta2 receptors, ACE and
other anti-inflammatory entities.
2 H Omalizumab binds to the Fc receptor portion of IgE and blocks IgE,
interacting with its receptor on inflammatory cells and reduces
circulating IgE concentrations.
3 I Second-generation antihistamines are competitive antagonists at the
H1 receptor without significant binding to other receptors including
the gastric H2, muscarinic and serotonin receptors.
4 F Sodium cromoglicate – whose precise anti-inflammatory mechanism is
not clearly defined modulates the firing of cough C fibres.
5 C Tiotropium is a competitive antagonist at respiratory muscarinic
receptors and blocks parasympathetic effects on bronchiolar smooth
muscle.
ALIMENTARY SYSTEM
253 Antacids:
a) Large doses heal gastric ulcers more frequently than duodenal
ulcers
b) Standard doses reduce gastric acidity for approximately 4 hours
c) Magnesium salts tend to cause diarrhoea
d) Aluminium salts tend to cause a diuresis
e) Magnesium and aluminium salts reduce the rate and extent of
absorption of phenytoin
254 Cimetidine therapy is associated with:
a) Transient increase in serum prolactin
b) Irreversible gynaecomastia
c) Mental confusion in the elderly
d) Asystole after rapid intravenous injection
e) Reversible rise in serum creatinine
255 Eradication of H. pylori following a positive breath test is recommended
in the following situations:
a) Duodenal ulcer
b) Gastric ulcer
c) Patients requiring long-term proton pump inhibitor treatment
d) Severe gastritis
e) Mucosa-associated lymphoid tissue lymphoma
256 In comparison to cimetidine, ranitidine:
a) Does not bind to androgen receptors
b) Is less likely to cause gynaecomastia
c) Penetrates the blood–brain barrier to a lesser extent
d) Is not available for parenteral use
e) Has a lower affinity for CYP450
257 Omeprazole:
a) Is an irreversible inhibitor of the hydrogen/potassium adenosine
triphosphatase locus of the gastric parietal cell
b) Reduces gastric acid secretion
c) Is the drug of choice in Zollinger–Ellison syndrome
d) Has a plasma half-life of approximately 1 hour
e) Requires dose reduction in renal failure
258 Omeprazole enhances the effects of the following drugs through
inhibition of drug metabolism:
a) Atenolol
b) Amoxicillin
c) Captopril
d) Warfarin
e) Phenytoin
MULTIPLE CHOICE QUESTIONS 111
265 Metoclopramide:
a) Is most effective in centrally mediated vomiting
b) Is ineffective in drug-induced nausea
c) Increases the rate of gastric emptying
d) Should be avoided for 3–4 days following gastrointestinal surgery
e) High doses block 5HT3 receptors
266 Ondansetron:
a) Is a phenothiazine
b) Is not absorbed after oral administration
c) Is effective in preventing nausea and vomiting due to cancer
chemotherapy and radiotherapy
d) Is ineffective in ciplastin-induced nausea
e) 1 per cent of patients have dystonic reactions
267 In ulcerative colitis:
a) Intravenous hydrocortisone is of proven value in the treatment of
acute colitis
b) Oral corticosteroids are first line for maintenance treatment
c) Localized rectal disease often responds to prednisolone
enemas/suppositories
d) In severe colitis codeine should be used
e) Fibre is contraindicated
268 Sulfasalazine:
a) Is a prodrug
b) Is used for maintenance treatment of ulcerative colitis
c) Is effective in small bowel Crohn’s disease
d) Should be avoided in glucose 6-phosphate dehydrogenase (G6PD)
deficiency
e) Should be avoided in salicylate hypersensitivity
269 Adverse effects associated with sulfasalazine include:
a) Blood dyscrasias
b) Oligospermia
c) Stevens–Johnson syndrome
d) Systemic lupus erythematosus (SLE)-like syndrome
e) Hepatitis
270 Mesalazine:
a) Is a prodrug consisting of a dimer of two 5-aminosalicylic acid
molecules
b) Dissolves at the pH found in the terminal ileum and colon
c) Is contraindicated in sulphonamide hypersensitivity
d) Is associated with oligospermia
e) Is associated with interstitial nephritis
MULTIPLE CHOICE QUESTIONS 113
271 Infliximab:
a) Inhibits tumour necrosis factor (TNF)
b) Can only be administered on one occasion due to antibody
production
c) Is licensed for management of irritable bowel syndrome
d) Can be used for maintenance therapy in Crohn’s disease and
ulcerative colitis
e) Should not be used in a patient who has been treated with
corticosteroids within the previous 12 months
272 The following drugs cause constipation:
a) Amiodarone
b) Amitriptyline
c) Amoxicillin
d) Misoprostol
e) Metformin
273 Lactulose:
a) Is a chemical stimulant to the colon
b) Produces its effect 10–12 hours after an oral dose
c) Requires colonic bacteria for activity
d) Should not be administered concurrently with bran
e) Is contraindicated in liver failure
274 Loperamide:
a) Decreases intestinal transit time
b) Increases bulk of gut contents
c) Requires systemic absorption for activity on the bowel
d) Causes pupil constriction
e) Causes hypersalivation
275 Treatment of hepatic encephalopathy includes:
a) Dietary protein restriction
b) Emptying the lower bowel
c) Oral lactulose
d) Prophylactic vitamin K
e) Oral methionine
276 The emergency drug therapy of portal hypertension and oesophageal
varices may include:
a) Terlipressin
b) Chenodeoxycholic acid
c) Calcitonin
d) Octreotide
e) Isoprenaline
114 CHAPTER 6 ALIMENTARY SYSTEM
Match the drug from the list above with the mode of action/indication below:
1 Serotonin (5HT3) receptor blockade
2 Symptomatic treatment of acute diarrhoea
3 Maintenance of remission of ulcerative colitis
4 Chemotherapy for patients with advanced or metastatic
adenocarcinoma of the pancreas
5 Chronic hepatitis C
ANSWERS: see page 121
116 CHAPTER 6 ALIMENTARY SYSTEM
ANSWERS
MCQ ANSWERS
Vagal stimulation
Parietal cell
Acetylcholine
M1-receptor Ca2
H
Ca2
Gastrin H ATP
receptor stomach
Proton pump lumen
Gastrin K
ATP
K
H2-receptor
cAMP Cl
Histamine
Gastrin
receptor
Mast cell
Histamine
258 a) False For drugs such as phenytoin and warfarin which have a
b) False narrow therapeutic index this is clinically significant
c) False
d) True
e) True
259 a) True There are currently five proton pump inhibitors licensed in
b) True the UK: esomeprazole, omeprazole, lansoprazole,
c) True pantoprazole and rabeprazole
d) True
e) False
260 a) True Misoprostol inhibits gastric acid secretion, causes
b) False vasodilatation in the submucosa and stimulates production
c) True of protective mucus. It contracts uterine muscle and causes
d) True abortion
e) True
261 a) True Several studies show bismuth chelate to be as active as
b) True cimetidine in the healing of duodenal and gastric ulcers
c) True after 4–8 weeks of treatment. It is, however, associated with
d) False frequent minor adverse effects. Ranitidine bismuth chelate can
e) True be substituted for a proton pump inhibitor as part of ‘triple
therapy’ for the eradication of H. pylori
262 a) False Sucralfate, a basic aluminium salt, becomes a sticky
b) True adherent paste in the presence of acid which retains antacid
c) True efficacy and apparently coats the floor of ulcer craters
d) False
e) True
263 a) True – Muscarinic antagonist; NB: anticholinergic side-effects
b) True – H1 blocker minor antimuscarinic action
c) True – H1 blocker minor antimuscarinic action
d) False – Dopamine receptor antagonist
e) False – Chlorpromazine is not used for motion sickness
264 a) False Cyclizine is an H1 blocker with additional antimuscarinic
b) True actions. Its indications are nausea, vomiting, vertigo,
c) False motion sickness and labyrinthine disorders
d) True
e) True
265 a) False – Relatively ineffective in motion sickness and other forms of
centrally mediated vomiting
b) False
c) True – Increases the rate of absorption of oral drugs
d) True
e) True – Effective in some patients in preventing cisplatin-induced
nausea and vomiting
MCQ ANSWERS 119
EMQ ANSWERS
280 ALIMENTARY SYSTEM
ENDOCRINE SYSTEM
284 Sulphonylureas:
a) Are used in obese diabetics who show a tendency to ketosis
b) Improve symptoms of polyuria and polydipsia
c) Have been proven to reduce the vascular complications of type 2
diabetics
d) Require functioning beta cells for a hypoglycaemic effect
e) Are usually administered once daily at bed time
285 Gliclazide:
a) Should never be combined with acarbose
b) Can be safely prescribed concomitantly with an angiotensin-
converting enzyme (ACE) inhibitor
c) Hypoglycaemia can be reversed by intramuscular glucagon
d) Should not be prescribed concurrently with metformin
e) Stimulates appetite
286 Metformin, a biguanide:
a) May cause lactic acidosis
b) Is particularly useful in alcoholic diabetic patients
c) Causes hypoglycaemia in non-diabetic patients
d) Should be discontinued before major elective surgery
e) Causes anorexia and weight loss
287 ‘Glitazones’ (e.g. pioglitazone and rosiglitazone):
a) Are indicated in type 1 diabetes
b) Bind to peroxisome proliferating activator receptor γ (PPAR γ), a
nuclear receptor found mainly in adipocytes and also in hepatocytes
and myocytes
c) Have a rapid onset of action and should be taken shortly before each
main meal
d) Reduce peripheral insulin resistance
e) Are associated with weight gain and fluid retention
288 Carbimazole:
a) Decreases thyroid hormone synthesis
b) Inhibits the peripheral conversion of T4 to the more active T3
c) Should be stopped immediately if a rash develops
d) Has an active metabolite
e) Is associated with neutropenia
289 In a thyroid crisis with hyperpyrexia, tachycardia, vomiting,
dehydration and shock the following are usually indicated:
a) Metaraminol
b) Propranolol
c) Intravenous saline
d) Glucocorticoids
e) Aspirin
124 CHAPTER 7 ENDOCRINE SYSTEM
292 Glucocorticoids:
a) Reduce circulating numbers of eosinophils by inducing apoptosis
b) Reduce circulating numbers of T lymphocytes
c) Increase circulating numbers of neutrophils
d) Increase circulating numbers of platelets
e) Increase the transcription of proteins such as tumour necrosis factor
(TNF), interleukin 1 (IL-1) and granulocyte colony-stimulating
factor (G-CSF)
301 There is reliable evidence that giving oestrogen for several years
starting at the menopause to a woman with an intact uterus:
a) Reduces risk of osteoporosis
b) Reduces risk of coronary artery disease
c) Reduces age-related decline in cognitive function
d) Increases risk of stroke
e) Increases risk of breast cancer
302 Octreotide:
a) Is a synthetic peptide with a molecular weight of 10 000
b) Is effective in reducing symptoms of carcinoid syndrome
c) Is effective in treating diarrhoea states induced by irinotecan cancer
chemotherapy
d) Commonly causes hyperglycaemia
e) Is effective in the acute treatment of bleeding from oesophageal
varices
303 Clomifene:
a) Is an oestrogen receptor agonist
b) Is used in infertility treatment
c) Reduces follicle-stimulating hormone/luteinizing hormone
(FSH/LH) secretion
d) Causes multiple births
e) Can cause acute psychotic reactions
304 The following may help alleviate symptoms associated with prostatic
hyperplasia:
a) Clonidine
b) Tamsulosin
c) Doxazosin
d) Cyproterone acetate
e) Finasteride
305 Sildenafil:
a) Is administered by intracavernosal injection
b) Inhibits prostaglandin E1
c) Inhibits type V phosphodiesterase
d) Potentiates the action of organic nitrates
e) May cause headaches, flushing, nasal congestion and disturbances
of colour vision
Answers: see pages 129–132
EXTENDED MATCHING QUESTIONS 127
307 THYROID
A Salbutamol F 131
I
B Carbimazole G Thyroxine
C Lithium H Lugol’s iodine
D Imatinib I Thyrotropin-releasing hormone (TRH)
E Tri-iodothyronine J Amiodarone
309 ADRENAL
A Metyrapone F Aldosterone
B Fludrocortisone G Isoprenaline
C Dexamethasone H Phenoxybenzamine
D Adrenaline I Dipivefrine
E Aliskiren J Spironolactone
310 PITUITARY
A Octreotide F Demeclocycline
B Atosiban G Pegvisomant
C Goserelin H Tetracosactide
D Somatropin I L-Arginine
E Desmopressin J Prolactin
ANSWERS
MCQ ANSWERS
EMQ ANSWERS
306 DIABETES MELLITUS
307 THYROID
309 ADRENAL
310 PITUITARY
SELECTIVE TOXICITY
315 Benzylpenicillin:
a) Is inactivated in gastric acid
b) Is effective in meningococcal infections
c) Has a half-life of 24 hours
d) Is less susceptible than flucloxacillin to beta-lactamase-producing
strains of staphylococci
e) Approximately 1 in 500 injections cause anaphylactic shock
316 Amoxicillin:
a) Unlike benzylpenicillin is not susceptible to beta-lactamases
b) Is effective against many strains of Haemophilus influenzae
c) Is ineffective in most cases of community-acquired urinary tract
infections
d) Drug-related skin rashes may appear after dosing has stopped
e) Drug-related skin rashes are more common in patients with
infectious mononucleosis
318 Cefuroxime:
a) Has activity against streptococci
b) Has no activity against Gram-negative organisms
c) Plasma concentrations should be monitored to avoid
toxicity
d) Is principally renally eliminated
e) Has approximately 5–10 per cent cross-sensitivity for allergic
reactions with benzylpenicillin
MULTIPLE CHOICE QUESTIONS 137
322 Erythromycin:
a) Is poorly absorbed when given by mouth
b) Has a shorter half-life than azithromycin
c) The most common adverse effect is headache
d) Inhibits CYP450 enzymes
e) Cannot be prescribed with amoxicillin
325 Ciprofloxacin:
a) Is a drug of first choice in Streptococcus pneumoniae infections
b) Is effective in Pseudomonas infections
c) Should be avoided in children
d) Should be avoided in epileptics
e) Is ineffective if administered orally
326 Isoniazid:
a) Undergoes acetylation (by N-acetyltransferase) in the liver
b) Is used for only the initial two months of the recommended
six-month anti-TB regimen in the UK
c) Is readily absorbed from the gut
d) Does not diffuse into the CSF
e) Is contraindicated in children under the age of 10 years
327 Adverse effects associated with rifampicin include:
a) Hepatitis and cholestatic jaundice
b) Peripheral neuropathy
c) Convulsions
d) Influenza-like symptoms
e) Pink/red urine and tears
328 Rifampicin accelerates the CYP450-mediated metabolism of:
a) Corticosteroids
b) Warfarin
c) Streptomycin
d) Digoxin
e) Oestrogen
329 The following adverse effects are correctly paired with a causative
antituberculous drug:
a) Peripheral neuropathy – isoniazid
b) Ototoxicity – rifampicin
c) Hyperuricaemia – pyrazinamide
d) Retrobulbar neuritis – ethambutol
e) Hepatotoxicity – streptomycin
330 Dapsone:
a) Is used in the treatment of amoebiasis
b) Is indicated in multibacillary leprosy
c) Is used in the treatment of dermatitis herpetiformis
d) Is acetylated in the liver
e) Has cross-sensitivity with sulfonamides
MULTIPLE CHOICE QUESTIONS 139
331 Amphotericin:
a) Is effective in local Candida spp. infections
b) Is effective in systemic Candida spp. infections
c) Is nephrotoxic
d) Causes hypokalaemia
e) Is ineffective in cryptococcosis
332 The following antifungal agents have been paired correctly with an
appropriate indication:
a) Nystatin – oral Candida infections
b) Voriconazole – invasive aspergillosis
c) Flucytosine – tinea pedis
d) Clotrimazole – intertrigo
e) Miconazole – cold sores
333 Voriconazole:
a) Is available and effective as oral and intravenous therapy
b) Is active against Aspergillus
c) Inhibits cortisol biosynthesis
d) Inhibits CYP3A
e) Gastrointestinal absorption is reduced by omeprazole
334 Fluconazole:
a) Oral absorption is minimal unless taken on an empty stomach
b) Presystemic metabolism is extensive
c) Penetrates the central nervous system well
d) Is excreted 80 per cent by the kidney
e) Causes gynaecomastia
335 Terbinafine:
a) Is indicated in dermatophyte nail infections
b) A topical preparation is indicated in ringworm infection (e.g. tinea
pedis/cruris)
c) A single dose is usually effective
d) Is a potent CYP450 enzyme inducer
e) May exacerbate psoriasis
336 Aciclovir:
a) Inhibits viral DNA polymerase
b) Is indicated in herpetic keratitis
c) Should be avoided if possible in pregnancy
d) Is indicated in herpetic meningoencephalitis
e) Is ineffective in chicken pox
140 CHAPTER 8 SELECTIVE TOXICITY
337 Foscarnet:
a) Is indicated in cytomegalovirus (CMV) retinitis in acquired immune
deficiency syndrome (AIDS) patients
b) Aciclovir-resistant herpes simplex virus infections
c) Is nephrotoxic
d) Causes fits
e) Is usually administered by mouth or topically
338 Ribavarin:
a) Is indicated in CMV retinitis in AIDS patients
b) Inhibits viral RNA methyltransferase
c) Must be taken up into cells and phosphorylated to be effective
d) Can be administered via aerosol inhalation to treat bronchiolitis
e) Is combined with interferon alfa in the treatment of hepatitis C
339 The following are used in the prophylaxis or treatment of influenza:
a) Amantadine
b) Palivizumab
c) Entecavir
d) Oseltamivir
e) Zanamivir
340 Adverse effects associated with the interferons include:
a) Hypocalcaemia
b) Inhibition of spermatogenesis
c) Renal tubular acidosis
d) Lymphopenia
e) Influenza-like symptoms
341 One or more of the interferons are indicated in:
a) Herpes simplex encephalitis
b) Chronic hepatitis B infection
c) Chronic hepatitis C infection
d) Hairy cell leukaemia
e) CMV retinitis
342 Which of the following antiretroviral drug combinations is accepted
first-line therapy for patients with human immunodeficiency virus
(HIV) infection?
a) Zidovudine (AZT) plus 2,3-dideoxycytidine (ddC)
b) AZT lamivudine lopinavir/ritonavir
c) Ritonavir amprenavir enfuvirtide
d) AZT lamivudine nevirapine
e) AZT stavudine (d4T) enfuvirtide
MULTIPLE CHOICE QUESTIONS 141
Which antibacterial drug or drug combination from the list above is the most
appropriate choice for the infection scenarios listed below?
1 Lyme disease
2 Invasive salmonellosis
3 Antibiotic-associated colitis (pseudomembranous colitis)
4 Peritonitis in a patient allergic to cephalosporins
5 Uncomplicated community-acquired pneumonia in a penicillin-allergic
patient
From the above list, choose the most appropriate antibiotic regime for each of
the following clinical situations:
1 A 35-year-old man severely ill with community-acquired pneumonia
2 A 40-year-old man with acute septic arthritis in his knee caused by
Staphylococcus aureus
3 A 25-year-old woman with suspected bacterial meningitis
4 Suspected bacterial endocarditis following dental extraction in a
65-year-old man with mitral valve prolapse
5 A 38-year-old woman allergic to beta-lactam antibiotics with
pyelonephritis
EXTENDED MATCHING QUESTIONS 145
361 HIV
A Azatanavir F Enfuvirtide
B Rimantidine G Raltegravir
C Efavirenz H Adefovir
D Zidovudine (ZDV) I Ganciclovir
E Zanamivir J Foscarnet
Match the correct drug with its pharmacodynamic effect (either on the HIV
virus or the human host)
1 Competitive inhibition of the HIV reverse transcriptase
2 Inhibition of HIV entry into T cells
3 Non-competitive inhibition of HIV reverse transcriptase
4 Inhibition of HIV protease
5 Competitive inhibition of HIV integrase
362 HIV
A Lopinavir F Maraviroc
B Lamivudine G Abacavir
C Nevirapine H Tenofovir
D ZDV I Ganciclovir
E Didanosine J Foscarnet
Select a drug/drug combination from the list above most appropriate for the
indication below:
1 Acute falciparum malaria in a country with widespread chloroquine
resistance (e.g. Ghana) where parenteral therapy is required
2 Malaria prophylaxis for a European tourist in Ghana
3 Eradication of hepatic forms of P. vivax
4 Threadworm infection in a 3-year-old child
5 Giardiasis
146 CHAPTER 8 SELECTIVE TOXICITY
364 CANCER
A Imatinib F Capecitabine
B Oxaliplatin G Gemcitabine
C Irinotecan H Gefitinib
D Rituximab I Docetaxel
E Trastuzumab J Bevacizumab
365 CANCER
A Dasatinib F Vincristine
B Cisplatin G Doxorubicin
C Fludarabine H Sorafenib
D Interleukin 2 I Paclitaxel
E Interferon J Panimumomab
Match the drug with the correct common and serious adverse effect:
1 Hypothyroidism
2 Cerebellar ataxia
3 Acute renal tubular necrosis
4 Adult respiratory distress syndrome (non-cardiogenic pulmonary
oedema)
5 Hypertension
ANSWERS: see pages 154–158
MCQ ANSWERS 147
ANSWERS
MCQ ANSWERS
333 a) True
b) True – Voriconazole is a potent broad-spectrum triazole antifungal
active against Candida and Aspergillus
c) True – Inhibits enzymes involved in cortisol and testosterone
synthesis
d) True – Inhibits the metabolism of many drugs which are
metabolized by CYP3A
e) False – The absorption of fluconazole and voriconazole is not
significantly reduced by agents which increase gastric pH
(H2 blockers or proton pump inhibitors)
d) True solid tumours (e.g. breast cancer, small cell lung cancer).
e) True In cytotoxic doses it is usually given by intravenous
injection
352 a) True
b) True
c) False – Contraindicated in significant renal impairment, excreted
primarily in the urine
d) True
e) True
353 a) False – Peripheral neuropathy is common with vincristine
b) True – Etoposide, a topoisomerase II inhibitor, is particularly
active in small cell lung cancer
c) True
d) True – Irinotecan is a topoisomerase I inhibitor
e) False – Pulmonary fibrosis is associated with busulfan or
bleomycin therapy
354 a) True Cisplatin is of value in metastatic germ cell cancers
b) True (seminoma and teratoma). Carboplatin is widely used
c) False in advanced ovarian cancer and lung cancer (especially
d) True in small cell lung cancer). It is generally better tolerated
e) True than cisplatin; however it is more myelosuppressive.
Oxaliplatin is used in metastatic colorectal cancer in
combination with fluorouracil and folinic acid.
Neurotoxicity is dose limiting
355 a) True Paclitaxel was derived from the bark of the Pacific yew
b) False tree. It antagonizes the depolymerization of microtubules,
c) True halting mitosis. The affected cells undergo apoptosis.
d) True Hypersensitivity reactions, bone marrow suppression,
e) False myalgia, arthralgia, nausea and vomiting and alopecia are
also associated adverse effects
356 a) False – Use parenteral iron. Erythropoietin treatment will
precipitate iron deficiency and generally supplemental iron
should be prescribed concomitantly with erythropoietin
b) False
c) True
d) True
e) False
357 a) True – Often self-administered
b) True
c) False – Increases proliferation of the malignant clone
d) True
e) True – Also myalgia, fever, splenomegaly, thrombocytopenia and
abnormal hepatic transaminases
154 CHAPTER 8 SELECTIVE TOXICITY
EMQ ANSWERS
359 ANTIBACTERIAL DRUGS
361 HIV
362 HIV
The anaemia it causes is macrocytic (with normal B12 and folate) and
impaired erythroid precursor development manifested as
reticulocytopenia. Aplastic anaemia can be observed, as can suppression
of the myeloid lineages (neutropenia). This effect is dose-dependent
and minimized by treatment with erythropoietin.
3 G Ritonavir is one of the least potent HIV-protease inhibitors used to treat
HIV. One of its ancilliary properties is that it is a potent inhibitor of
CYP3A (gastrointestinal and hepatic) and the drug efflux protein in the
gastrointestinal tract P-glycoprotein (MDR-1/ABC-B1). By inhibiting
the function of both these proteins low-dose ritonavir is used in
combination with other agents in this drug class (e.g. lopinavir) to
enhance their bioavailability. This is termed ‘boosted’ lopinavir therapy.
4 H Tenofovir is the first nucleotide (as distinct from nucleoside – a
non-phosphorylated purine or pyrimidine) reverse transcriptase
inhibitor and is used in combination with NRTIs. It is a derivative of
adenosine monophosphate, but lacks the ribose ring. It undergoes
further sequential phosphorylation to the diphosphate and then the
triphosphate which is a competitive inhibitor of HIV-RT.
5 A Lopinavir – see explanation for answer 3 G above.
364 CANCER
365 CANCER
CLINICAL
IMMUNOPHARMACOLOGY
Match a drug from the list above which corresponds most closely to the state-
ment below:
1 An anti-IL-2 receptor antibody
2 Toxicity can be reduced by ‘folinic acid rescue’
3 A calcineurin inhibitor that is more potent than ciclosporin
4 An anti-α4β3 integrin monoclonal antibody used in patients with
progressive multiple sclerosis
5 Used in metastatic renal cell carcinoma
Match the single agent most correctly linked with each of the following phar-
macodynamic effects:
1 Gingival hyperplasia
2 Inhbition of mammalian target of rapamycin (mTOR)
3 Hypokalaemia
4 Thrombocytopenia
5 Binds to the α4β3 integrin
ANSWERS: see pages 165–166
MCQ ANSWERS 163
ANSWERS
MCQ ANSWERS
376 a) True
b) False – Fexofenadine, cetirizine and loratadine are ‘non-sedative’
antihistamines
c) False
d) True
e) False – Fexofenadine is the non-cardiotoxic metabolite of terfenadine
377 a) False Avoidance of allergens is ideal but rarely practical. With the
b) False exception of oral H1 blockers, local therapy is preferred. If
c) True indicated, desensitization therapy with a single allergen is
d) False acceptable, but the risk of anaphylaxis is high and it should
e) True only be undertaken in specialist allergy clinics
EMQ ANSWERS 165
EMQ ANSWERS
379 CLINICAL IMMUNOPHARMACOLOGY
391 The following treatments have been correctly paired with their licensed
indication in ophthalmology:
a) Aciclovir – cytomegalovirus (CMV) retinitis
b) Ranizumab – age-related macular degeneration
c) Ciprofloxacin – corneal ulceration
d) Fusidic acid – hypersensitivity reactions
e) Travoprost – open angle glaucoma
Answers: see pages 171–172
170 CHAPTER 10 THE SKIN AND THE EYE
Match the most appropriate drug from the list above with the indication
below:
1 Topical treatment for acne
2 Topical treatment for psoriasis
3 Systemic treatment for refractory psoriasis
4 Tinea pedis
5 Fungal nail infection
Match the indication/effect from the list below with the most appropriate
drug:
1 Causes miosis
2 CMV retinitis
3 Acute glaucoma
4 Short-duration mydriatic
5 Discolours soft contact lenses
ANSWERS: see page 173
MCQ ANSWERS 171
ANSWERS
MCQ ANSWERS
d) True
e) True
387 a) True – With unusual/recurrent skin infections consider diabetes
mellitus or immunosuppression. Antibiotic therapy,
diabetes mellitus and immunosuppression are risk factors
b) True
c) True
d) True
e) True
388 a) True – Intraocular administered doses avoid hepatic first-pass
metabolism and can lead to bradycardia
b) False
c) False – Not enough absorbed to cause systemic toxicity
d) False
e) True – With high doses enough can be absorbed to produce
systemic anticholinergic effects
389 a) True – Muscarinic (M3 in the eye) receptor antagonist blocks
action of sphincter muscle of the iris
b) False – Topical carbonic anhydrase inhibitor
c) True – Muscarinic (M3 in the eye) receptor antagonist blocks
action of sphincter muscle of the iris
d) True – Stimulates α1 adrenoreceptors constricting the radial
muscle of the iris
e) False – Non-steroidal anti-inflammatory drug (NSAID) used in eye
drops for prophylaxis and reduction of inflammation
following ocular surgery
390 a) True – Carbonic anhydrase inhibitor given systemically reduces
production of the aqueous humour
b) False – First-generation antihistamine which will dilate the pupil
(due to its anticholinergic properties), worsening glaucoma
c) False – Steroids can exacerbate glaucoma in certain genetically
predisposed patients
d) True – Prostaglandin F2α analogue lowers intraocular pressure by
increasing uveoscleral flow
e) True – Beta-adrenergic antagonist reduces secretion/formation of
aqueous humour
391 a) False – Aciclovir is indicated for herpes simplex infection
b) True – Blocks vascular endothelial growth factor (VEGF)
c) True
d) False – Useful for staphylococcal infections
e) True – Prostaglandin analogue which increases uveoscleral flow
EMQ ANSWERS 173
EMQ ANSWERS
392 DRUGS AND THE SKIN
CLINICAL TOXICOLOGY
394 Methadone:
a) Has the potential to cause dependence
b) Can only be prescribed to registered addicts by doctors with a
special licence
c) Is usually administered as an elixir
d) Depresses the cough centre
e) Effects are reversed by naloxone
395 The following are clinical signs consistent with heroin (diamorphine)
intoxication:
a) Hypertension
b) Rapid respiratory rate
c) Hypothermia
d) Pinpoint pupils
e) Slurred speech
396 Features of the opioid withdrawal syndrome include:
a) Yawning
b) Rhinorrhoea
c) Mydriasis
d) Diarrhoea
e) Tremor
397 Specific causes of death which are positively related to smoking
include:
a) Ischaemic heart disease
b) Cancer of the oesophagus
c) Emphysema
d) Aortic aneurysm
e) Cancer of the tongue
MULTIPLE CHOICE QUESTIONS 175
Choose the drug overdose from the list above which is most likely to present
with the symptoms/signs listed below:
1 Coma, hypotension, flaccidity
2 Coma, pinpoint pupils, hypoventilation
3 Coma, dilated pupils, hyperreflexia, tachycardia
4 Restlessness, hypertonia, hyperreflexia, pyrexia
5 Tinnitus, overbreathing, pyrexia, sweating, flushing, usually alert
Match the most appropriate antidote/other specific measure from the above
list to treat a clinically significant overdose with the agent listed below:
1 Aspirin
2 Paracetamol
3 Methanol
4 Iron
5 Cyanide
ANSWERS: see pages 182–183
MCQ ANSWERS 179
ANSWERS
MCQ ANSWERS
400 a) True
b) False – Associated with smoking
c) True
d) False – Associated with smoking
e) False – Associated with smoking
401 a) False – 10 per cent
b) True
c) False – Clormethiazole and benzodiazepines (long half-life) are
suitable sedatives
d) True – To avoid precipitation of acute thiamine deficiency when
intravenous dextrose/oral carbohydrates are administered
e) False
402 a) False Anabolic steroids are abused by athletes to build up muscle
b) False tissue
c) True
d) True
e) False
403 a) True MDMA is widely abused for its stimulant and hallucino-
b) True genic properties. It is metabolized by CYP2D6, which it
c) True inhibits for up to two weeks following a single dose. It is
d) True occasionally associated with hyperpyrexia, hyponatremia,
e) True rhabdomyolysis and coma
404 a) False A meticulous, rapid but thorough clinical examination is
b) True essential not only to exclude other causes of coma or
c) False behaviour, but also because the symptoms and signs may
d) True be characteristic of certain poisons (see Table 4)
e) False
405 a) True – See Table 5
b) True
c) False
d) False
e) True
406 a) True – See Table 6
b) True
c) True
d) False
e) True
407 a) False Paracetamol and salicylate overdoses only very rarely
b) False cause coma acutely. Acetylcysteine is a potentially
c) True life-saving antidote in paracetamol overdose
d) True
e) False
MCQ ANSWERS 181
Note: DMSA, DMPS and 4-methyl-pyrazole are not licensed in the UK.
EMQ ANSWERS
409 CLINICAL MANIFESTATIONS OF DRUG OVERDOSE
PRACTICE EXAMINATION
BEST OF FIVES
1 Individuals who are slow acetylators (i.e. have a relatively low activity
of hepatic N-acetyltransferase):
A Have a prevalence of 15–20 per cent in European caucasians
B Are more likely to develop thrombocytopenia, nephrotic syndrome
and rash during gold treatment
C Are more likely to develop hepatotoxicity following halothane
anaesthesia
D Are more likely to develop antinuclear antibodies during
hydralazine therapy
E Are more likely to develop agranulocytosis during clozapine therapy
2 Which of the following has the shortest elimination half-life?
A Naloxone
B Morphine
C Methadone
D Fentanyl
E Remifentanil
3 Estimation of plasma/serum drug concentrations are most useful in
optimizing the therapeutic dose required of:
A Warfarin
B Omeprazole
C Salbutamol
D Olanzapine
E Ciclosporin
BEST OF FIVES 185
Question 55
Serum vitamin B12 comes back as 160 ng/L (normal range 150–750) and
intrinsic factor antibodies are positive. She improves initially with appropri-
ate therapy but one month later develops symptoms of classical angina. Her
heart rate is 72 and regular and the examination otherwise unremarkable. An
ECG is normal. Management should include:
A Bone marrow examination
B Atenolol
C Measurement of serum thyrotropin
D Simvastatin
E Cardiological referral
Question 56
Walking home from the consultation with her GP she becomes acutely unwell
with chest pain and palpitations. She is taken by ambulance to the emergency
department. Her BP is 126/68. An ECG shows heart rate of 96 and is other-
wise normal except for some non-specific T wave changes. Immediate man-
agement should include:
A Ciclosporin
B Thrombolysis
C Aspirin (300 mg p.o.)
D Carbimazole
E Beta blockade
PROBLEM SOLVING QUESTIONS 199
Question 58
Following appropriate changes to his medication, his BP improves to around
150/95 and his serum creatinine falls to 280 μmol/L. Pain in his hip becomes
more troublesome. A magnetic resonance angiogram of the renal arteries
shows irregularities of both renal arteries. Irbesartan is commenced.
A This may protect residual renal function
B This may precipitate acute renal failure
C A statin is indicated
D Low-dose aspirin is contraindicated
E Codeine could usefully be prescribed
Question 59
His BP improves to around 130/80 as does the pain in his hip, but he becomes
constipated and his ankle swelling persists.
A Watchful waiting and dietary advice are appropriate
B Hip replacement is contraindicated
C Angioplasty of renal arteries is indicated
D Substitution of modified release verapamil for amlodipine is indicated to
improve ankle swelling
E Senna may be useful
200 CHAPTER 12 PRACTICE EXAMINATION
Question 61
Two days following delivery she becomes acutely short of breath. BP is
104/64, respiratory rate 24; pulse 128 irregular, there is a gallop rhythm, oxy-
gen saturation is 88 per cent, an ECG confirms atrial fibrillation.
A Computerized tomography (CT) pulmonary angiogram is appropriate
B Post-partum cardiomyopathy is the probable underlying diagnosis
C Digoxin is appropriate
D Serum thyrotropin should be measured
E DC cardioversion is indicated
Question 62
Following discharge:
A Warfarin is indicated
B Oral contraception is contraindicated in the long term
C Electrophysiological mapping of pre-excitation pathways should be
undertaken
D Anticoagulation should be life-long
E Residual effort dyspnoea could be due to pulmonary hypertension
PROBLEM 5 CHILD WITH HEADACHE, VOMITING, FEVER AND
NECK STIFFNESS
Question 63
A 4-year-old child presents to A&E complaining of a 6-hour history of grad-
ually increasing and severe headache and vomiting. On examination, she has
a temperature of 38.5°C, and marked neck stiffness, but no rash is present.
Fundoscopy proves impossible due to severe photophobia. Initial manage-
ment should include:
A Immediate lumbar puncture
B Oral co-amoxiclav
C CT head scan
D Intravenous ceftriaxone
E Antibiotics should not be started until a lumbar puncture has been
performed and cerebrospinal fluid sent for bacteriological analysis
PROBLEM SOLVING QUESTIONS 201
Question 64
A CT head scan reveals no evidence of raised pressure, and is otherwise unre-
markable. A subsequent lumbar puncture reveals a purulent meningitis, with
high neutrophil count, raised protein and depressed glucose levels.
Microscopy reveals the presence of Haemophilus influenzae, and this is con-
firmed on subsequent culture to be H. influenzae type b. Further management
should include:
A Ceftriaxone for 5 days
B Ceftriaxone for 10 days
C Amoxicillin for 10 days
D Metronidazole
E Rifampicin
Question 65
She makes a good recovery. However, soon after the antibiotic is stopped, she
develops watery diarrhoea associated with abdominal pain. Two days later,
she has fever and bloody diarrhoea (frequency 20 times per day). Appropriate
management should now include:
A Restarting the original antibiotic
B Intravenous vancomycin
C Oral metronidazole
D Intravenous fluid replacement
E Corticosteroid therapy
Answers: see pages 208–210
202 CHAPTER 12 PRACTICE EXAMINATION
ANSWERS
PROBLEM 1
Question 51, Answers: T F T T F
Question 52, Answers: T F T T F
Question 53, Answers: T T F T T
Comment
Initial treatment with metformin is problematic in view of congestive heart
failure (CHF). Her acute deterioration could have been precipitated by a gas-
trointestinal bleed (aspirin) or acute ischaemia and appears to be complicated
by acidosis – probably lactic acidosis (predisposed by metformin) in view of
only 1 urine ketones and only moderately elevated blood glucose. This is not
the presentation of rhabdomyolysis and CK is only moderately elevated.
Hyperbaric O2 is not evidence based and not available in ITU.
PROBLEM 2
Question 54, Answers: F F F F T
Question 55, Answers: F T T T T
Question 56, Answers: F F T F T
Comment
Carpal tunnel syndrome is a common presentation of hypothyroidism (con-
firmed by measuring serum thyrotropin). This can cause a raised serum chol-
esterol, macrocytosis and mildly raised CK. There is a family history of
autoimmune disease and she may well be developing vitamin B12 deficiency
in addition to hypothyroidism. Appropriate medical treatment is oral thyroxine.
This may obviate the need for surgery and may correct her dyslipidaemia.
Thyroxine has a long half-life so occurrence of angina after four weeks treat-
ment when accumulation will have occurred and serum levels have
increased, suggests that she may have underlying ischaemic heart disease
which has been masked by bradycardia and hypothyroidism. The dose of thy-
roxine should be reduced and a beta blocker added. The acute event is
strongly suggestive of an acute coronary syndrome. Aspirin 300 mg rapidly
blocks platelet cyclo-oxygenase (COX) and is the appropriate starting dose in
this acute setting. Carbimazole blocks thyroid hormone synthesis so would
not antagonize exogenous thyroxine.
PROBLEM 3
Question 57, Answers: F F T T F
Question 58, Answers: T T T F T
Question 59, Answers: T F F F T
PSQ ANSWERS 209
Comment
Possible explanations of loss of BP control and occurrence of renal impairment
include onset of renal disease (e.g. renal artery stenosis or obstructive uropa-
thy) and/or inhibition of renal COX by naproxen. Paracetamol, codeine and
low-dose aspirin do not share these effects on BP and renal function. Atenolol
suppresses renin, making measurement of this uninformative. An ACE
inhibitor or ARB can protect against progressive renal dysfunction, but can
precipitate acute renal failure if there is haemodynamically significant bilat-
eral renal artery stenosis (possible in view of the irregularities seen).
Angioplasty is not indicated unless renal function deteriorates and is not
particularly effective in atheromatous disease. Verapamil is less likely to cause
oedema than amlodipine but will make constipation worse and may precipi-
tate heart failure with concomitant atenolol.
PROBLEM 4
Question 60, Answers: F T F F F
Question 61, Answers: T F T T F
Question 62, Answers: T T F F T
Comment
LMWH does not cross the placenta. Warfarin is contraindicated in the last
trimester because of the risk of intracranial haemorrhage in the infant and of
maternal bleeding. After delivery warfarin can be used and appears safe in
breastfeeding. Antiplatelet therapy is inadequate prophylaxis in deep vein
thrombosis (DVT). The acute episode following delivery is presumably due to
pulmonary embolism which may have precipitated atrial fibrillation but other
causes of atrial fibrillation remain possible. Serum thyroxine is difficult to
interpret peripartum but serum thyrotropin can be interpreted (a depressed
level would signal probable hyperthyroidism). Anticoagulation would not
need to be indefinite since DVT occurred in the setting of pregnancy. If there
has been a large pulmonary embolus, this may cause pulmonary hypertension.
PROBLEM 5
Question 63, Answers: F F T T F
Comment
If bacterial meningitis is suspected, as in this case, i.v. antibiotic should be
started without waiting for microscopy/culture results from the cere-
brospinal fluid, due to the often rapid progression of the disease with poten-
tially devastating consequences. Intravenous ceftriaxone is a good initial
broad-spectrum treatment, pending bacteriology results. Since fundoscopy
was not possible, a lumbar puncture should not be performed until a CT scan
has confirmed the absence of raised intracranial pressure, due to the possibil-
ity of coning being induced in this situation.
210 CHAPTER 12 PRACTICE EXAMINATION
Comment
H. influenzae meningitis should be treated with a third-generation cephalosporin
intravenously for at least 10 days. Chloramphenicol can be substituted where
there is a history of anaphylaxis to penicillin or to cephalosporins, or if the
organism is resistant to cephalosporins. For H. influenzae type b, rifampicin
should be given for 4 days before hospital discharge, to prevent carriage.
Metronidazole is active against anaerobic organisms.
Comment
This patient has developed pseudomembranous colitis, due to Clostridium dif-
ficile overgrowth in the gut, whose toxin gives rise to this condition. It can
occur following treatment with any antibiotic, but appears to be a particular
hazard with clindamycin and cephalosporins. Oral metronidazole or oral
vancomycin are used as specific treatment.