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.

Micron

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.

i
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 is bacteriostatic for resting bacilli C. It is bactericidal for dividing organisms. D. Its mechanism o f action is that it inhibits the enzyme DNA gyrase. E. None

204. Which o f the following antitubercular agents have the lowest incidence o f resistance? A. B. C. D. E. Isoniazid Rifamipicin Pyrazinamide Ethambutol A and B

209. Isoniazid is active against which of the following organisms: A. tuberculosis B. bovis C. kansasii D. A& B only

205. Most patients with tuberculosis are started on: A. Isoniazid, rifamipicin, Pyrazinamide

E. A, B&C

D. Inhibition o f mycobacterial protein synthesis. E. None

210. Pyridoxine 15-50 mg/day should be administered to patients taking Isoniazid in order to: A. Decrease the gastrointestinal absorption o f Isoniazid B. Minimize the peripheral neuropathy associated with Isoniazid use C. Increase the gastrointestinal absorption o f Isoniazid D. Decrease the hepatic metabolism o f Isoniazid. E. None

214. Which o f the following organisms are susceptible to Rifampicin? A. B. C. D. E. S.aureus H.influenzae Legionella pneumophilia Most mycobacterial strains All o f the above

215. Rifampin, colors urine, sweat, tears. saliva, and feces: A. B. C. D. E. Orange-red Yellow Red Pink None

211. Use o f Isoniazid concurrently with Carbamazepine increases the risk of: A. B. C. D. E. Blood dyscriasis Hepatitis Convulsions Peripheral neuropathy None

216. Which of the following statements is FALSE about Rifampin? A. It may be used in combination with dapsone in the treatment o f leprosy. B. Probenecid decreases the blood level o f Rifampin. C. It may induce influenzae like syndrome. D. It should not be administered alone because this may lead to the emergence o f highly drug-resistant organisms. E. None

212. Which o f the following antitubercular agents may cause additive nervous system effects when given with Isoniazid? A. B. C. D. E. Cycloserine Ethionamide Pyrazinamide Rifampin A and B

213. The antitubercular effect o f Rifampin is due to: A. Inhibition o f mycobacterial cell wall synthesis. B. Impairment o f bacteria] RNA synthesis by binding to DNAdependent RNA polymerase. C. Disruption o f mycobacterial cell wall synthesis by inhibiting mycolic acid synthesis.

217. of: A. B. C. D. E.

Pyrazinamide is a pyrazine analogui

Nicotinamide Isonicotinic acid Ascorbic acid Lactic acid None

218. Pyrazinamide is a highly specific agent and has activity only against: A. B. C. D. E. avium bovis Kansasii tuberculosis None

C. Both are ototoxic D. Both are nephrotoxic E. Both are ototoxic and nephrotoxic

223. A retreatment anti-tubercular agent implicated in peripheral neuropathy is: A. B. C. D. E. Capreomycin Ethionamide Cycloserine Kanamycin None

219. Which of the following statements is NOT TRUE about retreatment antitubercular agents? A. They are more effective than primary agents. B. They are more toxic than primary agents. C. They are always used in combination with primary agents. D. They are less effective than primary agents. E. None

224. Which o f the following gives the correct composition o f the antitubercular product rifater? A. Rifampin 120mg, Isoniazid 500 mg, Pyrazinamide 50mg. B. Ethambutol 300mg, Rifampin 200mg. amikacin 600mg C. Rifampin 120 mg, Isoniazid 50 mg, Pyrazinamide 300mg D. Cycloserine 250mg, Isoniazid 1OOmg, Rifampin. E. None -

220. All o f the following antitubercular drugs are retreatment agents EXCEPT: A. B. C. D. E. Kanamycin Capreomycin Ethionamide Cycloserine Ethambutol

225. The quinolone antibacterials used in tuberculosis therapy are: A. B. C. D. E. Enoxacin Cinoxacin Ciprofloxacin Levofloxacin C and D

221. The mechanism o f action o f amino salicylic acid is similar with that of: A. B. C. D. E. Penicllins Aminoglycosides Cephalosporins Trimethoprim None

226. Which o f the following statements is FALSE about rifabutin? A. It has been reported to inhibit reverse transcriptase and block the in vitro infectivity and replication o f HIV. B. Its use has resulted in mild elevation o f liver enzymes and thrombocytopenia.

222. Concomitant use o f Capreomycin and streptomycin is contraindicated because: A. Capreomycin is ototoxic B. Streptomycin is nephrotoxic

c.

It is more effective than Rifampin in the treatment o f tuberculosis. ; D. It may increase the hepatic metabolism o f drugs, but to a lesser extent than Rifampin. E. None

B. C. D. E. 231. A. B. C. D. E.

Viral thymidine kinase Viral topoisomerase 11 Viral deoxykinase None Acyclovir is active against: Herpes simplex-1 ( HSV-1) Herpes simplex-1 (HSV-2) Varicella-zoster virus Cytomegalovirus A,B&C

227. Which o f the following statements is NOT TRUE: A. Viruses lack independent metabolic activity Viruses can replicate only within B. living host cells. C. Antiviral agents tend to injure host cells. D. Antiviral agents tend to injure viral cells E. Antiviral agents act by inhibiting viral cell wall synthesis.

232. Amantadine inhibits replication o f influenzae A virus by: A. Inhibiting the enzyme DNA polymerase. B. Interfering with viral attachment and uncoating. C. Inhibiting the enzyme thymidine kinase. D. Inhibiting the enzyme deoxyadenosine kinase. E. None

228. All o f the following anti-DNA viral agents are prodrugs that require viral and host cellular enzymes to phosphorylate them to the active triphosphate form before exerting their antiviral activitv EXCEPT: A. B. C. D. E. Acyclovir Ganciclovir Valacyclovir Foscamet None

Which o f the following anti-viral 233. drugs is used in the treatment o f Parkinsonism? A. B. C. D. E. Acyclovir Famciclovir Ganciclovir Amantadine None

229. Which o f the following is an RNA virus: A. B. C. D. E. Herpes simplex virus HIV-1 Varicella- Zoster virus Cytomegalovirus None

234. A. B. C. D. E.

Cidofovir is a synthetic: Acyclic Purine nucleoside Pyrimidine nucleoside Amino acid Amine None

230. Antiviral agents which act against DNA viruses inhibit viral DNA synthesis by inhibiting the enzyme: A. Viral DNA polymerase

235. All o f the following may occur as side effects o f amantadine EXCEPT:

A. B. C. D. E.

Dry mouth Blurred vision Bradycardia CNS depression Insomnia

240. Foscamet is highly nephrotoxic if it is given by: A. B. C. D. E. IV route IM route Inhalational route Oral route None

236. Famciclovir is prodrug o f the antiviral drug: A. B. C. D. E. Acyclovir Ganciclovir Penciclovir Zanamivir None

241. All o f the following are electrolyte abnormalities associated with Foscamet EXCEPT: A. B. C. D. E. Hypomagnesemia Hypophosphatemia Hypokalemia Hypercalcemia Hypocalcemia

237. Famciclovir is rapidly phosphorylated in virus infected cells to Penciclovir monophosphate by: A. B. C. D. E. Viral deoxyguanosine kinase Viral thymidine kinase Viral DNA polymerase Viral topoisomerase II None

242. Foscarnet is not recommended for patients with creatinine clearance o f less than: A. B. C. D. E. 243. by: A. B. C. D. E. 80 mL/min 75 mL/min 150 mL/min 50 mL/min None Foscamet is exclusively excreted

238. Which of following statements best describes the chemical nature o f Foscamet? A. B. C. D. E. It is a pyrophosphate analogue. It is disubstituted benzene. It is a phenyl alkyl amine. It is a modified amino acid None

239. Which one o f the following statements is FALSE about Foscamet? A. It is the drug o f choice in cases of acyclovir or ganciclovir resistance. B. It is not active against H IV -1 C. It is a noncompetitive reversible inhibitor o f HIV reverse transcriptase. D. It competitively binds to DNA polymerase to form an inactive complex. E. None '

Glomerular filtration Tubular secretion Feces All o f the above A and B

244. Which o f the following drugs should not be given concurrently with Foscamet? A. B. C. D. Streptomycin Amikacin Ceftibuten Cefuroxime

E. A and B 249. The hydrolysed product o f Oseltamivir invivo is: 245. Which o f the following statements is NOT TRUE about ganciclovir? A. It is converted to triphosphate form and then gets incorporated into viral DNA which results in inhibition of DNA polymerase. B. It is available in oral and IV formulations. C. It is incapable o f penetrating the CNS. D. Its oral formulation is only approved for prevention and maintenance treatment o f Cytomegalovirus infections. E. None A. B. C. D. E. Oseltamivir Phosphate Oseltamivir Carboxylate Oseltamivir Sulfate Oseltamivir Carbonate None

250. An enzyme of the influen inhibited by Oseltamivir is: A. B. C. D. E. Neuraminidase DNA polymerase Reverse transcriptase Thymidine kinase None

246. Ganciclovir is associated with all o f the following adverse effects EXCEPT: A. B. C. D. E. Neutropenia Thrombocytopenia Anemia Ototoxicity Teratogenic

251. Which o f the following agents is the best for the prophylaxis o f influenzae infections? A. B. C. D. E. Amantadine Influenzae virus vaccine Rimantadine Oseltamivir None

247. Which o f the following antibiotics may induce generalized seizures when given concurrently with ganciclovir? A. B. C. D. E. Imipenem -cilastatin Ertapenem Meropenem Cefuroxime None

252. Valacyclovir is prodrug o f the antiviral agent: A. B. C. D. E. Valganciclovir Cidofovir Acyclovir Zanamivir None

248. Oseltamivir is related pharmacologically to: A. B. C. D. E. Cidofovir Famciclovir Ganciclovir Zanamivir None

253. The mechanism o f action o f ribavarin is: A. It inhibits RNA and DNA synthesis by depleting intracellular nucleotide reserves. B. It inhibits the enzyme DNA polymerase.

c. It inhibits the early viral replication

cycle, possibly by inhibiting the uncoating o f the virus. D. It inhibits the enzyme reverse transcriptase. E. None

D. It does not have carcinogenic potential. None E.

258.

Which o f the following anti-viral drugs are active against both influenzae A and influenzae B virus infections? A. B. C. D. E. Zanamivir Oseltamivir Amantadine Rimantadine A and B

254.

The antiviral drug ribavarin is administered by which route. A. B. C. D. E. Intramuscular route Intravenous route Inhalational route Oral route None

259. 255.
Ribavarin is not recommended in patients using ventilators because: A. It corrodes the internal wall of ventilators. B. It may precipitate on respirator valves and tubing causing lethal malfunction. C. It may result in hypersensitivity reactions. D. It may result in bacterial pneumonia. E. None

Which o f the following are classes of antiretroviral drugs A. Nucleoside reverse transcriptase inhibitors B. Nucleotide reverse transcriptase inhibitors C. Nonnucleoside reverse transcriptase inhibitors D. Fusion inhibitors E. All o f the above

260. AH o f the following drugs are Nucleoside reverse transcriptase inhibitors EXCEPT: A. B. C. D. E. Abacavir Zidovudine Stavudine Tenofovir Didanosine

256. Valganciclovir is a prodrug o f the antiviral agent; A. B. C. D. E. Acyclovir Ganciclovir Famciclovir Valacyclovir None

261. The fusion inhibitor used in the treatment o f HIV-1 and HIV-2 infections is: 257. The advantage o f Valganciclovir over ganciclovir is: A. That it has broader spectrum o f activity. B. It has markedly increased bioavailability when given with A. Enfuvirtide B. Zalcitabine C. Lamivudine D. Indinavir E. None

Infectious Diseases

A. B. C. D.

Dry mouth Blurred vision Bradycardia CNS depression

240.

Foscamet is highly nephrotoxic if it

262. Which of the following is/are Nonnucleoside reverse transcriptase inhibitors A. B. C. D. E. Delaviridine Efavirenz Nevirapine A, B&C Stavudine

266. The anti-retroviral drug Didanosine results in hyperuricemia because: A. It stimulates the degradation o f body proteins. B. It stimulates the enzyme xanthine oxidase. C. It is metabolized to uric acid. D. It inhibits the elimination of uric acid. E. None

263. Which one o f the following statements is FALSE about reverse transcriptase inhibitors? A. They are competitive inhibitors of the enzyme reverse transcriptase. B. They are inactive until phosphorylated by human cellular kinases into the active triphosphate metabolite. C. All agents in the nucleoside class have a black box warning concerning the potential for the development o f lactic acidosis and severe hepatomegaly. D. They canbe used alone in the treatment o f HIV infection. E. None

267. Didanosine is available in a specially buffered formulation in order to: A. Prevent degradation at acidic pH. B. Increase gastrointestinal absorption. C. To control rate o f drug release. D. To decrease the urinary elimination o f Didanosine. E. None

268. Which o f the following anti retroviral drugs is used in the treatment o f chronic hepatitis B? A. B. C. D. E. Abacavir Didanosine Stavudine Lamivudine None

264. A reverse transcriptase inhibitor with good penetration into the cerebrospinal fluid is: A. B. C. D. E. Zidovudine Didanosine Stavudine Lamivudine Abacavir

269. The major toxicity associated with Stavudine is: A. B. C. D. E. Headache Sleep disorders Abdominal pain Peripheral neuropathy None

265. Abacavir has a black box warning about A. A hypertensive crisis B. A life threatening hypersensitivity reaction C. Lactic acidosis D. Liver damage E. None

270. Which o f the following anti retroviral drugs have not been reported to interact with any drug?

A. B. C. D. E.

Lamivudine Stavudine Abacavir Didanosine B and C

C. Co-trimoxazole D. Fansidar E. None

275. of 271. The nucleoside reverse transcriptase inhibitor Tenofovir is available in prodrug form as: A. B. C. D. E. Tenofovir disoproxil fumarate Tenofovir sulfate Tenofovir gluconate Tenofovir estolate None A. B. C. D. E.

Zidovudine is a synthetic analogue

Guanosine Thymidine Adenosine Cytosine None

276. Zalcitabine should not be used in combination with which o f the following drugs A. B. C. D. E. Didanosine Lamivudine Stavudine Zidovudine A,B&C

272. Tenofovir may increase the serum concentrations o f one o f the following if they are given together: A. B. C. D. E. Lamivudine Abacavir Didanosine Stavudine None

277. Combivir is a combination product containing Zidovudine and: A. B. C. D. E. Lamivudine Stavudine Zalcitabine Didanosine None

273. Zalcitabine is indicated for combination therapy with one o f the following for the treatment o f adult patients with advanced HIV infection. A. B. C. D. E. Zidovudine Stavudine Lamivudine Abacavir None

278. Which one o f the following statements is NOT TRUE about Combivir? A. It has improved compliance in patients by decreasing the number o f tablets typically ingested daily when administered as individual agents. B. It has fewer incidences o f adverse effects and drug interactions than the individual agents. C. It is administered as Lamivudine 150mg/zidovuidne 300 mg per tablet twice daily.

274. An HIV patient was taking a medication for P.carinii infection. The same patient was taking the nucleoside reverse transcriptase inhibitor Zalcitabine. The patient suffered from severe pancreatitis, this suggests that the drug used in the treatment o f the P.carinii infection is: A. Pentamidine B. Atovaquone

D. It is the first FDA combination product treatment o f HIV. E. None

approved for the

283. The advantage o f Efavirenz over other Nonnucleoside reverse transcriptase inhibitors is: Its broader spectrum o f activity. Its better tolerability. Its once daily dosing. Its effect on the hepatic metabolism o f drugs. E. None A. B. C. D.

279. The first triple nucleoside combination product approved by the FDA contains Zidovudine. Lamivudine and: A. B. C. D. E. Didanosine Abacavir Stavudine Lamivudine None

284. Which o f the following hepatic enzymes is induced by Efavirenz? A. B. C. D. E. CYP3A4/5 CYP2E1 CYP3A4 CYPC19 None

280. All o f the following result in increased blood levels o f Zidovudine, leading to toxicity EXCEPT:

A. B. C. D. E.

Valproic acid Methadone Probenecid Acetaminophen Co-trimoxazole

285. All o f the following anti-retroviral drugs are protease inhibitors EXCEPT: A. B. C. D. E. Lopinavir Nelfinavir Ritonavir Nevirapine Amprenavir

281. Delavirdine inhibits its own metabolism by reducing the activity of: A. B. C. D. E. CYP3A4 CYP2A6 CYP2C8 CYP2C9 A and D

286. All o f the following protease inhibitors are indicated for use in the pediatric population EXCEPT: A. B. C. D. E. Lopinavir Nelfinavir Amprenavir Ritonavir None

282. Inhibition o f the metabolism of which the following drugs by Delavirdine may result in cardiac arrhythmias? A. B. C. D. E. Terfenadine Astemizole Alprazolam Midazolam A and B

287. The protease inhibitor with the longest half-life is: A. B. C. D. E. Nelfinavir Ritonavir Amprenavir Indinavir None

288. Fortovase is a soft gel cap formulation o f a protease inhibitor that has improved bioavailability and efficacy. The protease inhibitor is: A. B. C. D. E. Lopinavir Saquinavir Indinavir Ritonavir Amprenavir

D. Carbamazepine E. A and B

293. The first FDA approved combination o f protease inhibitors is: A. B. C. D. E. Lopinavir/Amprenavir Lopinavir/Ritonavir Ritonavir/Nelfinavir Saquinavir/Indinavir None

289. Nelfinavir has few adverse effects. The most commonly reported adverse effect is: A. B. C. D. E. Constipation Diarrhea Hyperglycemia Hypersensitivity reactions None

294. In the Lopinavir/Ritonavir combination product the ratio o f Ritonavir to Lopinavir is: A. B. C. D. E. 1:4 4:1 1:5 2:3 None

290. The vitamin included in Amprenavir capsules is: A. B. C. D. E. Vitamin Vitamin Vitamin Vitamin None A B C E 295. The protease inhibitor with the shortest half-life is: A. B. C. D. E. Lopinavir Saquinavir Amprenavir Nelfinavir None

291. Amprenavir is contraindicated in certain patient populations due to the potential toxicity from high amounts o f the excepient: A. B. C. D. E. Starch Acacia Propylene glycol Sucrose None

296. Which o f the following anti retroviral drugs does not have any effect on the metabolism o f drugs by CYP450? A. B. C. D. E. Delaviridine Nevirapine Amprenavir Enfuvirtide None

292. Which o f the following drugs increase the blood levels o f saquinavir? A. Ketoconazole B. Clarithromycin C. Phenytoin

297. The mechanism o f anthelmintic action o f mebendazole includes: A. Inhibition o f the formation o f microtubules.

B. C. D. E.

Blockage o f glucose uptake. Inhibition o f protein synthesis. All o f the above A and B only

headache and general malaise if they are treated with diethylcarbamazine. A. B. C. D. E. Mansonella pertans Dipetalonema streptocera Wuchereria bancrofti L oaloa None

298.

Which one o f the following represents a wrong pair o f a scientific name o f a parasite and its common name? A. B. C. D. E. Ancylostoma duodenale-hookworm Ascaris lumbricoides-roundworm Necator americanus-hookworm Trichinella spiralis-threadworm Trichuris thrichiura-whipworm

303. Pyrantel is used in the treatment of all o f the following infections EXCEPT: A. B. C. D. E. Round worm infection Pinworm infection Hook worm infection Tape worm infection Hair worm infection

299. Which o f the following anti epileptic may reduce the blood levels and subsequent efficacy o f mebendazole? A. B. C. D. E. Carbamazepine Phenytoin Zonisamide Lamotrigine A and B

304. An anthelmintic drug which antagonizes the action of Pyrantel is: A. B. C. D. E. Albendazole Mebendazole Piperazine Diethylcarbamazine None

300. Which o f the following anthelmintics are structurally related to each other? A. B. C. D. E. Mebendazole Diethylcarbamazine Albendazole Pyrantel A and C

305. An anthelmintic drug with anti inflammatory, antipyretic, and analgesic effects is: A. Albendazole B. Thiabendazole C. Mebendazole D. Niclosamide E. None

301. A. B. C. D. E.

Albendazole is active against: Taenia saginata Taenia solium Echinococcus granulosis Ascaris lumbricoides B and C 306. Which o f the following fungi are susceptible to the anthelmintic drug thiabendazole? A. B. C. D. E. Trichophyton Candida albicans Aspergillus Microsporum A and D

302. Patients treated for one o f the following infections often present with

307. The most common adverse effects o f thiabendazole are: A. B. C. D. E. Nausea and vomiting Anorexia Seizures Vertigo A and B

A. Dihydrofolate reductase B. Glucose-6-phosphate dehydrogenase C. Fumarate reductase D. Glycogen synthetase E. None

311. Which o f the following anthelmintics is also active against giardia? 308. Which of the following statements describes the mechanism o f action Piperazine? A. It causes flaccid paralysis o f the helminth by blocking the response o f the ascaris muscle to acetylcholine. B. It inhibits the formation o f microtubules. C. It inhibits glucose transport of the helminth. D. Its mechanism o f action is unknown. E. None A. B. C. D. E. Thiamebendazole Mebendazole Pyrantel Quinacrine None

312. Niclosamide is not active against cycticercosis because: A. It is not active against T.solium B. It affects only cestodes o f the intestine. C. It has short half life. D. It is not active against cestodes E. None 313. Which of the following anthelmintics should be taken in empty stomach? A. B. C. D. E. Piperazine Albendazole Oxamniquine Pyrantel None

309. A. B. C. D. E.

Piperazine is active against: Ascaris lumbricoides Enterobius Vermicularis Hymenolepis Nana Necator americanus A and B

310. Thiamebendazole was shown to inhibit the helminth-specific enzyme,

A n sw ers Infectious Diseases

1. Answer: E. I,II and III are correct Explanation: Anti-infective agents treat infection by suppressing or destroying the causative microorganisms.Anti-infective agents derived from natural substances are called antibiotics.Antiinfective agents produced from synthetic substances are called anti-microbials.

2. Answer: D. Fungi cannot be identified by gram stain Explanation: ' Gram staining is a technique, which helps determine 1. Gross morphology o f the bacteria and 2. Differentiation into two groups -(a) gram-positive and (b) gram negative Gram staining is performed on all specimens except blood cultures. It helps identify if the causative agent is gram-positive or gram-negative, and allows for a better choice o f drug therapy. Gram-positive microorganisms stain blue or purple and gram-negative microorganisms stain red or rose pink. Fungi can also be identified by gram stain

3. Answer: E. Lice

Explanation The microorganism is any organism o f microscopic size. Bacteria, mycobacterium, fungi, protozoa and viruses. Lice can be seen with naked eye.

4. Answer: D. All o f the above Explanation: Gram stain, microbiological culturing, and susceptibly tests should be performed before antiinfective therapy is initiated. Microbiological cultures are useful to identify the specific causative agent; specimens o f body fluids or infected tissue are collected for analysis. Most bacteria can be cultured artificially on culture media containing. Different strains o f the same pathogenic species may have widely varying susceptibility to a particular agent. Susceptibility tests determine microbial susceptibility to a given drug and, can be used to predict whether the drug will combat the infection effectively.

5. Answer: A. It is the lowest drug concentration that prevents microbial growth after 18-24 hours o f incubation. Explanation:

The minimum inhibitory concentration s the lowest concentration of a drug that prevents microbial growth after 18-24 hours o f incu bation. The lowest concentration o f a drug that red'uces bacterial density by 99.9% is called the minimum bactericidal concentration.

6. Answer: D. All o f the above Explanation: Break point concentrations o f antibiotits are used to characterize antibiotic activity. The interpretive categories are susceptible, moderately susceptible (intermediate), and resistant. These concentrations are determined by considering pharmacokinetics, serum and tissue concentrations following normal doses and the population distribution o f M1CS o f a group of bacteria for a given drug.

7. Answer: E. A and C Explanation: Disk diffusion technique is less expensive but less reliable than the microdilution method but it provides qualitative susceptibility information.

8. Answer: E. C and D Explanation: In order to treat infectious disease effectively, an anti-infective agent must be active against the causative pathogen. Susceptibility testing or clinical experience in treating a given syndrome may suggest the effectiveness o f a particular drug.

9. Answer: D. All o f the above Explanation: An anti-infective agent should be chosen on the basis o f its pharmacological properties.Pharmacological properties include the ability o f the drug to reach the infection site and to attain a desired level in the target tissue.

10. Answer: B. A drug that rapidly destroys the bacteria

i

Explanation: Bactericidal agent is a drug that inhibits tjie growth or reproduction o f a bacterium. A drug that only inhibits the growth and reproduction o f a bacterium is known as a bacteriostatic agent

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

Impaired immune mechanisms may require a drug that rapidly destroys pathogens (i.e. bactericidal agent) rather than one that merely suppresses a pathogens growth or reproduction (i.e.. bacteriostatic agent). Preexisting kidney or liver disease increases the risk o f nephrotoxicity or hepatoxicity during the administration o f some antibacterial agents. Drug therapy during Pregnancy and lactation can cause unwanted effects.

12.Answer: E. 1,H&1I1 Explanation: Drug therapy during pregnancy and lactation can cause unwanted effects. Therefore, the mothers need for the antibiotic must be weighed against the drugs potential harm. Pregnancy can increase the risk o f adverse effects for both mother and fetus. Most drugs, including antibiotics, appear in the breast milk o f nursing mothers and may cause adverse effects in infants. Also, plasma drug concentrations tend to decrease in pregnant women, reducing a drugs effectiveness.

13.Answer: B. Sulfonamides Explanation: Sulfonamides lead to toxic bilirubin accumulation in a newborns brain. Bilirubin is a by-product o f erythrocyte degradation. Sulfonamides may cause hemolytic anemia in susceptible individuals. The excessive degradation o f erythrocytes results in the formation o f excess bilirubin in the pregnant mother and this affects the infant. (The permeability o f the blood brain barrier to bilirubin is very high and accumulates in the brain) -

14.Answer: B. Glucose-6-phosphate dehydroganse Explanation: Sulfonamides may cause hemolytic anemia in patients with hereditary deficiency o f the enzyme glucose-6-phosphate dehydrogenase. Glucose-6-phosphate is an enzyme linked to metabolic pathways, which produce substances necessary in maintaining the integrity b f the membrane o f red blood cells. Sulfonamides interfere with these processes and it gets worse. In patients taking sulfonamides having hereditary deficiency o f this enzyme are exposed to hemolytic anemia (an anemia that results from lysis o f red blood cells).

15.Answer: A. Isoniazid Explanation: Patients who rapidly metabolize dru^s (rapid acetylators) may develop hepatitis receiving the antitubercular drug Isoniazid. The hepatitis may occur due to increased metabolic activity in liver. (The main organ where most drugs are metabolized).

16.Answer: A. A broad-spectrum antibiotit should be given until the specific organism has been identified Explanation: In serious life threatening disease, antiL infective therapy must begin before the infecting organism is identified.A broad-spectrum antibiotic usually is the most appropriate choice until specific organism has been determined. In all cases, culture specimens should be obtained before therapy begins.

17.Answer: D. A and B Explanation: A combination o f drugs should be given only when clinical experience has shown such therapy to be more effective than single-agent therapy in a particular setting. A multiple-drug regimen can increase the risk o f toxic drug effects and, in a few cases, may result in drug antagonism and subsequent therapeutic ineffectiveness.

18.Answer: E. A,B and C only Explanation: A multiple-agent regimen can increase the risk o f toxic drug effects and, in a few cases, may result in drug antagonism and subsequent! therapeutic ineffectiveness. Indications for multipleagent regimen include: j - Treatment o f an infection caused by multiple pathogenic organisms Need for increased antibiotic effectiveness. The synergistic (intensified) effect of two or more agents may ajlow a dosage reduction or a faster or enhanced effect fof the drug Prevention o f drug-resistant organisms

19.Answer: C. I&II Explanation: . In chronic infections such as endocarditis, osteomyelitis the treatment may require a longer duration (4-6 weeks) with follow-up culture analyses to assess therapeutic effectiveness. In acute uncomplicated infection treatment generally should continue until the patient has been afebrile and asymptomatic for at least 72 hours.

20. Answer: B. They help indicate the locus o f infection Explanation: Small effusions, abscesses, or cavities that appear on radiographs indicate the focus o f infection.

21 .Answer: B. Elevated erythrocyte sedimentation rate does not occur due to noninfectious cases

Explanation: Large elevations in erythrocyte sedimentation rate are associated with acute or chronic infection, particularly endocarditis, chronic osteomyelitis, and intra-abdominal infections. A normal ESR does not exclude infection. Erythrocyte sedimentation rate is elevated in noninfectious causes such as collagen vascular diseases.

22.Answer: E. A and B Explanation: Small effusions, abscesses, or cavities that appear on radiographs indicate the focus o f infection.Pain and inflammation may occur when infection is superficial or within a joint or bone, also indicating a possible focus of infedtion.

23 .Answer: D. All o f the above ! Explanation: Causes o f therapeutic infectiveness include:Misidentification o f the isolated organism may lead to misdiagnosis.Improper drug regimen. The drug dosage, administration route, dosing frequency, or duration . Survival o f microbes due to microbial resistance to a specific antibiotic, and inappropriate choice of antibiotic agent.

24. Answer: D. All o f the above Explanation: Fever frequently signifies infection, but it sometimes stems from non-infectious conditions such as drug reactions, phlebitis, neoplasmsj, metabolic disorders, arthritis.

25.Answer: D. Neutropenic cancer

Explanation: Conditions such as metabolic disorders, phlebitis, arthritis and drug reactions result in fever, but they do not respond to anti-microbial therapy .But Neutropenic cancer patients suffering from fever are widely treated with antimicrobial agents.

26. Answer: C. The most commonly used route o f administration o f the drugs is the oral route. Explanation: In perioperative antibiotic prophylaxis intravenous or intramuscular routes are preferred to guarantee good serum and tissue levels at the time o f incision.All other choices are true.

27. Answer: E. All o f the above Explanation:

In general, first-generation cephalosporins are drugs o f choice for most procedures and patients. These agents have an appropriate spectrum] a low frequency o f side effects, and a favorable half life, and low cost. I

28.Answer: E. I,II,&I1I are correct Explanation: They are primarily used in the treatment of infections caused by gram-negative enterobacteria and in suspected sepsis.The toxic potential o f these drugs limits their use.Aminoglycosides are bactericidal; they inhibit bacterial protein synthesis by binding to and impeding the function o f the 30 S ribosomal subunit. (Some Aminoglycosides also bind to the 50 S ribosomal subunit).

29.Answer: C. Streptomycin
i

Explanation: Streptomycin is used in the treatment o f mycobacterium tuberculosis in combination with other antitubercular drugs.

30. Answer: C. Amikacin

i

Explanation: Amikacin is the broadest spectrum antibiotic with activity against most aerobic gram-negative bacilli as well as anaerobic gram-negative bacilli strains that resist gentamicin and tobramycin. It is also active against M.tuberculosis and mycobacterium tuberculosis.

31 .Answer: C. Netilmicin

Explanation: Netilmicin appears to be less ototoxic than other Aminoglycosides. Ototoxicity involves progressive damage to and destruction o f the sensory cells in the cochlea and vestibular organ of the ear.

32. Answer: E. C and D Explanation: Pseudomonas aeruginosa and most streptococci are now resistant to neomycin.

33.Answer: B. Tetracycline Explanation: Streptomycin is used to treat plague, acute tularemia, acute brucellosis (given in combination with tetracycline), bacterial endocarditis caused by streptococcus viridans (given in combination with penicillin), and tuberculosis (given in combination with other antitubercular agents).

34.Answer: E. A and D Explanation: Gentamicin and streptomycin primarily cause vestibular damage (manifested by tinnitus, vertigo, and ataxia)

35.Answer: B. Netilmicin Explanation: Amikacin, kanamycin, an i neomycin cause mainly auditory damage (hearing loss)

36.Answer: A. Tobramycin

Explanation: Tobramycin can cause both vestibular and auditory damage.

37.Answer: A. Neomycin Explanation: j Nephrotoxicity consists o f damage to; the kidney tubules and can be reversed if the use o f the drugs is stopped. Neomycin is the mbst nephrotoxic aminoglycoside; streptomycin is the least nephrotoxic. Gentamicin and tobramycin are nephrotoxic to approximately the same degree.
i

38. Answer: E. All o f the above

|
i

Explanation: Aminoglycoside associated nephrotoxicity is more likely to occur in patients with pre-existing renal disease or in conditions in which urine volume is reduced,concomitant use o f other nephrotoxic drugs or previous or prolonged aminoglycoside therapy.

39.Answer: C. Imipenem Explanation: Imipenem is given intravenously. In the kidneys it is partly broken down by a dipeptidase in the proximal tubule and is,therefore, givdn in combination with cilastatin, a specific inhibitor o f this enzyme.( cilastatin is not required with Meropenem or Ertapenem since these are not sensitive to renal dipeptidases).

40.Answer: C. They are destroyed easily by most |3-lactamases. Explanation: Carbapenems are resistant to destruction by most (3-lactamases. They are derived from streptomyces jspecies.These drugs have the broadest spectrum o f activity as compared to other (3-lactam antibiotics.

41 .Answer: A. Thiazolidine ring Explanation: Cephalosporins are known as p-lactam antibiotics because their chemical structure consists o f a p-lactam ring adjoined to a thiazolidine ring.

42.Answer: D. Cefmetazole Explanation: Cefmetazole is a second generation cephalosporin.

43.Answer: D. Cefepime
i

Explanation: Cefepime is a fourth generation cephalosporin.

44.Answer: D. Enterococci Explanation: First generation antibiotics are active against most gram-positive cocci (except enterococci)

45.Answer: D. Haemophilis influenzae Explanation: First and second generation cephalosporins are active against E.coli, K. Pneumoniae, and Proteus Mirabilis and second generation cephalosporins have extended gram-negative coverage, including p-lactamase producing strains o f Haemophilis influenzae.

46. Answer: D. Cephalosporins are generally jclassified in four groups based mainly on structural similarity. Explanation: Cephalosporins are classified into four major groups based on their spectrum o f activity (not based on structural similarity). Each generation o f cephalosporin has shifted toward increased gram-negative activity but lost activity toward gram-positive organism. Fourth-generation cephalosporins have improved activity toward gram-positive organisms over third generation cephalosporins.

47.Answer: C. Cefuroxime

Explanation: Cefuroxime is commonly administered for community-acquired pneumoniae.

48.Answer: A. They penetrate the cerebrospinal fluid Explanation: Third generation cephalosporins are , valuable in the treatment o f meningitis caused by meningococci, pneumococci and H. influenzae because they penetrate the cerebrospinal fluid.

49.Answer: C. Cefoperazone Explanation: All cephalosporins (except cefoperazone) are eliminated renally, so doses should be adjusted for patients with renal impairment.Cefoperazone is eliminated by liver.

50.Answer: C. Ceftazidime Explanation: Probenecid may impair the excretion o f cephalosporins (except ceftazidime), causing increased cephalosporin levels and possible toxicity.

51 .Answer: D. All o f the above Explanation: Alcohol consumption may result in a disulfiram-type reaction in patients taking cefmetazole, cefotetan, and cefoperazone.

52.Answer: A. Lactone Explanation: The chemical structure o f macrolide antibiotics is characterized by a lactone ring to which sugars are attached.

53.Answer: E. C and D Explanation: Erythromycin base and the estolate, i ethylsuccinate and stearate salts are given orally; erythromycin lactobionate and gluceptate are given parenterally.

54.Answer: B. Erythromycin estolate

Explanation: Cholestatic hepatitis may arise in patients treated for 1 week or longer with erythromycin estolate; symptoms usually disappear within a few days after drug therapy ends.

55.Answer: E. A and D | Explanation: I Clarithromycin and erythromycin increase terfenadine and astemizole concentrations. Cardiac arrhythmia may result. Azithromycin and dirithromcyin do not appear to interfere with terfenadine metabolism; however, if used Concomitantly,patients should be closely monitored.

56.Answer: B. Clarithromycin

Explanation: Sudden deaths have been reported when Clarithromycin was added to ongoing pimozide therapy .Therefore, co-administration is coiitraindicated.

57.Answer: E. B and C only Explanation: Semi-synthetic macrolides Azithromycin,clarithromycin and dirithromycin are well tolerated as compared to erythromycin and they are given once daily.They are expensive.

58.Answer: C. Clarithromycin Explanation: Clarithromycin is used in combination with omeprazole or lansoprazole for H.Pylori eradication. 59.Answer: E. C and D Explanation: Azithromycin is less active than erythromycin against gram-positive cocci. Clarithromycin is more effective than erythromycin against staphylococci and streptococci.

60.Answer: C. Azithromycin Explanation: Azithromycin persists in high concentrations in the tissues (which could be significant in some infections) but its peak plasma concentration can be quite low (which needs to be taken into account in infections such as pneumococcal: pneumonia which can be complicated by septicemia).

61 .Answer: E. B and D Explanation: ' Penicillin G procaine and penicillin benzathine are repository drug forms. Administered intramuscularly, these insoluble salts allow slow drug absorption from the injection, and thus, have a longer duration o f action (12-24 hours).

62.Answer: A. 5-10 times Explanation: Penicillin G is 5-10 times more active than penicillin V against gram-negative organisms and some anaerobic organisms

63.Answer: A. Vancomycin Explanation: j The alternative drug for penicillin G resistant S.pneumoniae is vancomycin.

64. Answer: B. They do not occur in patients with a negative history o f penicillin allergy. Explanation: The hypersensitivity reactions may occur even in patients with a negative history.All other choices are correct.

65.Answer: C. Seizures Explanation: With high dose therapy of penicillins seizures may occur, particularly in patients with renal impairment.
!

66.

Answer: D. All o f the above

Explanation: Antibiotic antagonism occurs when erythromycins, tetracyclines or chloramphenicol is given within 1 hour of the administration o f penicillin. The clinical significance of such antagonism is not clear. j

67. Answer: E. A,B,&C Explanation: I The isoxazolyl penicillins are cloxacillin, Dicloxacillin and Oxacillin.
i

68.Answer: B. Nafcillin [ Explanation: Nafcillin is excreted by the liver and!thus may be useful in treating staphylococcal infections in patients with renal impairment. | 69. Answer: D. All o f the above

Explanation:

Oxacillin, cloxacillin, and dicloxacillin are most valuable in long-term therapy o f serious staphylococcal infections (e.g. endocarcjiitis, osteomyelitis) and in the treatment o f minor staphylococcal infections o f the skin and soft tissues.

70.Answer: C. Their spectrum o f activity iis narrower than that o f penicillinase resistant penicillins. Explanation: Aminopenicillins have a spectrum o f activity that is similar to but broader than that o f the natural and penicillinase resistant penicillins.; They are easily destroyed by staphylococcal penicillinases,and thus they are ineffective; against most staphylococcal organisms.

71 .Answer: E. Penicillin Explanation: The aminopenicillin group includes the semi-synthetic agents ampicillin and amoxicillin and their derivatives, Bacampicillin and cyclacillin.

72.Answer: C. Sulbactam Explanation: For infections resulting from penicillin-resistant organisms, ampicillin may be given in combination with sulbactam.

73.Answer: A. Clavulanic acid inactivates penicillinases Explanation: Amoxicillin is more effective against S. aureus, Klebsiella and bacteroides fragilis when given in combination with clavulanic acid because clavulanic acid inactivates penicillinases.

74.Answer: E. C and D Explanation: Extended-spectrum penicillins include the carboxypenicillins (e.g. carbenicillin, carbenicillin indanyl, ticaricillin) and the ureidopenicilHns (e.g. mezlocillin, piperacillin)

75. Answer: C. Carbenicillin is two to four times more active than Ticaricillin against P.aeruginosa. Explanation: Ticaricillin is 2 to 4 times as active as carbenicillin against Pseudomonas aeruginosa.

76.Answer: D. Pseudomonas

Explanation: Tazobactam is a [3-lactamase inhibitor that expands the spectrum o f activity to include some organisms not sensitive to piperacillin alone ( if resistance is due to p-lactamase production) , including strains o f staphylococci, Haemophilis ,bacteriodes, and enterobacteriacae. Generally, Tazobactam does not enhance activity against pseudomonas.

77.Answer: E. B and C Explanation: Carbenicillin and ticaricillin may cause hypokalemia.The high sodium content o f carbenicillin and ticaricillin may pose a danger to patients with heart failure.

78. Answer: A. They suppress bacterial!growth by triggering a mechanism that blocks folic acid synthesis. Explanation: Sulfonamides suppress bacterial growth by triggering a mechanism that blocks folic acid synthesis, thereby forcing bacteria to synthesize their own folic acid.

79.Answer: B. Glucose-6-phosphate dehydrogenase Explanation: In patients with hereditary deficiency Of the enzyme glucose-6-phosphate dehydrogenase, there is problem in maintaining the integrity o f the red blood cells.The rate o f rupture o f erythrocytes increases and results in hemolytic anemia.

80.Answer: D. Sulfonamides Explanation: Sulfonamides are bacteriostatic; they suppress bacterial growth by triggering a mechanism that blocks folic acid synthesis.

81 .Answer: B. Sulfisoxazole
j

Explanation: Sulfisoxazole is sometimes used in combination with erythromycin ethylsuccinate to treat acute otitis media caused by H. influenzae organisms.

82.Answer: D. Pseudomonas Explanation: Pseudomonas and proteus organisms are resistant to tetracyclines.

83.Answer: C. Doxycycline
j

Explanation: Doxycycline is highly effective in the prophylaxis o f travelers diarrhea commonly caused by E.coli.

84.Answer: B. It is excreted mainly in the feces j i Explanation: Doxycycline is excreted mainly in the feces, thus it is the safest tetracycline for the treatment o f extrarenal infections in patients with renal impairment.

85.Answer: D. Demeclocycline Explanation: Demeclocycline antagonizes the action o f antidiuretic hormone (ADH) in the renal tubules; therefore, it is used as an adjunctive to treat the syndrome o f inappropriate antidiuretic hormone secretion.

86. Answer: E. A and C Explanation: Phototoxic reactions are common with Demeclocycline and Doxycycline.

87.Answer: C. Minocycline Explanation: Minocycline can cause vestibular toxicity! The vestibular toxicity includes nausea, and vomiting.

Dizziness, vertigo,

88.Answer: D.Members o f the tetracycline group do not have cross-sensitivity among themselves. Explanation: I f a patient is hypersensitive to any one o f the tetracyclines, he/she is likely to be sensitive to any other tetracycline.Cross sensitivity within the tetracycline group is common.

89.Answer: D. Doxycycline Explanation: Dairy products and other foods, and antacids and laxatives containing aluminum, calcium, or magnesium can cause reduced tetracycline absorption. Absorption o f Doxycycline is not inhibited by these factors.

Explanation: Fluoroquinolone antibacterials inhibit thfe enzyme DNA gyrase topoisomerase 11, an enzyme that produces a negative supercoil in DNA, permitting transcription or replication.

91 .Answer: D. Ofloxacin
i

Explanation: Ofloxacin has the greatest activity against Chlamydia.

92.Answer: A. Sparfloxacin Explanation: Sparfloxacin is a third generation quinolone.

93.Answer: C. Trovafloxacin Explanation: Trovafloxacin has been associated with serious liver injury leading to liver transplantation and /or death. Liver injury has been reported with both short term and long-term drug exposure. 94.Answer: D.Theophylline Explanation: Ciprofloxacin has been shown to increase itheophylline levels.

95.Answer: E. A and B Explanation: Gatifloxacin, moxifloxacin should be avoided in patients with known prolongation o f the QTC interval o f cardiac action potential, with uncorrected hypocalcaemia, or who are receiving class IA or class III antiarrhythmic drugs.

96.Answer: C.I &II are correct Explanation: They get concentrated in the renal tubules and bladder, exerting local antibacterial effects.Most of them do not achieve blood levels high (enough to treat systemic infections.All urinary tract antiseptics do not have the same mechanistn o f action.
i

1 97.Answer: A. Ammonia and formaldehyde Explanation:

Methenamine is hydrolyzed to ammonia and formaldehyde in acidic urine; formaldehyde is antibacterial against gram-positive and gram-hegative organisms. 98.Answer: A. Enolylpyruvyl transferase Explanation: j The bactericidal action fosfomycin tromethamine occurs due to inactivation o f the enzyme enolylpyruvyl transferase thereby blocking the condensation o f uridine diphosphate-Nacetylglucosamine with penolpyruvate, one Of the first steps in bacterial cell wall synthesis.

99.Answer: C. Pseudomonas Explanation: Nalidixic acid and oxolinic are active against most gram-negative organisms that cause urinary tract infections, including P.mirabilis, E.colij, Klebsiella, and enterobacter organisms. These drugs are not effective against Pseudomonas organisms.

100.

Answer: C. Fosfomycin

Explanation: I Fosfomycin is indicated for the treatment o f uncomplicated urinary tract infection (acute cystitis) in women caused by susceptible strains o f S.coli and E.faecalls.

101.

Answer: E. B and C only

Explanation: Acetozolamide is inhibitor o f the enzyme Carbonic anhydrase. Carbonic anhydrase is the enzyme responsible for catalyzing the reaction between carbon dioxide and water to give carbonic acid. If this enzyme is inhibited the urine will have an alkaline pH which is unfavorable for methenamine to act. Sodium bicarbonate makes the pH o f urine alkaline thus rendering it unsuitable for methenamine to act. Aspirin is an acidic drug, and thus it makes the pH o f urine acidic and this does not have affect on the antibacterial effect of methenamine. (Acidic media is required for methenamine to act).

102.

Answer: E. And B

Explanation: Nitrofurantoin blood levels are increased and urine levels decreased by sulfinpyrazone and probenecid, leading to increased toxicity and reduced therapeutic effectiveness.
j

I 103. Answer: B. It resembles the Aminoglycosides in its efficacy against many gram-negative organisms, and its ototoxic and nephrotoxic adverse effects. Explanation:

Aztreonam resembles the aminoglycoside;s in its efficacy against many gram-negative organisms but it does not cause nephrotoxicity or oto toxicity .All other statements are true.

104.

Answer: A. a nitrobenzene derivative

Explanation: Chloramphenicol is a nitrobenzene derivative.

105.

Answer: E. A and B

Explanation: Chloramphenicol and tetracyclines are active against ricketsia.Cefaclor and amoxicillin are not active against Rickettsial organisms.

106. Answer: C. The bone marrow suppression associated with Chloramphenicol is not doserelated. Explanation: The bone marrow suppression associated with chloramphenicol is dose-related. It is more likely to occur at higher doses. All other statements are true.

107.

Answer: A. Inadequate liver detoxification o f Chloramphenicol

Explanation: The gray baby syndrome which commonly occurs in neonates taking chloramphenicol is due to inadequate liver detoxification o f chloratnphenicol.Several enzymes that is important for drug metabolism, for example hepatic microsomal oxidase, glucuronyltransferase and plasma transferases have low activity in neonates, especially if they have been born prematurely. These enzymes take 8 weeks or longer to reach the adult level o f activity. The relative lack o f conjugating activity in the newborn cah have serious consequences such as the gray baby syndrome caused by chloramphenicol.

108.

Answer: D. Phenytoin

Explanation: Chloramphenicol inhibits the metabolism o f phenytoin, tolbutamide and chlorpropamide and dicumarol, leading to prolonged action and intensified effect o f these drugs.

109.

Answer: B. Acetaminophen

Explanation: Acetaminophen elevates the blood levels o f chloramphenicol and may cause toxicity. This may be due to the structural similarity between chloramphenicol and acetaminophen.

Explanation: Because o f its marked toxicity, clindamy ;in is used only against infections for which it has proven to be the most effective drug. Typ cally, such infections include abdominal and female genitourinary tract infections caused by B.fr agilis.

111.

Answer: A. Sulfone

Explanation: Dapsone is a member o f the sulfone class o f antibiotics.

112.

Answer: D. Cefonicid

Explanation: Cefonicid is a second generation cephalosporin and it has bactericidal action. All others have bacteriostatic action.

113.

Answer: E. I,II,&III are correct

j

Explanation: Dapsone has been shown to be active against all the three: P.carinii,Plasmodium, and Mycobacterium leprae.

114.

Answer: A. Pyrimethamine

Explanation: Maloprim is a combination product o f dapsone and Pyrimethamine. It is used in the prophylaxis and treatment o f malaria.

115.

Answer: A. Oxazolidine

Explanation: Linezolid is chemically a synthetic Oxazolidine.

116.

Answer: B. Streptococci

Explanation: Linezolid is bacteriostatic against Enterococci and Staphylococci, and bactericidal against Streptococci.

117.

Answer: D. All o f the above

Explanation: Patients receiving concomitant therapy jwith adrenergic or serotogenic agents or consuming more than 100 mg o f tyramine a day may experience an enhancement o f linezolids effect.

118.

Answer: C. Aminoglycosides

Explanation: Spectinomycin is an aminocyclitol related structurally to the aminoglycosides.

119.

Answer: A. 1M

Explanation: Spectinomycin is given only as a single dose IM injection.

120.

Answer: B. Pyrimidine

Explanation: Trimethoprim is chemically a substituted Pyrimidine.

121.

Answer: B. Dihydrofolate reductase

Explanation: Trimethoprim inhibits the enzyme Dihydrofolate reductase, thus blocking bacterial synthesis o f folic acid.

122.

Answer: A. synergism

Explanation: The trimethoprim-sulfamethoxazole combination is synergistic; many organisms resistant to one component are susceptible to the combination.

123.

Answer: D. Cyclosporine

Explanation: Cyclosporine does not increase the plasma concentration o f caspofungin. When cyclosporine is combined with caspofungin, clinically significant rises in ALT were observed. Serum transaminases should be monitored, and this combination should be avoided in patients with pre-existing liver diseases. When used in combination, carbamazepine, nelfinavir, nevirapine, phenytoin, and rifampin increase the clearance o f caspofungin. Higher doses o f caspofungin should be considered when this combination is administered.

124.

Answer: A. Fluorinated pyrimidine

Explanation: Flucytosine is chemically a fluorinated py imidine.

125.

Answer: C. It is converted to fluorouracil, which results in defective protein synthesis.

Explanation: Flucytosine penetrates fungal cells and is converted to fluorouracil , a metabolic antagonist, Incorporated into the RNA o f the fungal c ill, Flucytosine causes defective protein synthesis.

126.

Answer: C. I&II are correct

Explanation: Flucytosine is primarily active against cryptococcus and Candida. It is most commonly used in conjunction with amphotericin B. Flucytosine alone is not recommended.

127.

Answer: E. B and C

Explanation: Flucytosine has demonstrated synergy with amphotericin B and fluconazole against cryptococcus and Candida species.

128.

Answer: A. Penicillium griseofulvum dierckx

Explanation: Griseofulvin is produced from penicillium griseofulvum dierckx.

129.

Answen.E. A,B&C

Explanation: Griseofulvin is active against various strains o f microsporum, Epidermophyton, and trichophyton. It has not been shown to be active against aspergillus.

130.

Answer: E. All o f the above

Explanation: Griseofulvin is effective in tinea infectioris o f the skin, hair, and nails (including athletes foot, jock itch, and ringworm) caused by microsporum, epidermophyton, and trichophyton.lt is used in infections that do not respond to topical antifungal agents.lt may be used in raynauds disease. It can also be used in the treatment o f gout, i

131.

Answer: D. Colchicine

'

Explanation: Griseofulvin inhibits fungal cell activity by interfering with mitotic spindle structure. Its mechanism o f action is similar to Colchicine and that is why it is also used in the treatment of gout.

132.

Answer: C. Hepatotoxicity

Explanation: The most common adverse effects associated with griseofulvin are: headache, fatigue, syncope,impaired performance and lethargy. Occasional adverse effects: leukopenia, neutropenia, and agranulocytopenia Rare adverse effects: serum sickness, angioedema, urticaria, and hepatotoxicity.
i j

133.

Answer: A. The particle size o f the product

j

Explanation: The dosage o f griseofulvin is dependentlon the particle size o f the product. For example 350 ultramicrosize is to equivalent 700 mg o f micro size in therapeutic effectiveness. !

134.

Answer: B. Alcohols

j
i

Explanation: Alcohol consumption in patients taking griseofulvin may cause tachycardia and flushing.
i

135. Answer: B. They inhibit sterol Synthesis in fungal cell membranes and increase cell wall permeability Explanation: Imidazoles inhibit sterol synthesis in fungal cell membranes and increase cell wall permeability; this, in turn, makes the cell more vulnerable to osmotic pressure.

136.

Answer: E. All o f the above

Explanation: Imidazole antifungals are active against many fungi, including yeasts, dermatophytes, actinomycetes, and some phycomycetes. I 137. Answer: E. C and D

Explanation:

Ketoconazole is slow-acting and requires a long duration o f therapy (up to 6 months for some chronic infections).

138.

Answer: E. A and B

Explanation: Miconazole is available both in oral and parenteral forms.

139.

Answer: D.II & III are correct

Explanation: Parenteral miconazole serves as a second-line agent in severe systemic fungal infections only when other antifungal drugs are ineffective or cannot be tolerated. The reason for this could be the adverse effefcts associated with the drug.

140.

Answer: E. Fluconazole

Explanation: Fluconazole is used in the treatment o f CNS'infections involving cryptococcus and Candida.

141.

Answer: E. All o f the above

Explanation: Deep mycotic infections susceptible to itraconazole include blastomycosis, coccidioidomycosis, cryptococcosis, and histoplasmosis.

142.

Answer: B. Amphotericin B is associated with hematological toxicity

Explanation: Itraconazole is preferred to amphotericin B against systemic and invasive pulmonary aspergillosis because it is devoid o f hematological toxicity.

143.

Answer: E. A and B

j
i

Explanation: Nausea and vomiting are common to all imidazole antifungal agents.

144. Answer: B. They decrease the level d>f gastric acidity, which is necessary for ketoconazole and itraconazole to act. Explanation: Both ketoconazole and itraconazole need the presence o f stomach acid for adequate absorption. Use with antacids, H2-blockers, or proton pump inhibitor is contraindicated.

145.

Answer: D. Amphotericin B

Explanation: Ketoconazole may antagonize the antibiotic effects o f amphotericin B.

146.

Answer: E. All of the above

Explanation: Fluconazole has been shown to elevate the serum levels o f phenytoin, cyclosporine, warfarin, and sulfonylreas.

147.

Answer: D. All o f the above

Explanation: Voriconazole inhibits cytochrome P4502C19. CYP2C9, and CYP3A4.

148.

Answer: C. Amphotericin B

Explanation: Nyastatin is related chemically to amphotericin B. Both o f them are polyene antibiotics.

149.

Answer: B. Candida

Explanation: Nyastatin is active primarily against Candida species.

150.

Answer: D. It has been shown to be ineffective against tinea capitis and tinea corporis

Explanation: Terbinafine is very effective against tinea capitis and tinea corporis infections. All other statements are true.

151.

Answer: D.

All o f the above

Explanation: Amphotericin B is available as a 3% cream or lotion or an oral suspension that is not absorbed.

152.

Answer: E. A & B

Explanation:

Dry skin and local irritation with er> threma, pruritis, or burning, along with mild skin discoloration, has occurred with the lotion and cream.

153.

Answer: D.

It is ineffective against Candida species

Explanation: Butenafine is active against Trichophytor rubrum, Trichophyton mentagrophytes, microsporum canis, Sporothrix schenckii, and yeasts inc luding Candidaparapsilosis and Candida albicans.

154.

Answer: D.

1 % cream

Explanation: 1 % cream o f butenafine is used in the treatment o f infection due to dermatophytes.

155.

Answer: D.

Butoconazole

j !

Explanation: Butoconazole is an azole antifungal available for vaginal use to treat vulvovaginal candidiasis.

156.

Answer: E. I,II, & III

Explanation: Butoconazole contains antibacterial activity against some gram-positive organisms such as S. aureus, S. pyrogenes and E. Faecalfs. But E.coli is a gram-negative bacterium and butoconazole is not active against gram-positive bacteria.

157.

Answer: C.

Ciclopirox

i
j

Explanation: Ciclopirox is a synthetic antifungal agent! that is chemically unrelated to any other antifungal agent. It causes intracellular depletion o f amino acids and ions necessary for normal cellular function. Naftifine, terbinafine, and butoconazole interfere with fungal cell wall synthesis and permeability.

158.

Answer: A.

Hydrocortisone

l I

Explanation: Clioquinol is a topical antifungal in a 3% ointment that can be used alone or in combination with hydrocortisone. i

159.

Answer: B. Phospholipids in membrane

Explanation: Clotrimazole alters fungal cell membrane permeability by binding with phospholipids.

160.

Answer: E. All o f the above

Explanation: Clotrimazole is active against yea: its dermatophytes (T.rubrum, T.mentagrophytes, and E.floccosum, M.canis), and some grant -positive bacteria. At higher concentrations, clotrimazole inhibits M.fufur, Aspergillus fumigatus, C. albicans, and some strains o f S. aureus, S.pyogenes, Proteus vulgaris, and Salmonella.

161.

Answer: B. Parenteral solution^

Explanation: | Clotrimazole is available in the following formulations Lozenges: Clotrimazole 10 mg Topical: Cream: Lotion: - Solution: Clotrimazole 1% It is not used in parenteral formulations.

Clotrimazole Clotrimazole

1% 1%

162.

Answer: E. A and B

Explanation: Abnormal liver function tests (elevated AST) have occurred in patients taking clotrimazole lozenges. (The interference with liver function tests seems to occur with oral formulations only). Vaginal tablets are associated with mild burning, skin rash, itching, vulval irritation, lower abdominal cramps vaginal soreness during intercourse, and an increase in urinary frequency. Cross-sensitization occurs with imidazole antifungals.

163.

Answer: A.dye

Explanation: Gentian violet is a dye and is useful as an antifunagal agent against Candida, Epidermophyton,Cryptococcus,Trichophyton,and some Staphylococcus species.

164.

Answer: A. Ophthalmic suspension

Explanation: Extemporaneously prepared ophthalmic suspension is used in the treatment o f fungal keratitis

165.

Answer: C. Steroids

Explanation: j When combined with a steroid, ketoconazole is useful in treating the following: diaper rash, eczema, impetigo, lichenoid dermatitis, and psoriasis.

Explanation: , Miconazole is available topically as a 2 % kerosol, 2 % aerosol powder. 2 % cream, 2 % powder, and 2 % vaginal cream, 100 mg and 200 m^ vaginal suppositories.

167.

Answer: D. All o f the above

Explanation: j Miconazole is advantageous over other ageAts such as Nyastatin and tolnaftate in that its activity covers dermatophytes {Tinea mentagrophites, Tinea rubrum, and E.Floccosum) as well as Candida. I

168. Answer: B. Vaginal suppositories art manufactured from a vegetable oil base that may interact with latex products : Explanation: j Vaginal suppositories are manufactured from a vegetable oil base that may interact with latex products. Avoid using diaphragms or condorris concurrently with suppositories.

169.

Answer: B. It acts by interfering withi fungal protein synthesis

Explanation: j Naftifine interferes with sterol biosynthesis by accumulating squalene in the fungal cell.

170.

Answer: B. Griseofulvin

Explanation: Nyastatin, Terbinafine, and Nyastatin mdy be fungistatic or fungicidal concentration of the drug. Griseofulvin has fungistatic action only.

depending on

171. Answer: A. It has a direct physicochemical effect on the destruction o f unsaturated fatty acids present in fungal cell membranes Explanation: i The antibacterial effects exerted by sulconazole are thought to be due to a direct physicochemical effect on the destruction o f unsaturated fatty acids present in fungal cell membranes i 172. Answer: C. Nyastatin j Explanation:
Nyastatin is prim arily used as a topical agent inivaginal and oral Candida infections. It has not been shown to be active against M.furfur

173.

Answer: E. A and B

Explanation: Sulconazole is active against selected gram-positive aerobes (S.aureus, S. epidermidis and Staphylococcal saprophyticus, E.faecdlis and Bacillus subtilis) and anaerobes (Clostridium and Propionibacterium) \ Tetraconazole is active against gram-positive and gram-negative bacteria. Miconazole and Econazole have not beLn shown to have antibacterial activity.

174.

Answer: A. Plasmodium
i

Explanation: Malaria results from infection by any o f four species o f the protozoal genus plasmodium.

175.

Answer: E. A and B

Explanation: Chloroquine and Hydroxychloroquine^ bind to and alter the properties o f microbial and mammalian DNA. The mechanism o f action o f primaquine and Mefloquine is not known.

176.

Answer: D. Primaquine

Explanation: Schizonts are cells that reproduce by schizogony, producing a varied number o f daughter trophozoites and merozoites.

177.

Answer: C. Fansidar

Explanation: ; Fansidar is a blood schizonticidal agent that is active against the erythrocytic forms o f susceptible plasmodia. It is active against T.Gondii, i

178.

Answer: A. Primaquine

Explanation: Primaquine is active against liver forms of P. Vivax and P.Ovale.

179.

Answer: B. Pyrimethamine

Explanation: * Pyrimethamine is effective in the prevention and treatment o f chloroquine-resistant strains o f P.falciparum. It is now almost exclusively iused with a sulfonamide or sulfone.

180.

Answer: A. Quinine dihydrochlorid

Explanation: Quinine dihydrochloride is a parenteral form used in severe cases o f chloroquine-resistant malaria. Quinine sulfate is an oral form use d in the prophylaxis.

181.

Answer: B. Pneumocystis carinii

Explanation: Co-trimoxazole (a combination product containing Sulfamethoxazole and trimethoprim) is used in the prophylaxis o f pneumonia caused by Pneumocystis carinii, which occurs most commonly in AIDS patients. Fansidar is used in the prophylaxis o f Pneumocystis carinii infection in AIDS patients unable to tolerate co-trimoxazole.

182.

Answer: E. B and D |

Explanation: Quinine and Primaquine may result in hemolytic anemia in patients with hereditary deficiency of the enzyme glucose-6-phosphate dehydrogenase.

183.

Answer: C. Sulfonamides

Explanation: Primaquine is contraindicated in patients with rheumatoid arthritis and in those receiving potentially hemolytic drugs or bone marrow depressants. Sulfonamides may result in hemolytic anemia in patients with hereditary deficiency o f the enzyme glucose-6-phosphate dehydrogenase.

184.

Answer: A. pyrimethamine

Explanation: Fansidar is a combination containing sulfadoxine and pyrimethamine.

185.

Answer: D. Chloroquine

Explanation: Concomitant use o f Mefloquine and quinine or chloroquine may increase the risk o f convulsions.

186.

Answer: . E. Emetine

Explanation:

Emetine is an alkaloid, Quinacrine is an acridine derivative, Diloxanide is a dichloroacetamide derivative, Metronidazole is an imidaz ole derivative,and Paramomycine is an aminoglycoside.all these agents are useful as amebicides and trichomonacides.

187.

Answer: B. It is poorly absorbed

Explanation: Paromomycin is not effective in extral-intestinal amoebiasis because it is poorly absorbed when given by the oral route.

188.

Answer: E. A and D

Explanation: Metronidazole acts as amebicidal drug by disrupting the helical structure o f DNA. Quinacrine inhibits DNA metabolism. Emetine and paromomycin inhibit protein synthesis.

189.

Answer: D. Metronidazole

Explanation: Metronidazole is the drug o f choice in the treatment o f urogenital trichomoniasis, amebic dysentery, giardiasis and against bacterial anaerobes.lt is also a drug o f choice in the treatment o f C.difficile colitis infections.

190.

Answer: D. A and B only

Explanation: Quinacrine is useful in the treatment o f giardiasis and tapeworm infection.

191.

Answer: C. Emetine

Explanation: ! Emetine may induce potentially lethal systemic toxicity. The most serious symptoms and findings o f cardiovascular toxicity are tachycardia and other symptoms, precordial pain, and congestive heart failure.

192.

Answer: B. Metronidazole

Explanation: Metronidazole has a disulfiram-like iffect, so that nausea and vomiting occur if alcohol is consumed while the drug is still in the body.

193.

Answer: C. Iodoquinol

Explanation:

Iodoquinol can produce severe neurotoxicity, particularly if they are given at greater than recommended dose and for long periods o f t me. Iodoquinol has not been implicated in the production o f neurotoxic effects when used at the standard dosage o f 650 mg 3 times daily for 21 days.

194.

Answer: D. A ,B&C

Explanation: Pentamidine can be administered intramuscularly, intravenously, or by inhalation. It is not given by oral route because it is not well absorbed from the gastrointestinal tract.

195.

Answer: A. Infections due to P. carinii

Explanation: Pentamidine is indicated for the prevention and treatment o f infections due to P.carinii. Its unlabeled uses include treatment o f Trypanosomiasis, visceral leishmaniasis and Babesiosis.

196.

Answer: A. An aromatic diamide

i Explanation: Pentamidine is chemically an aromatic dianliide. | 197. Answer: B. Decreases

Explanation: Hypoglycemia may occur with initial admihistration o f drug via the IV, IM, or inhalational route. After the patient has been on the drug for a period o f time, hyperglycemia will result. The effect o f the drug may actually induce a reversible insulin-dependent diabetes mellitus.

198.

Answer: A. Pyrimidine synthesis

Explanation: Atovaquone blocks mitochondrial electron synthesis at complex III o f the respiratory chain o f protozoa, resulting in inhibition o f Pyrimidine synthesis.

199.

Answer: C. Its oral absorption is decreased when administered with food

Explanation: The oral absorption o f atovaquone increases when it is administered with food. (Especially a high fat meal) j Atovaquone is used as a second-line treatment o f mild to moderate P.carinii pneumonia in patients intolerant o f Co-trimoxazole or other sulfonamides, or nonresponsive to co-trimoxazole.

200.

Answer: A. Intravenous route

Explanation: Eflomithine HC1 is an antiprotozoal driig given intravenously.

201.

Answer: B. It inhibits the enzyine ornithine decarboxylase

Explanation: Eflomithine is an irreversible inhibitor b f the enzyme ornithine decarboxylase.

202.

Answer: E.A11 o f the above

Explanation: Atovaquone is active against P.carinii T.Gondii, and Cryptosporidium parvum, P.falciparum, Isoporidium, and Microsporidia. \

203.

Answer: C. Myelosuppression

Explanation: I Myelosuppression is the most frequent serious side effect ofEflom ithine. Nausea and vomiting are not reported.Ckses o f Hearing impairment have been reported.

204.

Answer: E. A and B

Explanation: Antitubercular agents such as Isonia zid,rifamipicin and streptomycin have relatively low incidence o f adverse effects as comparec to Pyrazinamide or Ethambutol. 205. Answer: A. Isoniazid, rifamipicih, Pyrazinamide

Explanation: Most patients are started on isoniazic), rifamipicin, and Pyrazinamide. A fourth drug (e.g Ethambutol, streptomycin,) is added wijth suspected resistance (i.e. if patients were previously treated or if resistance is expected). Patients failing this therapy must be treated with five drugs (isoniazid, rifamipicin, Pyrazinamide, Ethambutol. and streptomycin). If one or more o f these agents can not be used ethionamide, para-aminosalicyclic acid, cycloserine, or capreomycin can be used.

206.

Answer: A. In order to overcome; resistance |

Explanation: Combination therapy is used in the treatmjent o f tuberculosis in order to overcome resistance.
j

l 207. Answer: E. A and B !

Explanation: Ethambutol is used in combination with Clarithromycin or Azithromycin and rifabutin in the treatment of mycobacterium avium complex.

208.

Answer: D. Its mechanism of action is that it inhibits the enzyme DNA gyrase

Explanation: j The mechanism o f action o f Isoniazid is probably disruption o f bacterial cell wall synthesis by inhibiting mycolic acid synthesis. [

209.

Answer: E.A,B&C

Explanation: Isoniazid has activity only against organisms in the genus mycobacterium. More specifically, it has demonstrated activity against M .tuberculosis, M.bovis and selected strains o f M.kansasii.

210.

Answer: B. Minimize the peripheral neuropathy associated with Isoniazid use

Explanation: Pyridoxine 15-50 mg/day should be administered to patients taking Isoniazid to minimize the peripheral neuropathy associated with its uSe.

! i ! Explanation: j Concurrent Carbamazepine therapy may increase the risk o f hepatitis.

211.

Answer: B. Hepatitis

212.

Answer: E. A and B

Explanation: Cycloserine and ethionamide may cause additive nervous system effects when used along with isoniazid.

213. Answer: B. Impairment o f bacterial RNA synthesis by binding to DNA-dependent RNA polymerase
i

Explanation: Rifampicin impairs bacterial RNA synthesis by binding to DNA-dependent RNA polymerase.

214.

Answer: E. All o f the above

Explanation: Rifampin has activity against most mycobacterial strains. In addition, Rifampin has activity against many other organisms, including N.meningitidis, S.aureus, and H. influenzae, Legionella pneumophilia, and C. trachomatis.

215.

Answer: A. Orange-red

Explanation: Rifampin colors urine, sweat, tears, saliva and feces orange red.

216.

Answer: B. Probenecid decreases the blood level of Rifampin

Explanation: Probenecid may increase the blood levels o f Rifampicin.

217.

Answer: A. Nicotinamide

Explanation: Pyrazinamide is a pyrazine analogue of nicotinamide.

218.

Answer: D. M.tuberculosis

Explanation: Pyrazinamide is a highly specific agent and has activity only against M.tuberculosis.

219.

Answer: A. They are more effecti ye than primary agents

Explanation: Retreatment agents are less effective, more toxic, and are used in combination with primary agents.

220.

Answer: E. Ethambutol

Explanation: Retreatment agents include aminosalicylic acid, capreomycin, cycloserine, ethionamide,and Kanamycin. Ethambutol is a primary anti-tubercular agent.

221.

Answer: D. Trimethoprim

Explanation: Amino salicylic acid inhibits the enzymes responsible for folic acid synthesis.Trimethoprim has almost similar mechanism o f action.

Explanation: Capreomycin and streptomycin are ototo xic and nephrotoxic, they should not be administered together.

223.

Answer: B. Ethionamide

Explanation: Ethionamide may induce nausea, vomiting and orthostatic hypotension, metallic taste, epigastric distress, and peripheral neuropathy.

224.

Answer: C. Rifampin 120 mg, Isoniazid 50 mg, Pyrazinamide 300mg

Explanation: Rifater is a combination o f Rifampin 120 i)ng, Isoniazid 50 mg, and Pyrazinamide 300mg

225.

Answer: E. C and D

Explanation: Ciprofloxacin and Levofloxacin are used ih the treatment o f tuberculosis.

226.

Answer: C. It is more effective than Rifampin in the treatment o f tuberculosis

Explanation: Rifabutin is an antimycobacterial agent that is similar to Rifampin, with activity against both tubercular and non-tubercular mycobacter al, and offers no clear advantage over Rifampin.

227.

Answer: E. Antiviral agents act b> inhibiting viral cell wall synthesis

Explanation: Antiviral agents act by inhibiting viral rep ication.

228.

Answer: D. Foscarnet

Explanation: Foscarnet does not need to be activated to act against viruses.

229.

Answer: B. HIV-1

Explanation: HIV is an RNA virus. Others are DNA viiiises.

Explanation: Antiviral agents which act against DNjj\ viruses are virustatic and arrest DNA synthesis by inhibiting the enzyme viral DNA polymerase.
i

231.

Answer: E.A,B&C

Explanation: Acyclovir is active against HSV-1, HSV-2, and Varicella Zoster virus.

232.

Answer: B. Interfering with viral attachment and uncoating

Explanation: Amantadine inhibits replication o f the influenzae A virus by interfering with viral attachment and uncoating.

233.

Answer: D. Amantadine

Explanation: Amantadine is an-anti-viral drug used in the treatment o f Parkinsonism.

234.

Answer: A. Acyclic Purine nucleoside

Explanation: Cidofovir is a synthetic acyclic purine nucleoside.

235.

Answer: C. Bradycardia

Explanation: The most pronounced adverse effects o f amanatadine are ataxia,nightmares,and insomnia.The anticholinergic side effects of amantadine include dry mouth, blurred vision, and tachycardia.

236.

Answer: C. Penciclovir

Explanation: Famciclovir is a prodrug o f the antiviral agent Penciclovir.lt has activit against HSV-1,HSV2,and VZV.The drug is indicated for managemnt o f acute herpes zoster(shingles) and oral genital herpes.

237.

Answer: B. Viral thymidine kinase

Explanation: Famciclovir is rapidly phosphorylated in virus infected cells by viral thymidine kinase to Penciclovir monophosphate. Penciclovir is a competitive inhibitor o f viral DNA polymerase and prevents viral replication by inhibition o f hp;rpes virus DNA synthesis.

238.

Answer: A. It is a pyrophosphate analogue

Explanation: Foscarnet is a synthetic pyrophosphate analogue.

239.

Answer: B. It is not active against HIV-1

Explanation: Foscarnet is active against HIV-1.

240.

Answer: A. IV route

Explanation: IV Foscamet is highly nephrotoxic, causing acute tubular necrosis.

241.

Answer: D. Hypercalcemia

Explanation: Foscamet The electrolyte abnormalities associ ated with hypomagnesemia, Hypokalemia and Hypo phosphatemia.

include

hypocalcaemia,

242.

A nsw er:. 50 mL/min

Explanation: Foscarnet is not recommended for patients \ vith creatinine clearance of less than 50 mL/min.

243.

Answer: E. A and B

Explanation: Foscamet is exclusively eliminated by glom :rular filtration and tubular secretion.

244.

Answer: E. A and B

Explanation:

Foscarnet should not be given concurr ently with drugs having nephrotoxic adverse effects, Aminoglycosides (e.g. streptomycin and amikacin) should not be given with Foscamet.

245.

Answer: C. It is incapable o f penbtrating the CNS.

Explanation: Ganciclovir is capable o f penetrating the CNS.

246.

Answer: D. Ototoxicity

Explanation: Ganciclovir has not been associated with ototoxicity.Ganciclovir has blackbox warnings concerning increased potential for dose-limited neutropenia,anemia,and thrombocytopenia.lt is also potentially teratogenic and carcinogenic.

247.

Answer: A. Imipenem-cilastatin |

Explanation: Imipenem is always given in combination with cilastatin (in order to protect the degradation of imipenem by renal dipeptidases), when this combination is given concurrently with ganciclovir it may induce generalized seizures.

248.

Answer: D. Zanamivir

Explanation: Oseltamivir is pharmacologically related to Zanamivir but structurally different.

249.

Answer: B. Oseltamivir Carboxylate

Explanation: Oseltamivir is a prodrug that must be hydrolyzed to Oseltamivir carboxylate to exert antiviral activity. :

250.

Answer: A. Neuraminidase

Explanation: Oseltamivir is a potent selective inhibitor o f the influenzae virus enzyme, neuraminidase.lt is approved for symptomatic treatment o f infjluenza-A& B infections.

251.

Answer: B. Influenzae virus vaccine

Explanation:

Although amantadine, Rimantadine and Oseltamivir are approved for the prophylaxis o f influenzae virus infections, the influenzae virus vaccine is still the gold standard for prophylaxis o f influenzae virus infection.

252.

Answer: C. Acyclovir

Explanation: Valacyclovir is the L-valine ester o f acyclovir.

253. Answer: A. It inhibits RNA and D liA synthesis by depleting intracellular nucleotide reserves. Explanation: Ribavarin inhibits RNA and DNA synthesis by depleting intracellular nucleotide reserves.

254.

Answer: C. Inhalational route

Explanation: Ribavarin is administered in aerosol form by the inhalation in the treatment o f respiratory syncytical virus (RSV).

255.

Answer: B. It may precipitate on respirator valves and tubing causing lethal malfunction.

Explanation: Ribavarin is not recommended in patiehts using ventilators because it may precipitate on respirator valves and tubing, causing lethal malfunction. However, use o f prefilter may permit ribavarin therapy in such patients.

256.

Answer: B. Ganciclovir

Explanation: Valganciclovir is L-valine ester (prodrug) o f the antiviral agent ganciclovir.

257.

Answer: B. It has markedly increased bioavailability when given with food.

Explanation: Valganciclovir has the same spectrum of activity as ganciclovir. Valganciclovir is a potential carcinogen and teratogen. The advantage o f Valganciclovir over ganciclovir is it has markedly increased bioavailability when given with food.

258.

Answer: E. A and B

Explanation:

Zanamivir and Oseltamivir are active against influenzae A and influenzae B, but amantadine and Rimantadine are active against influenzae A virus infection.

259.

Answer: E. All o f the above

Explanation: Currently 4 classes o f antiretroviral drugs are approved, these include Nucleoside reverse transcriptase inhibitors, nucleotide reverse transcriptase inhibitors, Nonnucleoside reverse transcriptase inhibitors, and fusion inhibitors and protease inhibitors.

260.

Answer: D. Tenofovir

Explanation: i Tenofovir is a Nucleotide reverse transcriptase inhibitor.

261.

Answer: A. Enfuvirtide

Explanation: Enfuvirtide is the fusion inhibitor used in the treatment of HIV-1 and HIV-2 infection. Zalcitabine and Lamivudine are nucleoside reverse transcriptase inhibitors.Indinavir is a protease inhibitor.

262.

Answer: D. A,B&C

Explanation: Stavudine is a nucleoside reverse transcriptase inhibitor.

263.

Answer: D. They can used alone in the treatment o f HIV infection.

Explanation: Monotherapy with any single antiretroviral agent is no longer considered acceptable in the treatment o f HIV infection.

264.

Answer: E. Abacavir

Explanation: Abacavir has good penetration into the cerebral spinal fluid, unlike other agents in this class.

265.

Answer: B. A life threatening hypersensitivity reaction

Explanation: Abacavir has a black box warning about a life-threatening hypersensitivity reaction that can lead to death. It occurs in approximately 5% o f patients taking this drug, typically within the first 6 weeks o f therapy. This reaction involves respiratory symptoms fever, rash, and GI complaints.

Explanation: Didanosine results in hyperuricemia beca use it is catabolized to uric acid.Didnosine carries a balck box warning for its potential to cause lethal pancratitis.

267.

Answer: A. Prevent degradation at acidic pH.

Explanation: Didanosine is available in a specially buffered formulation in order to prevent degradation at acidic pH.

268.

Answer: D. Lamivudine

Explanation: j Lamivudine is used in the treatment oi[ chronic hepatitis B in patients with active liver inflammation.

269.

Answer: D. Peripheral neuropathy

Explanation: The major toxicity associated with Stavudine is a dose-related peripheral neuropathy occurring in up to 21% o f patients. Other adverse effects include headache, rash, sleep disorders and abdominal pain.

270.

Answer: E. B and C

Explanation: No drug interactions have been reported with abacavir and Didanosine.

271.

Answer: A. Tenofovir disoproxil fumarate

Explanation: Tenofovir is available as Tenofovir disoproxil fumarate. Tenofovir disoproxil fumarate is rapidly hydrolyzed by plasma esterases to Tenofovir, with subsequent conversion to the active Tenofovir diphosphate.

272.

Answer: C. Didanosine

Explanation: Tenofovir may increase Didanosine serum cc ncentrations.

273.

Answer: A. Zidovudine

Explanation: Zalcitabine is indicated for combination therapy with Zidovudine for the treatment o f adult patients with advanced HIV infection.

274.

Answer: A. Pentamidine

Explanation: Zalcitabine has been associated with high incidence o f pancreatitis (inflammation o f the pancreas). Pentamidine has also a potential to result in pancreatitis when given in therapeutic doses. Zalcitabine treatment should be interrupted, when a drug with a potential to cause pancreatitis. (E.g. pentamidine)

275.

Answer: B. Thymidine

Explanation: Zidovudine is a synthetic thymidine analogue.

276.

Answer: E.A,B&C

Explanation: Zalcitabine should not be used in combination with Didanosine, Lamivudine, or Stavudine, in order to minimize the incidence o f drug antagonism. Zidovudine (Azidothymidine) is always used in combination with Zalcitabine.

277.

Answer: A. Lamivudine

Explanation: Combivir is a combination product containing Zidovudine and Lamivudine.

278. Answer: B. It has fewer incidences o f adverse effects and drug interactions than the individual agents. Explanation: Even though it is a combination product the adverse effects and drug interaction are the same as the single agents.

279.

Answer: B. Abacavir

Explanation: The first triple nucleoside combination product approved by the FDA is Zidovudine/Lamivudine/Abacavir. i

Infectious Diseases

Explanation:

n __ *

* -r -

Explanation: | Acetaminophen, ribavirin, rifabutin, and Rifampin may decrease blood levels o f Zidovudine.

281.

Answer: E. A and D

Explanation: j Cytochrome P450 enzymes are heme proteins, comprising a large family o f different enzymes (each referred to as CYP followed by a defining set o f numbers and letter). These enzymes differ from one another in amino acid sequencfe, in regulation by inhibitors and inducing agents. Delavirdine is a Nonnucleoside reverse trariscriptase inhibitor which inhibits its own metabolism by reducing the activity o f CYP3A4 and CYIP2C9.

282.

Answer: E. A and B

|
i

Explanation: j Delavirdine inhibits the metabolism o f terfehadine, astemizole, and Cisapride, and this increases the risk o f cardiac arrthymias. Alprazolam and Midazolam are benzodiazepines (a class o f sedative hypnotics) and an increase in their plasma level results in excessive sedation.

283.

Answer: C.

Itsonce daily dosing.

Explanation: ] The advantage o f Efavirenz over other Nomiucleoside reverse transcriptase inhibitors is its once daily dosing. j

284.

Answer: C.

CYP3A4

Explanation: j Efavirenz induces CYP3A4 enzyme and sljould not be used concomitantly with astemizole, Cisapride, Midazolam, Triazolam, or ergot derivatives. I 285. Answer: D. p ^ Nevirapine j j

Explanation: j Nevirapine is Nonnucleoside reverse transcriptase not a protease inhibitor. Indinavir, Lopinavir, nelfinavir, Ritonavir and jsaquinavir are protease inhibitors.

Amprenavir,

286.

Answer: D.

Ritonavir

Explanation: Saquinavir, Ritonavir, and Indinavir are not approved for use in the pediatric population.

287.

Answer: C. Amprenavir

Explanation: Amprenavir is the protease inhibitor with the longest half-life. It has a half-life o f 7.1-10.6 hrs.

288.

Answer: B. Saquinavir

Explanation: Saquinavir hard caps should be administered with fatty foods to improve bioavailability because the oral bioavailability alone is only 4 %. Fortovase is a soft gel cap formulaticfn o f a saquinavir that has improved bioavailability and efficacy. I

289.

Answer: B. Diarrhea

Explanation: The most commonly reported adverse effect of nelfinavir is diarrhea.

290.

Answer: D. Vitamin E

Explanation: Vitamin E is given in Amprenavir capsules, because it increases the absorption o f Amprenavir. 36 international units (IU) o f vitamin E arb included in 50mg o f Amprenavir.

291.

Answer: C. Propylene glycol

Explanation: | The oral liquid formulation o f Amprenavir contains a large amount o f propylene glycol. Therefore, it must not be used in infants and children under 4 years old, pregnant women, patients with severe kidney or liver problems, nor in patients who take disulfiram or metronidazole.

292.

Answer: E. A and B

Explanation: Rifabutin, Phenobarbital, Phenytoin, dexamethasone, and Carbamazepine also lower saquinavir plasma concentrations. Ketoconazole and Clarithromycin have increased saquinavir levels by 130%-180%.

293.

Answer: B. Lopinavir/Ritonavir

Explanation: Lopinavir/Ritonavir is the first FDA approv i:d combination o f protease inhibitors.

294.

Answer: B. 4:1

Explanation: The Lopinavir/Ritonavir combination is formulated as a 4:1 ratio o f Lopinavir to Ritonavir, Ritonavir markedly reduces the metabcjl ism o f Lopinavir, resulting in increased plasma concentrations.

295.

Answer: A. Lopinavir

Explanation: Lopinavir has the shortest half-life.

296.

Answer: D. Enfuvirtide

Explanation: Enfuvirtide is an antiretroviral drug that indibits the entry o f HIV-1 and CD4+ cells by interfering with the fusion o f viral and cellular mem branes. It does not have drug interactions with the CYP450 enzyme system.

297.

Answer: E. A and B only

Explanation: Mebendazole interferes with reproduction and survival o f helminthes by inhibiting the formation o f microtubules and irreversibly blocking glucose uptake, there by depleting glycogen stores in the helminthes.

298.

Answer: D. Trichinella spiralis-threadworm

Explanation: Trichinella spiralis is commonly known as pork worm.The scientific name o f threadworm is strongyloides stercoralis.

299.

Answer: E. A and B

Explanation: Carbamazepine and hydantoins may ieduce the blood levels and subsequent efficacy of mebendazole.

300.

Answer: E. A and C

Explanation: Both Albendazole and mebendazole ard synthetic imidazole derivatives. Pyrantel is a Pyrimidine, and diethylcarbamazine is a synthetic organic compound which is not structurally related to the above mentioned anthelmintics.

301.

Answer: E. B and C i !

Explanation: Albendazole is active against Taenia solium and Echinococus granulosis.

|

I
i

302.

Answer: C. Wuchereria bancrofti

Explanation: Patients treated for W.bancrofti infection often present with headache and general malaise.

303.

Answer: D. Tape worm infection

i

Explanation: ; Pyrantel is not used in the treatment o f tape worm infection.

304.

Answer: C. Piperazine

Explanation: I Piperazine is an anthelmintic drug which antagonizes the action o f Pyrantel.

305.

Answer: B. Thiabendazole

Explanation: j Thiabendazole besides its anthelmintic property, it exhibits anti-inflammatory, antipyretic, and analgesic effects.

306.

Answer: E. A and D

'

Explanation: Thiabendazole is active against trichophyton, and Microsporum species.

307.

Answer: E.A&B

Explanation: The most common adverse effects o f thiabendazole are anorexia, nausea, vomiting, and dizziness. Seizures, vertigo, paresthesias, and psychic disturbances may also occur less frequently.

308. Answer: A. It causes flaccid parah sis o f the helminth by blocking the response o f the ascaris muscle to acetylcholine. Explanation: Piperazine causes flaccid paralysis of the helminth by blocking the response o f ascaris muscle to acetylcholine.

309.

Answer: E. A and B

Explanation: Piperazine is active against Ascaris lumbrit aides and Enterobius Vermicularis.

310.

Answer: C. Fumarate reductase

Explanation: Thiamebendazole was shown to inhibit the helminth-specific enzyme, fumarate reductase.

311.

Answer: D. Quinacrine

Explanation: Quinacrine is used for the treatment o f gi irdiasis and cestodiasis. It is active against T.saginata, T.solium, H.nana, diphyllobothrium latum and the protozoa Giardia lamblia. 312. Answer: B. It affects only cestodcs o f the intestine.

Explanation: Niclosamide is used against T.saginata (beef tapeworm), D.latum (fish tapeworm), and H.nana (dwarf tapeworm). It is not active agair st cysticercosis (a disease caused by the presence o f tapeworm larvae of the species Taenia s k iu m in any o f the body tissues) because it affects the cestodes o f the intestine only. 313. Answer: A. Piperazine

Explanation: Piperazine should be taken in empty stom ich in order to be effective.

1. Catecholamines are from the amino acid A. B. C. D. E. Glycine Alanine Tyrosine Methionine Proline

synthesized

A. B. C. D. E.

Epinephrine / Adrenaline NaphazoJine Terbutaline Dobutamine Amphetamine Alkyl substitution at the a-carbon (adjacent to amino group) in adrenergic agonists shows all the below effects EXCEPT

2. Number of hydroxyl groups in Dopamine A. B. C. D. E.

A. B. C. D. E.

1 2 3 4 5

Retards destruction of compound Increases lipophilicity Produces prolonged action Increases water solubility None

7. a-adrenergic antagonist that is a quinazoline derivative A. B. C. D. E.

8.

3. Common chemical chain present in adrenergic agonists is A. B. C. D. E. Methylamine Ethylamine Acetic acid Chlorobenzene Pentylamine

Phentolamine Tolazoline Phenoxybenzamine Prazosin Amphetamine Isopropylamine is the common side chain in all the drugs mentioned below EXCEPT in Propranolol Acebutolol Pindolol Atenolol Tyramine

4. All the following statements are TRUE regarding direct acting adrenergic agonists EXCEPT A. Catecholamines are activated by the enzymes COMT (Catechol ortho methyl transferase) and MAO (Monoamino oxidase) B. Smaller substituents on N-, like hydrogen, a-methyl group produce a-receptor activity. C. Larger substituents on N-; like isopropyl group produces p receptor activity. D. For a- and p-receptor activity, hydroxyl group on meta position is necessary. E. Catecholamines are inactivated by the enzymes COMT (Catechol ortho methyl transferase) and MAO (Monoamino oxidase) 5. One of the following is indirect acting adrenergic agonist

A. B. C. D. E.

9. The common linking group between aromatic ring and nitrogen in Propranolol, Pindolol, Atenolol and Timolol is A. B. C. D. E. Ethoxy 2-hydroxy-prpoxyOxy butyl Methyl Methoxy

10.Choline is chemically A. B. C. D. E. 1 amino 2 amino 3 amino 4 amino None alcohol alcohol alcohol alcohol

l.The link, functional group, between acetic acid and choline in Acetylcholine is A. B. C. D. E. Ester Ether Amine Lactone Lactam

A. B. C. D. E.

Propantheline Dicyclomine Atropine Glycopyrrolate Tropicamide

16.Quaternary nitrogen is present in A. B. C. D. E. 17. Tropicamide Ipratropium Pirenzepine Dicyclomine Cyclopentolate Cholinomimetic drug is Dicycloverine Tyramine Neostigmine Tropicamide Ipratropium

12. Which of the following is chemically unstable and hence not useful systemically A. B. C. D. E. Methacholine Bethanechol Acetylcholine Carbachol None

A. B. C. D. E.

13. Which of the following statement is FALSE A. Acetylcholine is extremely short acting as it undergoes rapid hydrolysis by acetylcholinesterase enzyme B. Replacement of acetyl group by carbamoyl group in Acetylcholine produces Carbachol, which is less susceptible to hydrolysis and hence more stable C. Substitution of methyl group on pcarbon of Carbachol produces Bethanechol D. Substitution of methyl group on pcarbon of Acetylcholine produces Methacholine E. Acetylcholine is more stable than Carbachol, Methacholine and Bethanechol 14. Which of the following is direct acting cholinergic agonist A. B. C. D. E. Carbachol Physostigmine Neostigmine Echothiophate Isoflurophate

18.d-tubocurarine is an example of A. B. C. D. E. 19. WRONG choline Neuromuscular blocking agent Sympathomimetic agent Sympatholytic agent Cholinomimetic agent Para sympatholytic agent Which o f the following statement is regarding succinyl

A. Succinyl choline is non competitive depolarizing agent B. Aliphatic molecule C. Short duration of action D. Contains ester functional group E. Shows neuromuscular blocking effect by blocking the receptor because of its bulky nature like Tubocurarine .Natural competitive non depolarizing agent that comes under Neuromuscular blocker A. B. C. D. E. Atracurium Doxacurium Tubocurarine Vecuronium Pancuronium

15.All the below agents are synthetic anti-cholinergic agents EXCEPT

21. Which of the following is NOT a steroidal derivative A. B. C. D. E. Pancuronium Mivacurium Pipecuronium Vecuronium None

D. Contains one chlorine and two fluorine groups E. Available with the name Amidate 27.Ester type of Local anesthetic drug A. B. C. D. E. 28. Lidocaine Dibucaine Mepivacaine Benzocaine Prilocaine Which o f the following statement is FALSE regarding Local anesthetic

22. What is the chemical ring structure commonly present in Atracurium, Doxacurium, Tubocurarine, Metocurine and Mivacurium A. B. C. D. E. Pyrrole Piperidine Quinoline Isoquinoline Imidazole

23.Cyclohexanone ring is present in A. B. C. D. E. 24. Ketamine Fenatanyl citrate Midazolam Thiopental Etomidate General contain ether group Enflurane Desflurane Sevoflurane Isoflurane Halothane anesthetic that

A. Ester type of drugs are longer acting comparing to amide type of drugs B. Site of action of local anesthetic is the inner surface of the cell membrane C. Upon ionization, the cationic form is the active form D. Drugs pKa influences the chemical state of the drug E. None 29.Xylidine ring is not present in doesnt A. Lignocaine / Lidocaine B. Bupivacaine C. Procaine D. Etidocaine E. Mepivacaine 30.Which of the following drug structure contains Quinoline ring A. B. C. D. E. Benzocaine Lidocaine Etidocaine Butamben Dibucaine

A. B. C. D. E.

25.General anesthetic that is also called as laughing gas A. B. C. D. E. Desflurane Nitrous oxide Fentanyl Propofol Midazolam Which of the following statement is FALSE with Etomidate A. Non volatile general anesthetic B. Water soluble and available as aqueous propylene glycol solution C. Contains imidazole ring in the structure

31.Benzisoxazole derivative having Anti-psychotic drug action is A. B. C. D. E. Chlorprothixene Loxapine Pimozide Clozapine Risperidone is a derivative of

32.Haloperidol

A. B. C. D. E.

Thioxanthine Butyrophenone Phenothiazine Dibenzoxazepine Dihydroindolone

D. Quetiapine E. Butamben 37. Which of the following is NOT a dibenzazepine derivative A. B. C. D. E. Amitriptyline Imipramine Desipramine Clomipramine Trimipramine

33. Which of the following is WRONG statement A. Chlorprothiazine is thioxanthene derivative B. Fluphenazine and Fluoperazine are phenothiazine derivatives C. Clozapine is dibenzodiazepine derivative D. Pimozide is a dihydroindolone derivative E. Risperidone is benzisoxazole derivative 34. All statements are true regarding phenothiazines as Anti-psychotic agents EXCEPT A. Fluphenazine and long chain alcohols form highly hydrophilic compounds Substitution of nitrogen containing side chain on ring nitrogen is must for anti-psychotic activity. Ring and side chain nitrogens are to be separated by three carbon chain Side chains may be either aliphatic, piperidine or piperazine derivatives None from

38.A tetra cyclic Anti-depressant agent A. B. C. D. E. Doxepin Amitriptyline Nortriptyline Protriptyline Maprotiline

39.Dibenzoxazepine derivative A. B. C. D. E. Doxepin Amoxapine Imipramine Phenelzine Tranylcypromine

B.

40.Which of the following is NOT a serotonin reuptake inhibitor A. B. C. D. E. Fluoxetine Paroxetine Trazodone Sertraline Fluvoxamine

C.

D.

E.

41.Lithium carbonate is used as 35.Thioxanthenes differ phenothiazines in A. B. A. B. C. D. E. 42. Anthelmintic Anti-manic Anti-diarrhoeal Anti-spasmodic Local anesthetic Which o f the following is NOT a benzodiazepine derivative Diazepam Alprazolam Lorazepam Chlrodiazepoxide Thiopental

Having extra nitrogen Lacking thering nitrogen and having link to the side chain by double bond C. Not having anti-psychotic action D. Having analgesic action E. None 36.

A. Which o f the following is NOT B. an C. Anti-psychotic agent D. E. A. Loxapine B. Sertindole

Remoxipiride

C.

43.Which of the following statements is WRONG regarding Benzodiazepines A. Compound with 3-OH group are metabolized by Phase-I reactions B. Agents lacking 3-OH group will undergo phase I metabolism C. Metabolite of diazepam is having more potency and longer duration of action than diazepam D. Benzodiazepines contains an additional phenyl substituent to show anxiolytic activity E. None 44. Which of the following drugs is an azaspirone derivative Buspirone Zolpidem Glutethimide Paraldehyde Pentobarbital

48.Long acting barbiturates have below substituents in position-5 A. B. C. D. E. Phenyl and chloride Phenyl and ethyl Chloride and ethyl Phenyl and chloride None

49.Hypnotic drug that is barbiturate derivative A. B. C. D. E. Glutethimide Methypiylon Phenobarbitol Paraldehyde Chloral hydrate comes

A. B. C. D. E.

50. Anti-epileptic drug that under hydantoin derivative A. B. C. D. E. Phenytoin Ethosuximide Primidone Trimethadione Clorazepate

45.Buspirone structure doesnt contain A. B. C. D. E. Piperazine Pyrimidine Benzene Butyl group Cyclopentane

51. Valproic acid used as Anti-epileptic agent is a derivative of A. B. C. D. E. Iminostilbine Dialkyl acetate Oxazolidine dione Succinimide Hydantoin

46.Two side chains in position 5- of barbituric acid is essential for A. B. C. D. E. Sedative-hypnotic activity Analgesic activity Anti-pyretic activity Anti-spasmodic activity None

52.Phenyl triazine derivative used as Anti-epileptic agent A. B. C. D. E. Gabapentin Carbamazepine Dimethadione Lamotrigine Felbamate

47. In barbiturates, substitution of oxygen at 2 nd position with sulfur produces the below effects EXCEPT A. Lipophilicity B. Rapid distribution into lipid tissue C. Ultra-short acting agents that induce anesthesia D. Thiopental is an example E. Looses its lipophilicity

53.1midazolidinedione ring is present in A. B. C. D. E. Ethosuximide Trimethadione Phenytoin Clonazepam Primidone

54.An example for Anti-parkinsonism agent A. B. C. D. E. 55. A. B. C. D. E. Cocaine Tubocurarine Levodopa Amitriptyline Carbamazepine Selective inhibitor of COMT is Selegiline Tolcapone Carbidopa Fluoxetine Fluvoxamine

A. B. C. D. E.

Digitoxin Digoxin Gitoxin Ouabain None in cardiac

61.Glycosidic linkage glycosides is A. B. C. D. E. Ether Ester Amide Disulfide Peptide

56.Meperidine, an opioid analgesic contains the ring structure of A. B. C. D. E. Piperidine Pyrimidine Pyrazine Pyradiazine Pteridine

62.As the number of hydroxyl groups increases in the cardiac glycoside structure the following results will be observed EXCEPT A. Increases polarity B. Decreases protein binding C. Decreases renal tubular reabsorption D. Decreases liver bio-transformation E. Increases duration of action 63.The positive ionotropic agent that contains bipyridine moiety A. B. C. D. E. Amrinone Digoxin Digitoxin Gitoxin None

57.The basic ring present in Morphine, Codeine and Heroin is A. B. C. D. E. Naphthalene Phenanthrene Isoquinoline Phenothiazine Barbituric acid -

58.Morphinan derivative having opioid action is A. B. C. D. E. Morphine Pentazocine Levorphanol Buprenorphine Naloxane

64.An Anti-anginal drug that is an organic ester of nitrous acid

A. Nitroglycerin B. Isosorbide C. Amylnitrite D. Propranolol 59. Which of the following is an opioid E. Nifedipine antagonist 65.Dipiperdino-dipyrimidine derivative used as peripheral vasodilator A. Morphine B. Codeine A. Verapamil C. Methadone B. Nifedipine D. Tramadol C. Amlodipine E. Naltrexone D. Dipyridamole 60. Cardiac glycoside obtained from E. Milrinone Strophanthus gratus

66

.Xyly] derivative that comes under both Local anesthetic and: Anti arrhythmic agent Lidocaine Quinidine Acebutolol Diltiazem Phenytoin is

D. Pyrrole E. Thiazole 72. Which of the following statement is WRONG regarding thiazide diuretics A. Benzthiadiazide is the basic ring in almost all the thiazide diuretics B. Substitution of sulfonamide moiety on position-7 is not compulsory C. Saturation of 3,4-double bond produces increases potency D. Lipophilic substituents at position3 increases potency and provides prolong activity E. Replacement of sulfonyl group in postion- 1 with carbamoyl group prolongs the activity 73.Anthranilic acid derivative used as Loop diuretic A. B. C. D. E. Ethacrynic acid Triamterene Spironolactone Chlorothiazide Furosemide

A. B. C. D. E.

67.Anti-arrhythmic drug that diiodobenzyloxyethylamine derivative A. B. C. D. E.

68

Lidocaine Quinidine Verpamil Dipyridamole Amiodarone

.Which of the following Anti hypertensive agent is similar in structure to the thiazide diuretics Diazoxide Clonidine Diltiazem Captopril Losartan Which of the following is NOT a cardiovascular agent Propranolol Nadolol Esmolol Acebutolol Halothane

A. B. C. D. E. 69.

74.Potassium sparing diuretic, Triamterene is having the basic ring moiety A. B. C. D. E. Pyridine Piperidine Pteridine Pyrimidine Pyradiazine

A. B. C. D. E.

70.Carbohydrate derivative used as osmotic diuretic A. B. C. D. E. 71. Glucose Starch Mannitol Sucrose None

75.Steroidal moiety containing diuretic A. B. C. D. E. Spironolactone Amiloride Bumetanide Acetazolamide Quinethazone

Carbonic anhydrase inhibitors used 76.All the below statements regarding as diuretics contain the basic Cholestyramine are true EXCEPT structural ring A. Non-absorbable antiA. Benzene hyperlipidemic agent B. Thiadiazole B. Bile acid sequestrant C. Pyridine C. Basic anion-exchange resin

D. Consists co-polymer of styrene and divinyl benzene E. Consists co-polymer of diethyl pentamine and epichlorohydrin 77. Which of the following is NOT an absorbable Anti-hyperlipidemic agent A. B. C. D. E. Clofibrate Probucol Lovastatin Colestipol Gemfibrozil

A. B. C. D. E.

Iron dextran Ferrous sulfate Ferrous gluconate Ferrous fumarate None

83.Vitamin that contains cyanide ion and cobalt atom and used as Antianemic agent A. B. C. D. E. Vitamin BI Vitamin B2 Vitamin B 6 Vitamin B l2 Vitamin C

78.Anti-coagulant used both in vivo and in vitro A. B. C. D. E. Heparin Lepirudin Warfarin Dicumarol Phenindione

84.Amino acid present in the structure of Folic acid

A. Aspartic acid B. Glutamic acid C. Tyrosine D. Glycine E. Leucine 79. Which of the following is NOT a 85.Hematopoietic growth factors low molecular heparin fragment include A. Enoxaparin A. Erythropietin B. Dalteparin B. Filgrastin C. Tinzaparin C. Oprelvekin D. Ardeparin D. All the above E. Lepirudin E. None 80. Salicylic acid derivative having 86. Which of the following is NOT a Anti-platelet activity Hi-receptor antagonist A. Paracetamol A. Chlorpheniramine B. Ticlopidine B. Meclizine C. Aspirin C. Nizatidine D. Dipyridamole D. Cyproheptadine E. Piroxicam E. Pyrilamine 81. Serine protease obtained from 87. Which of the following has human kidney cells and having piperazine ring in its structure thrombolytic activity A. B. C. D. E. Streptokinase Urokinase Alteplase Anistreplase Reteplase A. B. C. D. E.
88

Dimenhydrinate Cetirizine Promethazine Cyproheptadine Astemizole

82. Anti-anemic agent that is NOT used for oral administration

.Anti-histamine drug Acrivastine and cetirizine shows less sedation

comparing to other anti-histamines due to their A. B. C. D. E. Limited ability to cross BBB High molecular molecular weight Complex structure Piperidine ring structure None

94. Which of the following statement is FALSE regarding prostaglandins A. COX-1 is a constitutive enzyme B. COX-11 is a pathologic enzyme C. Thromboxanes differ from prostaglandins mainly by the substitution of tetrahydropyran ring structure for pentane ring found in prostaglandins D. Prostaglandin is a derivative of prostanoic acid E. Prostaglandins are synthesized from glutamic acid 95. Thromboxane that is clinically relevant as platelet aggregating agent

89.Proton pump inhibitors are specific inhibitors of A. B. C. D. E. Na+ K+ ATPase pump H+ Na+ ATPase pump H+ K+ ATPase pump C ai+ channel pump None Tryptamine is also

90.5-Hydroxy called as A. B. C. D. E.

Epinephrine Acetyl choline Dopamine Serotonin Nor-epinephrine

A. B. C. D. E.

TXA] TXA2 TXB, TXB 2 None from

96.Leukotrienes differ prostaglandins in that

91. Which of the following serotonin agonist is NOT an indole derivative A. B. C. D. E. Sumatriptan Zolmetriptan Almotriptan Rizatriptan Cisapride

A. They contain no ring structure and are covalently linked to 2 or 3 amino acids B. They are 20-carbon derivatives of fatty acids C. They are not autocoids D. They have different nomenclature E. They wont have physiological actions 97.Lipoxygenase inhibitor A. B. C. D. E. 98. A. B. C. D. E. Aspirin Piroxicam Paracetamol Diclofenac Nimesulide Zafirlukast Montelukast Zilueton Misoprostol Carboprost Acetyl ester of salicylic acid is

92. An indole derivative that acts as 5HT 3 antagonist A. B. C. D. E. Ondasetron Sumatripton Rizatripton Zolmetriptan Almotriptan

93.Prostaglandins are synthesized from A. B. C. D. E. Maleic acid Fumaric acid Arachidonic acid Mandelic acid Phthalic acid

99. Winter green oil is the synonym of

A. B. C. D. E.

Diflunisai Sodium thiosalicylate Methyl salicylate Choline salicylate Sulphasalazine

C. Diclofenac D. Naproxen E. Paracetamol 103. Anthranilic acid derivative used as NSAID is A. B. C. D. E. Nabumetone Ibuprofen Mefenamic acid Aspirin Diclofenac

100. NSAID (Non Steroidal Anti inflammatory Drug) used as uricosuric agent A. B. C. D. E. Acetaminophen Sulfinpyrazone Etodolac Valdecoxib Piroxicam

104. Which of the following is a selective COX-11 inhibitor A. B. C. D. E. Celecoxib Ketorolac Naproxen Ketoprofen Aspirin

101. Gout is the disease condition, which involves deposition of A. B. C. D. E. Prostaglandins Leucotrienes Histamines Bradykinis Sodium urate crystals

105. Which of the following is NOT an Autocoid A. B. C. D. E. Histamine Prostaglandin Leukotriene Serotonin Cyclooxygenase

102. Propionic acid derivative used as NSAID is A. Etodolac B. Sulindac

ANSWERS

Medicinal Chemistry
1. Answer: C. Tyrosine

Explanation: Naturally occuring catecholamines include epinephrine (adrenaline) and norepinephrine (noradrenaline). They are biosynthesized from tyrosine, an amino acid. M H ,
Tyrosine
I Tyrosine hjdioxytsse

H ~ C00H

HH, i
HO

D O P A (D ih ^ ia iy p k n ^ lih iu n e )

| Aromatic L'amino aciddecasboxyiase

HO

i H O
D o p a m in e

|Dop*jwi* Plijriroxyiise

H O
Norep inep h rin e f N ora d re n a lin e | Phe-rijfe tlianoiarau* N '

O M M O^ ^ CH C H j NH C H j

2. Answer: B. 2. Explanation: Dopamine is a neurotransmitter biosynthesized from tyrosine by the action of tyrosine hydroxylase and aromatic L-amino acid decarboxylase. It is a catechol derivative and hence it contains two hydroxyl groups in its structure. 3. Answer: B. Ethylamine. Explanation:

Adrenergic agonists either direct acting or indirect acting contains ethylamine as a common chain and is essential to their activity. I t ..'V
HO
HO

C H j Dobutamine (Ethylamine chain)

Norepinephrine (Ethylamine chain)

Epinephrine (Ethylamine chain)

Naphazoline (Ethylamine chain) 4. Answer: A.

Terbutaline (Ethylamine chain)

Explanation: Direct acting adrenergic agonists interact directly with adrenergic receptors to produce a response. E.g., Epinephrine (adrenaline), norepinephrine (noradrenaline), naphazoline, terbutaline, dobutamine etc. Chemical Factor Ethylamine chain Smaller substituents on N-. E.g., hydrogen, a-methyl group Larger substituents on N-. E.g., isopropyl group Hydroxyl / sulfonamide on meta position Catechol ortho methyl tranferase (COMT) Monoaminooxidase (MAO). 5. Answer: E. Amphetamine. Effect Essential for activity a-receptor activity E.g., norepinephrine p-receptor activity E.g., isoproterenol Essential for a- and p-receptor activity Inactivation (Methylation o f the meta hydroxyl group) Inactivation (Oxidative Deamination)

1 2

. .

3. 4. 5.
6

Explanation: Indirect acting adrenergic agonists even though chemically related to the catecholamines they do not interact directly with the adrenergic receptors. They act by stimulating the release of endogenous catecholamine neurotransmitters. Hence they are also called as sympathomimetic agents. E.g., amphetamine, ephedrine and tyramine. Epinephrine/Adrenaline, Naphazoline, Terbutaline and Dobutamine are direct acting adrenergic agonists.

CHL

CH,

CH*

1 CH---- NH>
Amphetamine
OH CH CH, 1
CH N H -C H 3

HO

Hydroxy amphetamine

Methamphetamine

^ //

HO

Ephedrine
6

Tyramine

Answer: D.

Explanation: Chemical Factor Alkyl substitution on a-carbon (adjacent to amino group) More Hydroxyl groups Effect Increased lipophilicity > Increased absorption > Decreased destruction > Prolonged Activity Increased hydrophilicity > Decreased absorption > Increased destruction > Decreased Activity Increased direct [3-receptor activity

1 2

. .

3. 7.

Substitution of bulky groups on NAnswer: D. Prazosin.

Explanation: a -adrenergic antagonists include: Ergot alkaloids: Ergotamine Dibenzamines: Phenoxybenzamine Benzolines: Tolazoline Quinazolines: Prazosin Nonselective a -receptor blockers (adrenergic antagonists) include phenoxybenzamine and phentolamine. Selective cti-receptor blockers include prazosin, terazosin, doxazosin and indoramin. Selective a 2-receptor blockers include yohimbine, tolazoline and rauwolscine.

NHj

Prazosin (Quinazoline, piperazine, furan rings; ketone link) I'wp-x

Phenoxybenzamine (Dibenzamine; ether link)

Phentolamine (Imidazoline ring)

8

. Answer: E. Tyramine

Explanation: Nonselective p-receptor blockers (p-adrenergic antagonists) commonly contain isopropyl chain in their structure. E.g., Propranolol, pindolol, timolol, sotalol, penbutolol, carteolol etc. Selective Pj-receptor blockers include acebutolol, atenolol,, betaxolol, celiprolol, esmolol and metoprolol. Selective p2-receptor blocker includes butoxamine. Tyramine is an indirect acting adrenergic agonist that doesnt contain isopropyl chain in its structure.

(Naphthalene ring, ether link, isopropylamine side chain)

(Ether link, isopropylamine side chain)

Pindolol (Indole ring, ether link, isopropylamine side chain)

ch 2 c h 2- imh2

(Ehter link, isopropylaminb side chain)

//
HO

Tyramine (Ethylamine side chain) 9. Answer: B. 2-hydroxy-propoxyExplanation: In all the drugs propranolol, pindolol, atenolol, timolol the common linking chain between ring structure and nitrogen is 2 -hydroxy-propoxy- chain.

ch3 Atenolol ( 2 -hydroxy-propoxy- link) Propranolol (2 -hydroxy-propoxy- link)

QH

H
.N CH3

H .NY
ch

C3

A H3 G OH 3
Timolol (2 -hydroxy-propoxy- link)

(2 -hydroxy-propoxy- link) 10. Answer: D. 4 amino alcohol.

h3 c + ch3

Acetylcholine chloride (Acetic acid + choline = Acetylcholine + water) (Choline = Quaternary amino alcohol [trimethyl amino ethanol]) 11. Answer: A. Ester Explanation: Acetylcholine, the most potent neurotransmitter acting at cholinergic receptor as agonist, is an endogenous neurotransmitter. It is an ester of acetic acid and choline (quaternary amino alcohol).

h3 c ch3
C f

CH3
Acetylcholine (Ester link) 12. Answer: C. Acetylcholine. Explanation: Acetylcholine, methacholinb, bethanechol, carbachol; all are cholinergic agents (direct acting cholinergic agonists), but vary in their stability and duration of action. Acetylcholine is chemically very unstable and readily undergoes hydrolysis both in vivo and in vitro resulting in extremely short duration of action and hence didnt got attention as therapeutic agent. Acetylcholinesterase is the enzyme that causes hydrolysis of acetylcholine in vivo. Substitution of methyl group on p-carbon of acetylcholine produces methacholine. Replacement of acetyl group by carbamoyl group in acetylcholine produces carbachol, which is less susceptible to hydrolysis and hence more stable. Substitution of methyl group on p-carbon of carbochol produces bethanechol. Methacholine, Carbachol and Bethanechol, which are less susceptible to acetylcholinesterase, are said to be stable and produces longer duration o f action.

9
h 3c

CHjH sC .C h,

Cl

"c h 3
Methacholine chloride
0

Acetylcholine chloride

o
h2n

h3 c

+/ch 3
Cl
Ct

ch 3
Carbachol chloride

H2 N

jQ

ch3

Bethanechol choride

13. Answer. E. Explanation: Acetylcholine is chemically very unstable and undergoes hydrolysis readily hence not used systemically whereas Methacholine, Bethanechol and Carbachol are stable than acetylcholine and somehow more resistant to hydrolysis hence got therapeutic value and utility. 14. Answer: A. Carbachol. Explanation: Direct acting cholinergic agonists: They act directly on the cholinergic receptors and show the cholinergic actions. E.g., Acetylcholine, methacholine, bethanechol and carbachol. Indirect acting cholinergic agonists: They act by increasing the levels o f acetylcholine in vivo by inhibiting the acetylcholinesterase enzyme that causes degradation (hydrolysis) of acetylcholine. These are again of two types: Reversible inhibitors (short acting) E.g., Cambamates (carbamic acid esters): physostigmine (eserine), neostigmine Irreversible inhibitors (long acting) E.g., Organophosphorous agents (organophosphorate esters): echothiophate, isoflurophate, parathion, malathion.

Physostigmine 15. Answer: C. Atropine.

Neostigmine

Explanation: Anti-cholinergic agents or cholinergic antagonists are those that block the actions of acetylcholine at muscarinic or nicotinic receptors. Atropine is a natural alkaloid obtained from plant source, Atropa.belladona. A pah of the structure of atropine is similar to acetylcholine allowing it to bind to postganglionic parasympathetic receptors. Atropine has no intrinsic activity and it simply acts by its bulky structure, preventing acetylcholine from binding to the receptor and thereby inhibiting the cholinergic actions. Propantheline, dicyclomine, glycopyrrolate, tropicamide, pirenzapine, ipratropium and benzatropine are synthetic anti-cholinergic agents.

T n -c h
3

L
OH

OH Homatropine

Atropine

Propantheline 16. Answer: B. Ipratropium.

Dicyclomine

Explanation: Propantheline, dicyclomine, glycopyrrolatc, tropicamide, pirenzapine, ipratropium and benzatropine are synthetic anti-cholinergic agents. Quaternary nitrogen is present in propantheline, glycopyrrolate and ipratropium; hence positive charge, thereby reducing passage across the blood brain barrier. Tertiary nitrogen is present in dicyclomine, pirenzapine, tropicamide and benzatropine, hence no significant charge, which provide higher volume of distribution.

j N rC H j

Br

OH

CH3

OH

Tropicamide (Tertiary amine)

ck3 Ipratropium (Quaternary amine)

17. Answer: C. Neostigmine Explanation: Neostigmine is the indirect acting cholinergic agonist that acts by reversibly inhibiting the acetylcholinesterase enzyme thereby increasing the concentration o f acetylcholine hence also called as cholinomimetic agent. Tyramine is an indirect acting adrenergic agonist. Tropicamide, dicycloverine (dicyclomine) and ipratropium are synthetic anti-cholinergic agents. 18. Answer: A. Neuromuscular blocking agent. Explanation: d-tubocurarine is a neuromuscular blocking agent. It is a competitive non-depolarizing agent obtained naturally as curare alkaloid. It is rigid and bulky molecule.

d-Tubocurarine (Isoquinoline ring, quaternary amine) 19. Answer: E. Explanation: Neuromuscular blocking agents are of two types. Competitive non-depolarizing agents and noncompetitive depolarizing agents. Former type include curare derivatives as examples, they act by competitively blocking nicotinic receptor because of their bulky structure and inhibits the action of acetylcholine thereby resulting in neuromuscular blocking effect and produces skeletal muscle relaxant effect. Noncompetitive depolarizing agents include succinyl choline and gallamine. These agents are aliphatic molecules. Succinyl choline has a short duration of action because of rapid hydrolyzing nature in the liver and plasma by pseudo cholinesterase (butylcholinesterase) as it contains simple ester functional group. 20. Answer: C. Tubocurarine. Explanation: d-tubocurarine is a natural competitive non-depolarizing neuromuscular blocking agent whereas Atracurium, Doxacurium, Vecuronium and Pancuronium are synthetic competitive non-depolarizing neuromuscular blockers. 21. Answer: B. Mivacurium. Explanation: A wide number o f compounds structurally related to naturally available d-tubocurarine used, as neuromuscular blockers are available synthetically. E.g., Isoquinoline derivaties: metocurine, atracurium, doxacurium and mivacurium. Steroidal derivatives: pancuronium, vecuronium and pipecuronium. o

Pancuronium bromide (Quaternary amine, steroidal moiety)

22. Answer: D. Isoquinoline. 23. Answer: A. Ketamine Explanation: Cyclohexanone ring is present in Ketamine. General anesthetics include: Volatile or inhalation anesthetics: These agents exist as gases or vapors and are lipophilic in nature. E.g., Nitrous oxide (inorganic agent; flammable; laughing gas), Halothane (halogenated hydrocarbon) and Ethers (methoxyflurane, isoflurane, desflurane, sevoflurane). Nonvolatile or intravenous anesthetics (occasionally intramuscular). These agents are available as aqueous solutions, aqueous propylene glycol solutions or emulsions. E.g., ultra short acting barbiturates (thiopental, methohexital, thiamylal), cyclohexylamines (ketamine), benzodiazepines (diazepam, midazolam), butyrophenones (droperidol), opioid analgesics (morphine, fentanyl), imidazole derivative (etomidate; an aqueous propylene glycol solution), dialkylphenol (propofol; as an emulsion)
ch3
H 3C H 2C C H C H i C H 2C H 3

Ketamine (Cyclohexanone ring)

Midazolam (Benzodiazepine ring)

Thiopental (Dihydropyrimidine dione)

Etomidate (Imidazole ring, ester link) 24. Answer: E. Halothane

Fentanyl (Piperidine ring)

Explanation: Halothane doesnt contain ether link whereas enflurane, desflurane, sevoflurane and isoflurane contains ether link in their structure. All these drugs comes under inhalation type of volatile genera] anesthetics.
F F F

Cl

Enflurane (Ether link)

CF3

Desflurane (Ether link)

Sevoflurane (Ether lnik)

Br F H C C F F

Cl

ci

Isoflurane (Ether link) 25. Answer: B. Nitrous oxide

Halothane (Halogenated hydrocarbon)

Explanation: Nitrous oxide (N 2 0 ) is a colorless gas also called as laughing gas. It is a nonflammable gas but it can support combustion. It can produce narcosis effect. 26. Answer: D. Explanation: Etomidate is a non volatile general anesthetic that is water soluble and available as aqueous propylene glycol solution. It is available commercially with the name Amidate. Structurally etomidate contains imidazole ring, ester link, but it wont contain any chlorine or fluorine groups. N

Etomidate (Imidazole ring, ester link) 27. Answer: D. Benzocaine. Explanation: Local anesthetics are similar in structure to natural alkaloid cocaine. These agents consist of a lipophilic aromatic group linked to hydrophilic moiety through an ester or amide bonding. Ester type of agents includes cocaine, benzocaine, procaine, chloroprocaine, butamben and tetracaine. These agents because o f simple ester group undergo rapid hydrolysis by plasma esterases resulting in short duration of action. Amide type of agents includes lidocaine(lignocaine/xylocaine), dibucaine, prilocaine, mepivcaine, bupivacaine and etidocaine. These are less susceptible to hydrolysis and hence show longer duration of action.

H2 N Benzocaine (Ester link)

Procaine (Ester link)

H Tetracaine (Ester link)

CHj

V ^ n^
W H3 UH3 Lignocaine or Lidocaine (Amide link) 28. Answer: A. Prilocainc (Amide link)

C H !
Mepivacaine (Amide link)

Explanation: Ester type o f local anesthetics are short acting than amide type as they undergo hydrolysis rapidly by plasma esterases whereas amide type drugs are less susceptible to degradation by esterases. The drugs pKa influences its chemical state and the site of action of local anesthetic drug is at the inner surface of the cel] membrane. Based on the form (charged or uncharged) of drug the mechanism of action of local anesthetic depends. At ordinary tissue pH, the drug is in uncharged form (secondary or tertiary amine) providing lipophilic nature and hence gets diffused through the tissue and cell membrane and enters the nerve cell, where it gets ionized (converts to charged form) into quaternary ammonium compound. This form of the drug (charged; cationic) is the active form that block the sodium channel thereby preventing the generation of action potential (impulse) at the membrane receptor complex. Because of its positive charge the drug gets trapped within the cell and hence results in prolonged action generally. 29. Answer: C. Procaine. Explanation: Xylidine is 2,6-dimethyl aniline. This ring structure is present in lignocaine (lidocaine/xylocaine), bupivacaine, etidocaine and mepivacaine whereas it is absent in procaine. All these drugs are local anesthetics. 30. Answer: E. Dibucaine. Explanation: Dibucaine is a quinoline derivative local anesthetic agent. Benzocaine and butamben are ester type local anesthetics whereas lidocaine and etidocaine are xylidine derivatives and amide type local anesthetics.

Dibucaine (Quinoline ring, amide link) 31. Answer: E. Risperidone. Explanation: Anti-psychotic agents include:

Phenothiazines: chlorpromazine, triflupromazine, fluoperazine etc. Thioxanthenes: chlorprothixene, thiothixene Dibenzodiazepines: clozapine Butyropbenones: haloperidol Benzisoxazoles: risperidone Dihydroindolones: molindone Dibenzoxazepines: loxapine Diphenyibutyl piperidines: pimozide

prochlorperazine,

fluphenazine,

(Pyrimidinone, Piperidine, Benzisoxazole)

Pimozide (Diphenyibutyl piperidine, Benimidazolidinone)

Clozapine (Dibenzodiazepine, piperazine) 32. Answer: B. Butyrophenone.

Ci Chlorprothixene (Thioxanthene)

Explanation: Haloperidol is an anti-psychotic agent that comes under butyrophenone derivatives.

C!

Haloperidol (Butyrophenone, Piperidine) 33. Answer: D. Explanation: Pimozide is a diphenyibutyl piperidine derivative that comes under anti-psychotic agents. 34. Answer: A.

Explanation: Phenothiazines as anti-psychotic agents must have a nitrogen containing side chain as substitution on the ring nitrogen. There must be a three -carbon chain between the ring and side chain nitrogens (if two-carbon chain is present, then those phenothiazines show antihistaminic or sedative activity rather than anti-psychotic activity). The side chains may be either aliphatic, piperidine or piperazine (imparts more potentcy) derivatives. Fluphenazine and long chain alcohols form stable, highly lipophilic esters e.g., enantate or decanoate provides prolonged activity. 35. Answer: B. Explanation: Thioxanthene derivatives used as anti-psychotic agents include chlorprothixene and thiothixene. These agents differ from phenothiazines in that they wont contain the ring nitrogen and gets linked to the side chain by a double bond.

CHS
CHj

Chlorpromazine (Phenothiazine) 36. Answer: A. Butamben.

Chlorprothixene (Thioxanthene)

Explanation: Butamben is an ester type of local anesthetic whereas loxapine, sertindole, remoxipride and quetiapine are anti-psychotic agents. 37. Answer: A. Amitriptyline. Explanation: Anti-depressants include: MAO inhibitors (Mono amino oxidase inhibitors): phenelzine, isocarboxazid (hydralazine derivative), tranylcypromine (phenylcyclopropylamine derivative). Tricyclic anti-depressants: Dibenzazepines (imipramine, desipramine, clomipramine, trimipramine), dibenzocycloheptadienes (amitriptyline, nortriptyline, protriptyline), dibenzoxepine (doxepin) and dibenzoxazepine derivative (amoxapine). Tetracyclic agent: maprotiline. Atypical anti-depressants: Bupropion (aminopropiophenone), complex heterocyclics (trazodone, nefazodone). Serotonin reuptake inhibitors: fluoxetine, fluvoxamine, paroxetine, sertraline and venlafaxine. Cl

Imipramine (Dibenzazepine)

Desipramine (Dibenzazepine)

Clomipramine (Dibenzazepine)

Trimipramine (Dibenzazepine) 38. Answer: E. Maprotiline.

Amitriptyline (Dibenzocycloheptadiene)

XHj

. CH-i

Maprotiline (Ethanoanthracene; tetracyclic)

Doxepin (dibenzoxepine)

(Dibenzocycloheptadiene)

(Dibenzocycloheptadiene) 39. Answer: B. Amoxapine. Explanation: Amoxapine is a dibenzoxazepine derivative. Doxepin is a dibenzoxapine derivative, Imipramine is dibenzazepine derivative, Phenelzine is hydrazine derivative and Tranylcypromine is a phenylcyclopropylamine derivative. 40. Answer: C. Trazodone.
j

Explanation: Trazodone is a complex heterocyclic atypical anti-depressant whereas fluoxetine, paroxetine, sertraline and fluvoxamine are serotonin reuptake inhibitors. 41. Answer: B. Anti-manic agent Explanation: Lithium is an element used as carbonate salt in the treatment of manic depression or bipolar disease. Valproic acid and carbamazepine are also used as anti-manic agents. 42. Answer: E. Thiopental. Explanation:

Cl

(Dihydropyrimidine dione)

(Benzodiazepine)

Alprazolam (Benzodiazepine)

OH Cl t

Lorazepam (Benzodiazepine) 43. Answer: A.

Chlordiazepoxide (Benzodiazepine)

Explanation: Benzodiazepines can be used as anxiolytics and sedative-hypnotics. E.g., alprazolam, diazepam, lorazepam, halazepam, oxazepam, flurazepam, chlordiazepoxide etc. Agents with 3-OH group are easily metabolized by phase-11 reactions (conjugation reactions) particularly glucuronidation and hence short acting. Benzodiazepines that lack 3-OH group will preferably undergo phase-I metabolism E.g., 3-hydroxylation. These are long acting. Diazepam produces a metabolite desmethyldiazepam which is still potent and has very long half life. Thus, these agents can have cumulative action. As a structural feature these agents contain phenyl substitution. 44. Answer: A. Buspirone. Explanation: ' Anxiolytics and sedatives-hypnotics include: Benzodiazepines: diazepam, alprazolam, lorazepam, oxazepam etc. Azaspirodecanediones or azaspirones: buspirone, gepirone, tiaspirone, ipsapirone (Buspirone lacks CNS depressant activity unlike benzodiazepines) Imidazopyridine: zolpidem Barbiturates: Phenobarbital Aldehydes: paraldehyde, chloralhydrate Piperidinediones: glutethimide, methyprylon

Buspirone (Azaspirodecanedione, butyl chain, piperazine, pyrimidine)

Zolpidem (Imidazopyridine)

'H3C

Oi
.0

.CHa

H3C
Glutethimide (Piperidinedione)

ch3
Paraldehyde (Cyclic trimer of acetaldehyde) (Barbituric acid derivative, pentyl chain, ethyl chain)

45. Answer: C. Benzene. Explanation: Buspirone is an azaspirone derivative. Structurally it contains biispirone (cyclopentane+piperidinedione), butyl chain, piperazine and pyrimidine moieties. It wont contain benzene ring. 46. Answer: A. Sedative-hypnotic activity. Explanation: Barbiturates are 5,5-disubstituted derivatives of barbituric acid (saturated triketopyrimidine). At position 5, two side chains are essential for sedative-hypnotic activity. Phenyl and an ethyl group in position 5 produce long acting agents. Lipophilicity and metabolism rate gets enhanced due to the presence of branched side chains, unsaturated side chains or side chains longer than ethyl group, which results in shorter onset of action, shorter duration of action and increased potency. Since barbiturates and almost all their metabolites are weak acids, urinary pH h is great impact on their excretion. 47. Answer: E. Explanation: In barbiturates, substitution of oxygen at 2nd position with sulfur produces highly lipophilic molecule that distributes rapidly into the lipid tissues and are categorized as ultra-short acting barbiturates. These are not useful as sedative-hypnotics but they can effectively; induce anesthesia. E.g., thiopental. 48. Answer: B. Phenyl and ethyl Explanation: j Alkyl chains are substituted at 5-position in short and intermediate acting barbiturates.: E.g., Pentobarbital (Short acting), Butabarbital (Intermediate acting) Aryl and alkyl chains are substituted at 5-position in long acting barbiturates. E.g., Phenobarbital.

Phenobarbital (Barbituric acid derivative) (ethyl chain, phenyl moiety) 49. Answer: C. Phenobarbital.

ch3 Amobarbital (Barbituric acid derivative) (ethyl chain, methylbutyl chain)

Explanation: Phenobarbital is a barbituric acid derivative used as hypnotic agent. Glutethimide and Methyprylon are piperidinedione derivatives; Paraldehyde and Chloral hydrate are aldehyde derivatives. 50. Answer: A. Phenytoin Explanation: Anti-epileptics or anti-convulsants include: Long-acting barbiturates: Phenobarbital, mephobarbital, metharbital, primidone Hydantoins: phenytoin, ethotoin Succinimides: ethosuximide, phensuximide Oxazolidinediones: trimethadione, dimethadione Dialkylacetates: valproic acid Iminostilbines: carbamazepine Benzodiazepines: diazepam, clonazepam, clorazepate Phenyltriazine derivative: lamotrigine GABA-analogues: gabapentin Dicarbamate: felbamate Primidone acts as prodrug for phenobarbial. Upon metabolism primidone produces Phenobarbital and phenyethylmalonamide (PEMA). These metabolites tend to accumulate during chronic medication.

(Hydantoin derivative: imidazoilidinedione)

Ethosuximide (Succinimide derivative: pyrrolidinedione)

(Pyrimidinedione derivative)

h 3c h3 c

o
Cl
c o 2h

Trimethadione (Oxazolidinedione, trimethyl groups) 51. Answer: B. Di alkyl acetate

Clorazepate (Benzodiazepine derivative)

Explanation: Valproic acid is an anti-epileptic (anti-convulsant) agent and chemically it is a dialkyacetate derivative. Its IUPAC name is 2-propyl pentanoic acid. Iminostilbine derivative include carbamazepine; Oxazolidinedione derivatives include trimethadione, dimethadione; Succinimide derivative include ethosuximide and Hydantoin derivative include phenytoin.

Valproic acid

Carbamazepine (Iminostilbine derivative, Dibenzazepine) 52. Answer: D. Lamotrigine. Explanation: Lamotrigine is phenyltriazine derivative used as anti-epileptic agent. Gabapentin is a cyclohexane derivative, Carbamazepine is an iminostilbine derivative (dibenzazepine), Dimethadione is an oxazolidinedione derivative and Felbamatei is a dicarbamate derivative. 1 O II

H-JM

COOH

H2N N nh2 Lamotrigine (Phenyltriazine derivative)

Gabapentin (Cyclohexane ring)

Felbamate (Dicarbamate derivative)

53. Answer: C. Phenytoin. Explanation: Phenytoin is hydantoin derivative used as anti-epileptic agent. Chemically hydantoin is Imidazolidinedione. Pyrrolidinedione ring (succinimide) is present in ethosuximide, Oxazolidinedione ring is present in trimethadione, Benzodiazepine ring is present in clonazepam and Pyrimidinedione ring is present in primidone. Ring strucutre ^O Drug strucuture

NH
Imidazolidinedione (Hydantoin)

O
CH,

Pyrrolidinedione (Succinimide)

ch3

Ethosuximide

O
NH

O Oxazolidinedione

Trimethadione

g 2m '

JI

1,4-Benzodiazepine

Clonazepam

,NH

Pyrimidinedione 54. Answer: C. Levodopa.

Explanation: Levodopa is an anti-parkinsonism agent whereas Cocaine is a local anesthetic agent, Tubocurarine is a neuromuscular blocking agent (skeletal muscle relaxant), Amitriptyline is an anti-depressant agent and Carbamazepine is an anti-epileptic agent.

Levodopa

Dopamine

Anti-parkinsonism drugs include: Anti-cholinergic anti-parkinsonism agents: Atropine, benzatropine, trihexyphenidyl, procyclidine, orphenadrine and biperiden. i Dopaminergic anti-parkinsonism agents: Levodopa, ergot alkaloids (ergolines: bromotriptine, pergolide and nonergolines: pramipexole, ropinirole) 55. Answer: B. Tolcapone. Explanation: Levodopa is a prodrug that gets converted in vivo to dopamine by the action of enzyme dopadecarboxylase that is available both centrally and peripherally. Action o f that dopainine is required in brain. But if levodopa gets converted to dopamine in peripheral tissues, it is unable to cross BBB (blood brain barrier) hence peripheral conversion o f levodopa into dopamine is to be minimized by using agents that can inhibit peripheral dopa-decarb<j>xylase enzyme. ! Carbidopa, selegiline and tolcapone are the agents that improve the therapeutic efficacy and safety of levodopa. ; An analogue o f Levodopa namely carbidopa is able to inhibit the enzyme, dopadecarboxylase peripherally (as carbidopa is unable to cross BBB), hence more Levodopa is available to brain for better therapeutic action. Hence their combination (Levodopa + carbidopa) gained good attention. Selegiline is a MAO-B (selective monoamine oxidase-B) inhibitor, which inhibits the intracerebral degradation of dopamine. ; Tolcapone is a selective inhibitor of COMT (catechol ortho methyl transferase). j (COMT converts levodopa to 3-ortho methyl dopa, an inactive metabolite) Fluoxetine and Fluvoxamine are serotonin reuptake inhibitors used as anti-depressants. 56. Answer: A. Piperidine. :

Explanation: Pethidine (meperidine) is a synthetic opioid analgesic. Chemically it contains phenyl Nmethyl Piperidine ring in its strucuture. j

CH3

Mepiridine/Pethidine (N-methyl piperidine)

Explanation: . . . Phenanthrene is the basic ring present in almost all natural and semi-synthetic opioid analgesics. Opiate alkaloids are derived from the natural source, opium. Both natural and synthetic opioids can be classified as: Natural: Morphine, codeine Semi-synthetic: Hydromorphone, oxycodone, pholcodeine, heroin (diacetylmorphine /diamorphine) Synthetic: Pethidine (Mepiridme), fentanyl, methadone, tramadol etc. Tramadol is a new opioid analgesic agent that is chemically unrelated to the natural, semi synthetic and synthetic opiate derivatives. N CH3 N
CHg
h 3c

... N

/C H j
ch

CHs

HO

OH

Morphine M
CH3

Hydromorphone

Methadone
H 3C _ Ki C H 3 N

o c h

Codeine (Methylated morphine)

N3 C0 ; 0 Oxycodone

Tramadol

58. Answer: C. Levorphanol. Explanation: Phenanthrenes: Morphine, hydromorphine, codeine, hydrocodone, nalbuphine, buprenorphine, nalorphine, naltrexone and naloxone. Phenylheptylamines: Methadone, propoxyphene Phenylpiperidines: Meperidine, fentanyl, sufentanil, diphenoxylate and loperamide Morphone derivatives: Naloxone, naltrexone Morphinan derivatives: Dexromethorphan, levorphanol (levallorphan), Cyclorphan, oxilarphan and butorphanol Benzomorphan derivatives: Pentazocine, cyclazocine Thebaine (oripavine) derivatives: Buprenorphine, diprenorphine 59. Answer: E. Naltrexone Explanation: Substitution of bulky groups in the place o f methyl group on nitrogen atom produces opioid antagonists. Mixed agonist-antagonists (phenanthrene derivatives): Nalbuphine, buprenorphine, pentazocine Pure antagonists (phenanthrene derivatives): Naltrexone, naloxone Morphinan derived antagonists: Butorphanol, levallorphan

60. Answer: D. Ouabain Explanation: Cardiac glycosides also called as cardiotonics are used to increase myocardial contractility and efficiency without the consumption o f extra energy hence the name cardiotonics. These are steroidal glycosides obtained from natural sources (plants). E.g., Digitoxin (Digtalis purpurea), Digoxin (Digitalis lanata), Gitoxin (Digitalis purpurea and Digitalis lahata) and Ouabain (Strophanthus gratus). 61. Answer: A. Ether Explanation: Cardiac glycosides consist of a carbohydrate residue (e.g., digitoxose, rhamnose!), known generally as a glycone, linked to a non-sugar residue steroidal moiety, known generally as an aglycone or genin, by a so called glycosidic link to the anomeric carbon of the glycone. Since the glycosidic link is formed to the anomeric carbon both a- and b-isomers of a glycoside are known. The structures of glycosidic links vary, the most common being an ether group (oxygen glycosidic links) but amino (nitrogen glycosidic links), sulphide (sulphur glycosidic links) and carbon to carbon links (carbon glycosidic links) are also known to exist. Each type of glycosidic link will exhibit the characteristics of the structure forming the jlink. For example, oxygen glycosidic links are effectively acetals and so undergo hydrolysis iiji aqueous solution. Glycone portion helps in the bio-distribution of glycoside. Cardiac glycosides also contain an unsaturated lactone (cyclic ester) substituent on the aglycone (genin) moiety. Digoxin has an additional hydroxyl group at position 12. Ouabain has a rhamnose glycone portion and additional hydroxyl groups at positions 1,5, 1 1 and 19.

sugar residues [P ip to x o so j^ <ciycou-e portion) Digitoxin 62. Answer: E. Explanation: Increased number o f hydroxyl groups produces increased polarity resulting in increased tubular excretion (decreased tubular reabsorption), decreased protein binding, decreased biotransformation and thereby resulting in decreased duration of action. The same thing happens in cardiac glycosides. Digoxin has longer duration o f action and can undergo accumulation hence frequency is an important issue. Whereas ouabain which is having more hydroxy] groups shows extremely short duration of action and hence to be given intravenously for its effective action. 63. Answer: A. Amrinone. Explanation: Alternatives to cardiac glycosides obtained synthetically are Positive ionotropic agents. These agents contain bipyridine moiety in their structures. E.g., Amrinone, inamrinone and milrinone. Whereas cardiac glycosides contain steroidal ring (aglycone/genin), sugar moiety (digitoxose/rhamnose) and lactone ring in their structures. E.g., Digitoxin, digoxin, gitoxin.

64.

Answer: C. Amyl nitrite

Explanation: Organic nitrates are polyol esters of nitric acid, whereas organic nitrites are esters of nitrous acid. Nitrate esters (C 0 N 0 2 ) and nitrite esters (-C-O-NO) are characterized by a sequence of

carbon-oxygen-nitrogen, whereas nitro compounds possess carbon-nitrogen bonds (C N 02). Amyl nitrite is a highly volatile liquid that must be administered by inhalation and is of limited therapeutic utility. Organic nitrates of low molecular mass (such as nitroglycerin also called as glyceryl trinitrate) are moderately volatile, oily liquids (very unstable drug and undergoes extensive first pass metabolism), whereas the high-molecular-mass nitrate esters (e.g., erythrity] tetranitrate, isosorbide dinitrate, and isosorbide mononitrate) are solids. In the pure form (without an inert carrier such as lactose), nitroglycerin is explosive. The organic nitrates and nitrites, collectively termed nitrovasodilators, must be metabolized (reduced) to produce NO, the active principle of this class o f compounds (similar to EDRF (Endothelium Derived Relaxing Factor)).

HCON Q j HC O NOj

H fi

O - NO? -----------CM* Isosorbide dinitrate

Q "CHb Isosorbide-5-mononitrate

Nitroglycerine (glyceryl trinitrate)

i O CH 2CM 5*jN H C H (C H 3)j2

H jC
ch

CM

Propranolol (Naphthalene ring)

: > > ' Nifedipine (Pyridine and nitrobenzene moieties)

Anti-anginal drugs are used in the treatment of angina pectoris. These agents also include: Nitrites and nitrates: p-blockers: Propranolol, atenolol. Calcium channel blockers: Verapamil, nifedipine \ 65. Answer: D. Dipyridamole

Explanation: Dipyridamole is a dipiperidino-dipyrimidine derivative used as peripheral vasodilator. H OCHj'

HjCO OCHji

H3 C ''
o o

ch3

CHj Verapamil (methoxy anisole moieties, tertiary amine group)

Nifedipine (Pyridine and nitrobenzene moieties)

nh2 O o .
kilter Jmk

ON ! :
-j
t

OH

^ch

r
"OH
N* - -l)?pvfmij<i's'iw

HO.

OH

sU!

Itperulmc

Amlodipine (Pyridine and chloro benzene moities; ether and ester links)
66

Dipyridamole (Dipiperidino-dipyrimidine moiety)

. Answer: A. Lidocaine

Explanation: Drugs that comes under both local anesthetics and anti-arrhythmics include Procainamide (amide derivative) and Lidocaine/lignocaine (xylidine derivative).

'CH 3 'c h 3

Lignocaine (Lidocaine, Xylocaine) (Xylidine moiety, amide link, tertiary amine) o^,ch
3

C8 t

CH3

Acebutolol (Isopropyl amine)

Diltiazem (Anisole, Benzo thiazepane)

Phenytoin (lmidazolidine dione derivative) 67. Answer: E. Amiodarone. Explanation: Anti-arrhythmic drugs have diverse chemical structures. They include: Cinchona alkaloids: Quinidine (an optical isomer o f quinine) p-blockers: Propranolol, esmolol, acebutolol, nadolol Amide derivatives: Procainamide, disopyramide, flecainide Xylidine derivatives: Lidocaine (lignocaine, xylocaine), mexiletine

Quaternary ammonium salts: Bretylium Diiodobenzyloxyethylamines: Amiodarone Calcium channel blockers: Diltiazem Hydantoins: Phenytoin.
68

. Answer: A. Diazoxide:

Explanation: Thiazide (chlorthiazide), diuretic and diazoxide, anti-hypertensive agent, both are having the common structural ring benzothiadiazine. Even though both are having structural similarity and shows diuretic activity, only chlorthiazide is a potent diuretic whereas diazoxide is K+ channel opener and shows anti-hypertensive action. The prerequisite for thiazide diuretics is presence of electron-withdrawing group like halogen in its structure, ortho to sulfonamide group on the benzene nucleus. Since diazoxide doesnt have this feature it lacks diuretic property. On overall, benzothiadiazines without sulfonamide moiety exhibit anti-hypertensive activity but lack diuretic activity. 69. Answer: E. Halothane. Explanation: Halothane is a general anesthetic. Propranolol, nadolol, esmolol and acebutolol are cardiovascular drugs that comes under anti hypertensives, anti-arrhythmics and anti-anginals. 70. Answer: C. Mannitol. Explanation: Osmotic diuretics are highly polar, water-soluble, freely filtered at glomerulus and poorly reabsorbed from the renal tubule thereby increasing the osmolarity of the filtrate in the lumen hence causing limited tubular reabsorption of water and thus results in diuresis. Osmotic diuretics include mannitol, urea, glycerin and isosorbide. Glucose is a monosaccharide. Sucrose is a disaccharide. i Starch is a polysaccharide. 71. Answer: B. Thiadiazole. Explanation: Carbonic anhydrase inhibitors used as diuretics contain thiadiazole ring with sulfonamide moiety. These agents act by noncompetitive inhibition of the enzyme carbonic anhydrase thereby preventing the supply of tubular hydrogen ions required for exchange with sodium in the proximal convoluted tubule of nephron resulting in sodium bicarbonate diuresis. E.g., Acetazolamide.

N-Nj

Acetazolamide (Thiadiazole ring) 72. Answer: B r

Explanation: Thiazide diuretics contain the common basic ring structure benzothiadiazine with variable substituents. The structural features required for diuretic activity are: The benzene ring must have a sulfonamide moiety (preferably unsubstituted) at position-7 and a halogen (preferably chloride) or halogen like group (CF3) at position-6 . E.g., Chlorothiazide. Saturation of 3, 4 double bond generally produces increased activity. E.g., Hydrochlorthiazide Lipophilic substituents at position-3 prolong activity as with methyl groups at position- 2 produces increased activity. E.g., Cyclothiazide. Position-1 o f the heterocyclic ring may be carbonyl group or sulfonyl group. E.g., Quinethazone Benzothiadiazines without sulfonamide moiety exhibit anti-hypertensive activity but lack diuretic activity. E.g., Diazoxide. Some of the sulfamoylbenzamides have activity similar to benzothiadiazides. E.g., Indapamide, Chlorthalidone 73. Answer: E. Furosemide. Explanation: Loop diuretics act by inhibiting the co-transport of sodium, potassium and chloride from the filtrate at the ascending limb o f loop of Henle in nephron. Loop diuretics include: Anthranilic acid derivatives: Furosemide and Bumetanide Aiyloxyacetic acid derivatives: Ethacrynic acid. Triamterene, Amiloride and Spironolactone (aldosterone antagonist) are potassium sparing diuretics. Triamterene is a pteridine derivative, Amiloride is pyrazine derivative and spironolactoone is a steroidal analogue.

A
(Pyrazine ring)

N H
nh2

00

2H

m2 Cl Ethacrynic acid (Aryloxyacetic acid)

0

Triamterene (Pteridine ring)

COatf;

/X . h3c \ f
CH H j >

H*N

CO^H

2N

.CH* Furosemide (Anthranilic acid moiety, furan ring) Bumetanide (Anthranilic acid moiety)

Spironolactone (steroidal moiety) 74. Answer: C. Pteridine.

Explanation: Triamterene, Spironolactone and Amiloride are potassium sparing diuretics. Triamterene is a pteridine derivative, Amiloride is pyrazine derivative and spironolactone is a steroidal analogue.

75.

Answer: A. Spironolactone

Explanation: Spironolactone is a steroidal analogue antagonist of aldosterone (mineralocorticoid) at aldosterone receptors in the distal convoluted tubule and collecting duct. Eplerenone also comes under this category. They interferes with aldosterone mediated sodium-potassium exchange by inhibiting the Na+-K7 exchange pump thereby decreasing the potassium excretion hence the name potassium sparing diuretics. 76. Answer: E. Explanation: Anti-hyperlipidemic agents acting locally in the intestine are classified as nonabsorbable agents and those acting systemically as absorbable agents. Nonabsorbable agents are hydrophilic in nature but water insoluble resins that bind to bile acids in the intestine and inhibits their reabsorption hence also termed as bile acid sequestrants. E.g., Cholestyramine. It is a basic anion exchange resin and it consists of trimethylbenzyl ammonium groups in a large copolymer o f styrene and divinylbenzene. Another example includes Colestipol, which is a copolymer of diethylpentamine and j epichlorohydrin. I 77. Answer: D. Colestipol. Explanation: Non-absorbable anti-hyperlipidemic agents: Bile acid sequesterants: Cholestyramine, colestipol. Ezetimibe, phytosterols: Selcetive inhibitors of dietary cholesterol absorption.

Absorbable anti-hyperlipidemic agents: Nicotinic acid Aryloxyisobutyric acid derivatives: Clofibrate, fenofibrate (prodrug) and gemfibrozil. ; HMG-CoA (3-hydroxy-3-methyIgIutaryl-coenzyme A) reductase inhibitors (Statins): Atorvastatin, Lovastatin, simvastatin, pravastatin, fluvastatin and cerivastatin.

Bisphenol derivative (sulfur containing): Probucol.

O O ^C H j
h 3c ch3

CHa

Clofibrate

Fenofibrate

A .
OH

CH3

c h

Lovastatin 78. Answer: A. Heparin:

Simvastatin

Explanation: Heparin is an anticoagulant, highly acidic mucopolysaccharide (sulfated D-glucosamine and D-glucuronic acid) administered by parenteral route. Heparin has in vivo and in vitro effects whereas oral anticogulants (mostly used are warfarin and phenindione) show only in vivo effects. Other anticoagulants include: Heparins group: Heparin, Antithrombin III, Danaparoid and Sulodexide Low molecular weight heparin: Bemiparin, dalteparin, enoxaparin, nadroparin, pamaparin, reviparin, tinzaparin and ardeparin. Direct thrombin inhibitors: Lepirudin, argatroban, desirudin, hirudin, melagatran, ximelagatran and bivalirudin are used as anticoagulants. Vitamin K antagonists: Warfarin and dicumarol (4-hydroxycoumarin lactone derivative), acenocoumarol, clorindione, coumatetraly], diphenadione,. ethyl biscoumacetate and phenindione (indanedione derivative). Non-medical anticoagulants: EDTA (Ethylene diamino tetra acetate), citrates and oxalates.

Warfarin (Coumarin moiety) o

Dicumarol (Coumarin moiety)

o Phenindione (Indanedione moiety) 79. Answer: E. Lepirudin. Explanation: Lepirudin is a rDNA derived polypeptide used as direct thrombin inhibitor.

Low molecular weight heparin (LMWH) fragments are produced by controlled depolymerization of heparin. E.g., Bemiparin, dalteparin, enoxaparin, nadroparin, pamaparin, reviparin, tinzaparin and ardeparin. 80. Answer: C. Aspirin. Explanation: Aspirin is the acetyl ester of salicylic acid, which is also having anti-platelet action. Anti-platelet drugs include: COX (Cyclooxygenase) inhibitor: Aspirin (salicylate derivative) ADP (Adenosine diphosphate) inhibitors: Ticlopidine (thienopyridine) and Clopidogrel Phosphodiesterase inhibitors: Cilostazol Glycoprotein llb/Jlla inhibitors: Abciximab (monoclonal antibody), eptifibatide and tirofiban. Adenosine reuptake inhibitors: dipyridamole (dipiperidino-dipyrimidine derivative; peripheral vasodilator). Decreasing platelet production: Anagrelide. Paracetamol (acetaminophen, p-aminophenol derivative) comes under non-narcotic analgesic & antipyretic whereas piroxicam (oxicam derivative) comes under NSAIDs (Non-steroidal anti-inflammatory drugs). C 0 2 Hj

CT ch 3 Aspirin (Salicylic acid moiety) o ......... ;.......... 7

6

Ticlopidine (Thienopyridine)

rt

Paracetamol (p-aminophenol moiety) 81. Answer: B. Urokinase

Piroxicam (Benzothiazine, Pyridine)

Explanation: Thrombolytic agents include urokinase, alteplase, reteplase, tenecteplase, streptokinase and anistreplase. Urokinase, also called as urokinase-type Plasminogen Activator, is a serine protease obtained from cultured human kidney cells. Alteplase, reteplase and tenecteplase rDNA (recombinant DNA) derived tissue plasminogen activators (t-PA), converts plasminogen to plasmin, a fibrinolytic enzyme. Streptokinase is a potent plasminogen activator obtained from p-hemolytic streptococci. Anistreplase is also a Thrombolytic agent that converts plasminogen to plasmin and is also called as APSAC: Anisolyted plasminogen-streptokinase activator complex. 82. Answer: A. Iron dextran. Explanation: The important anti-anemic agents include: :

Iron preparations: Oral (ferrous sulfate, ferrous fumarate, ferrous gluconate) and Parenteral (iron dextran- a complex of ferric hydroxide and low molecular weight dextrans). Vitamins: Cyanacobalamin (vitamin B12) and folic acid. Hematopoietic growth factors: erythropoietin, colony stimulating factors and interleukin-11. 83. Answer: D. Vitamin B }2 Explanation: Vitamin B [2 or cyanocobalamin is a water-soluble vitamin with a corrin ring (modified porphyrin ring) containing a cobalt atom. Cyanide ion is also associated with cobalt atom. 84. Answer: B. Glutamic acid. Explanation: Folic acid and cyanocobalamin (vitamin B12) comes under anti-anemic agents therapeutically. Folic acid consists of two ring structures (pteridine moiety linked to niteogen o f p-amino benzoic acid) and one side chain Glutamic acid (linked through an amide bond).

Folic acid (Pteridine moiety + para amino benzoic acid (PABA) + Glutamic acid) 85. Answer: D. Explanation: Hematopoietic growth factors include: Erythropoietin (natural), similar agents like epoietin alfa and darbepoietin alfa are glycoproteins derived from rDNA technology. Colony stimulating factors (CSF): Filgrastin, prefilgrastin (granulocyte colony stimulating factor; G-CSF), and sargramostim (granulocyte macrophage colony stimulating factor; GMCSF) are also glycoproteins derived from rDNA technology. Interleukin-11 (oprelvekin) is a nonglycosylated growth factor derived from rDNA technology.
86

. Answer: C. Nizatidine

Explanation: Nizatidine is a H 2 receptor antagonist whereas chlorpheniramine, meclizine, ciproheptadine and pyrilamine are Hi receptor antagonists. Histamine is bioamine derived principally from dietary source, Histidine. Upon decarboxylation by L-histidine decarboxylase, Histidine will be converted to histamine. Anti-histamines are the drugs, which block the actions of histamine. They are classified as H] receptor antagonists and H 2 receptor antagonists. Hi receptor antagonists: Ethylene diamines: Pyrilamine, Tripelennamine Alkylamines: Chlorphenaramine, Bromphenaramine, Acrivastine Ethanolamines: Diphenhydramine, Dimenhydrinate, Clemastine, Doxylamine Piperazines: Meclizine, Cyclizine, Hydroxyzine, Cetirizine

Phenothiazines: Promethazine Dibenzocycioheptenes: Cyproheptadine Phthalazinone: Azelastine Piperidiens: Terfenadine, Astemizole, Levocabastine, Fexofenadine, Loratidine H2 receptor antagonists: Ranitidine, Famotidine, Cimetidine, Nizatidine. Cl

(Alkylamine derivative)
o :;.. "r
-

Diphenhydramine (ethanolamine derivative) H sC C H S

. it J
X
C! '

h bn

Or
N0
2

Azelastine (Phthalazinone, Azepine)

h3c

Terfenadine (Piperidine derivative)

NOj
,CH3

h3 c

N ^ N H N H
H

Nizatidine (Thiazole moiety) NH?

NH2

Ranitidine (Furan moiety)

r~~*H
:HN

iCN: .JN
-N A
H Hi

s tj
0 0

:...rh 3c

N ' CH

Famotidine (Guanidine, Thiazole moieties) 87. Answer: B. Cetirizine

Cimetidine (Imidazole, Guanidine moieties)

Explanation: Cetirizine is an antihistaminic drug having H2 receptor blocking effect, hence classified as H 2 receptor antagonist. The structure of cetirizine contains piperazine ring. Other drugs that contain piperazine ring structure include meclizine, cyclizine and hydroxyzine. And also cetirizine comes under second generation anti-histamines, which is less sedating than the first generation drugs, due to its limited ability to cross the blood brain barrier (BBB).

The ring structure present in diphenhydramine is phenyl (2 rings), in promethazine phenothiazine ring is present, in cyproheptadine dibenzocycloheptene ring and in astemizole piperidine ring are present. X

r
Cetirizine (Piperazine derivative)

Hydroxyzine
(Piperazine derivative)

(Piperazine derivative)

(ethanolamine derivative)

CH3 n y CH3 H CH3

Prom ethazine (Phenothiazine derivative)

(Dibenzocycloheptene)

H ,....... i V ' N '

'....... . Astemizole
(Benzimidazole, Piperidine)
88

. Answer: A. Limited ability to cross BBB.

Explanation: Cetirizine and acrivastine comes under second generation anti-histamines. Because of their limited ability to cross the blood brain barrier (BBB) they are less sedating than the first generation drugs.

89.

Answer: C. H+K+ ATPase pump

Explanation: Proton pump inhibitors are the alternative agents to H2 receptor antagonists. These drugs inhibit gastric acid secretion by specifically inhibiting the enzyme (proton pump), H+ K+ ATPase, which is the key mediator of gastric acid secretion. Drugs that come under proton pump inhibitors are omeprazole, lansoprazole, rabeprazole, pantoprazole and esomeprazole.

Omeprazole (Benzimidazole, pyridine moieties) 90. Answer: D. Serotonin. Explanation: Serotonin (5-OH tryptamine), the neurotransmitter, is a bioamine obtained from the amino acid Tryptophan by the action of enzymes tryptophan hydroxylase and L-amino acid decarboxylase. Serotonin agonists and antagonists both are having specific therapeutic applications. Epinephrine is the naturally occuring catecholamine, neurotransmitter synthesized biologically from the amino acid tyrosine by the action of various enzymes and is a directly acting adrenergic agonist. Acetylcholine, the most potent cholinergic agonist is an endogenous component, neurotransmitter, which is an ester o f acetic acid and choline (quaternary amino alcohol). Dopamine is also a neurotransmitter synthesized from tyrosine in the pathway of epinephrine and nor-epinephrine synthesis. 91. Answer: E. Cisapride Explanation: Serotonin also called as 5-hydroxy tryptamine is a bioamine synthesized from the amino acid tryptophan. Serotonin has various physiological functions based on the receptor on which it is acting.

Serotonin agonists:
5-HT id receptor agonists: Indole derivatives: Sumatriptan, rizatriptan, almotriptan, naratriptan, zolmetriptan and frovatriptan. 5-HT4 receptor agonists: Tegaserod (indole derivative) and cisapride (benzamide derivative, piperidine, phenyl rings). 5-HT3 antagonists: Indole derivatives: Ondasetron, alosetron and dolasetron; Benzimidozole derivative: Granisetron. Partial agonists/antagonists: Ergot alkaloids: Ergonovine. dihydroergotamine, methysergide and bromocriptine.

h 3c

ft

M -C

HjC
Sumatriptan (Indole derivative)

O Granisctron (Benzimidazole derivative)

a
h 2n

Cisapride (Benzamide, Piperidine derivative) 92. Answer: A. Ondasetron. Explanation: All the drugs ondasetron, sumatripton, rizatripton, zolmetriptan and almotriptan are indole derivatives but ondasetron is 5-HT3 antagonist whereas other drugs are 5-HT,D receptor agonists. 93. Answer: C. Arachidonic acid. Explanation: Prostaglandins are synthesized from arachidonic acid (obtained from membrane phospholipids by the action of phospholipase) by the action of enzyme cyclooxygenase, which exists as two isoenzymes, COX-I and COX-II. Chemically prostaglandins are derivatives o f prostanoic acid, a 20-carbon fatty acid containing a 5-carbon ring. 94. Answer: E. Explanation: Prostaglandins are synthesized from arachidonic acid by the action of enzymes COX-I or COX-II. COX-I enzyme is considered as constitutive enzyme, which synthesizes prostaglandins regularly and contributes to homeostasis. One example is protection of gastric miicosa from gastric HC1 by forming a prostaglandin layer over it. Whereas COX-II enzyme is considered as pathologic enzyme, which produces prostaglandins in pathologic states like inflammation or injury. The products o f cyclooxygenase are then converted into either prostaglandins by prostaglandin synthase or thromboxanes by thromboxane synthase. Thromboxanes differ from prostaglandins mainly by the presence of a tetrahydropyran ring structure instead of the pentane ring presence in prostaglandins. Chemically prostaglandins are derivatives of prostanoic acid, a 20-carbon fatty acid containing a 5-carbon ring.

CO OH / < \ Prostanoic acid (Source o f Prostaglandin structure) 95. Answer: B. TXA 2 Explanation: Clinically relevant thromboxane that causes platelet aggregation is TXA 2 96. Answer: A. Explanation: Leukotrienes are produced by the enzyme lipoxygenase. Like prostaglandins, they are aslo 20-carbon derivatives of fatty acids. Unlike prostaglandins, they wont contain any ring structure and are covalently linked to 2 or 3 amino acids. E.g., LTC4 and LTD 4 (differ by the presence of glutamine). 97. Answer: C. Zileuton Explanation: Leukotrienes are autocoids obtained by the action of lipoxygenase enzyme. Since leukotrienes were found to be involved in anaphylaxis reactions, leukotriene antagonists got therapeutic importance. Lipoxygenase inhibitors: Zilueton (Benzothiophene derivative) Leukotriene antagonists: Zafirlukast and Montelukast PGE] analogues: Misoprostol and Alprostadil. PGF2 analogues: Carboprost, Travoprost, Latanoprost, Bimatoprost and Unoprostone. PGI analogue: Epoprostenol. 98. Answer: A. Aspirin: Explanation: Aspirin is a NSAID (Non Steroidal Anti-inflammatory Drug), which is an acetyl ester of salicylic acid. Since, aspirin is a simple ester it undergoes hydrolysis readily and hence unstable in aqueous environment.

Aspirin (Acetyl ester o f salicylic acid)

Piroxicam (Benzothiazine, Pyridine, amide link)

COOH

OH

C ll Diclofenac (Dichloro aniline derivative, acetic acid derivative)

Paracetamol (p-aminophenol moiety, acetaminophen

2n

'Nimesulide (Methane sulfonamide derivative, ether link) 99. Answer: C. Methyl salicylate. Explanation: Methyl salicylate is called as oil of wintergreen, which is used as topical agent. It is a stable salicylic acid derivative. Other salicylate derivatives include Diflunisal, Salsalate, Sodium thiosal icy late (injectable), choline salicylate oral liquid), mesalamine, olsalazine and sulphasalazine. Mostly salicylates are weak acids.

Methyl salicylate

Diflunisal

'OH
Olsalazine

100.

Answer: B. Sulfinpyrazone

Explanation: Deposition of sodium urate crystals in joints results in inflammation and pain, the disease condition callcd as Gout (metabolic arthritis). Uric acid is obtained from the metabolism of

purines. The excess uric acid produced gets deposited in the joints as sodium urate crystals. Drugs used in the treatment of gout include: sulfinpyrazone (Pyrazolone derivative, also used as NSAID), colchicines (alkaloid), probenecid (benzoic acid derivative) and allopurinol (isopurine form). Acetaminophen (p-aminophenol derivative), Etodolac (Acetic acid derivative), Valdecoxib (Pyrazole derivative) and Piroxicam (Oxicam derivative) are NSAIDs but doesnt show uricosuric action.

Sulfinpyarazone (Pyrazolone derivative)

101. Answer: E. Sodium urate crystals. Explanation: Gout or metabolic arthritis is the disease condition observed due to the excess deposition of sodium urate crystals, in cartilage joints resulting in inflammation and injury, obtained from the excess metabolism o f purines. 102. Answer: D. Naproxen. Explanation NSAIDs: Acetaminophen (paracetamol) is a p-aminophenol derivative. Its prodrug forms include phenacetin and acetanilide. Acetic acid derivatives: Etodolac, diclofenac, ketorolac, indomethacin, nabumetone, sulindac and tolmetin. Propionic acid derivatives: Ibuprofen, ketoprofen, flurbiprofen, fenoprofen, carprofen, naproxen and oxaprozin. Fenamic acid or anthranilic acid derivatives: Mefenamic acid and meclofenamate Oxicams: Piroxicam Selective COX-II inhibitors: Pyrazole derivatives: Valdecoxib, celecoxib and rofecoxib

Naproxen (Naphthalene, propionic acid derivative)

\ss=> Etodolac (Acetic acid derivative)

HjC,

JU
o Sulin dac (Acetic acic; derivatve)

103. Answer: C. Mefenamic acid. Explanation: Mefenamic acid is an anthranilic ac id or fenamic acid derivative. Nabumetone and Diclofenac are ac ;tic acid derivatives, Ibuprofen is propionic acid derivative and Aspirin is salicylic acid derivat ive.

c o

2h

Mefenamic acic I (Anthranilic acid deri

(Naphthalene, acetyl derivative)

Ibuprofen (Propionic acid deri\ ative) 104. Answer: A. Celecoxib. Explanation: Celecoxib, rofecoxib and valdec jxib are selective COX-II inhibitors whereas ketorolac, naproxen, ketoprofen and aspirin ane non-selective COX inhibitors. 105. Answer: E. Cyclooxygena se Explanation: Autocoids are also called as local hormones and autopharmacolgical agents. They have wide range of physiological and pharma cological actions. They also have diversity in their structures. Examples include Hista mines, prostaglandins, leukotrienes, bradykinins, kallidin, ocoids like serotonin and histamine can function as cytokinins and serotonin. Some au|t< neurotransmitters.

Cyclooxygenase is the enzyme that participates in the conversion o f arachidonic into prostaglandins. It exists in isomeric forms namely COX-I (Cyclooxygenase-I) and COX-II (Cyclooygenase-II)

' /

RIO

Microbiology

Never let yesterday's disappointments overshadow tomorrow's dreams.

1. All o f the following are cellular organisms EXCEPT: A. B. C. D. Fungi Bacteria Viruses Protozoa

A. B. C. D. E.

Histoplasma Trichophyton Blastomyces Epidermophyton A and C

7. Protozoa are unicellular, non photosynthetic eukaryotes characterized by: A. B. C. D. E. Type o f motility Size o f cells Shape B and C None o f the above

2. Which one o f the following is NOT TRUE about Archaea? A. They have cell walls. B. Their cells are biochemically same as that o f eubacteria. C. They inhabit in extremes o f environments i.e., extreme hot, cold, pH, or saline environments. D. A and C 3. The domain Eukarya contains organisms: A. B. C. D. E. Microscopic fungi, protozoa Macroscopic fungi and algae Plants Animals All o f the above

8 . Which one o f the following is NOT a Protozoan?

A. B. C. D. E.

Giardia Entamoeba Balantidium Plasmodium Ascaris

9. Viruses are classified by: A. B. C. D. E. Capsid structure Type o f nucleic acid Envelope Presence o f enzymes All o f the above

4. Fungi are classified into phyla based on: A. The type o f reproductive structures observed B. The lack o f observable sexual structures. C. Shape and color D. A and B E. None 5. Dimorphic fungi exist in either unicellular (yeast) or filamentous (mold) phase depending on: A. B. C. D.
6

1 0 .Infectious proteins, implicated in mad cow disease and kuru are:

A. B. C. D.

Sporozoa Prions Viruses Flagellates

11 .Bacteria are grouped and named primarily by:

Humidity pH Temperature Moisture

. Which o f the following are dimorphic fungi?

A. Morphology B. Biochemical and metabolic differences C. Immunological and genetic relationships D. All o f the above

1 2 .In cultural morphology o f bacteria each colony originates from a colony-forming unit, consisting of:

A. B. C. D.

A single cell Group o f adherent cells Different types o f cells A and B

A. To make the color more intense B. To magnify the bacteria C. To stain both the cell and the background, allowing visualization o f the unstained capsular material D. In order to facilitate enhances the permeation o f one of the dyes to the cell.

13. Which one o f the following statement is FALSE? A. Because o f their small size and relative transparency, bacteria must be stained to be visible with the light microscope. B. Staining cannot be used as a classification system. C. Microscopic morphology describes bacteria on the basis o f the size, shape, and arrangement o f the cells. D. Cultural morphology is based on the size, shape and texture o f colonies that are grown in axenic or pure, culture.

17. All of the following bacteria are spherical in shape EXCEPT: A. B. C. D. Streptococci Neisseria gonorrhea Staphylococci Treponema palladium

18.Spherical shaped bacteria that exist in clusters are known as: A. B. C. D. Streptococci Staphylococci Sarcinae Vibrios

14. A differential staining procedure that divides the bacterial cells into either grampositive (purple) or gram negative (pink) is: A. B. C. D. Simple stain Acid-fast stain Gram stain Spore stain

19. Which one o f the following represents a wrong pair? A. B. C. D. Actinomycetes-Branching Vibrios-Comma shaped Spirochete- Helical Fusobacteria-Spherical

20

.Bacteria can be classified based upon: A. B. C. D. Spores Capsules Flagella All o f the above

15.A staining procedure that stains cells that have an outer layer o f a waxy-lipid but not those that lack this layer material is: A. B. C. D. Acid Fast stain Gram stain Simple stain Spore stain

21 .Bacteria that have flagella distributed evenly over the entire cell are called:

16. In capsule staining the purpose o f using two dyes is:

A. B. C. D.

Monotrichaete Amphitrichaete Peritrichaete Lopotrichaete

22. Which one o f the following statements is FALSE about Prokaryotic cells? A. Their cytoplasm is immobile. B. Multiply asexually by binary fission rather than by mitosis or meiosis. C. Bacterial genetic information is arranged on a single super coiled circular strand o f DNA, the nucleoid. D. They are more complex inside, but less complex outside.

A. Increases the virulence (degree of organism pathogenicity) o f a microorganism B. Prevents phagocytosis o f the organism by macrophages and neutrophils. C. Aids in adherence of the organism to host cells. D. It kills the host cells.

27.If the polysaccharide o f a capsule is nonadherent, it is called a: A. B. C. D. Microcapsule Slime layer Glycolyx None o f the above

23. Which of the following organelles are absent in prokaryotic cells A. B. C. D. E. True nucleus Endoplasmic reticulum Nuclear membrane Plastids All of the above

28.Transformation from smooth to rough colonies on bacterial media is indicative of: A. B. C. D. Loss o f Capsule Loss o f cell wall Multiplication Enhanced virulence

29. The decrease in virulence of bacteria after loss o f capsule is because: A. The capsule is changed to a substance that is harmful to the bacterial cells. B. The capsular material is immunogenic, thereby inducing the production o f antibodies. C. The capsular material induces antibody production, which enhance phagocytosis. D. B and C E. None

24. In prokaryotic cells Protein synthesis is mediated by ribosome o f : A. B. C. D. 70 80 90 60 S S S S

25.The capsule o f Bacillus anthracis is made up o f A. B. C. D. Polypeptide Polysaccharide Lipid Lipopolysaccharide

SO.The main parts, that comprise flagella, are:

26. Which one of the following is not a function o f a Capsule?

A. B. C. D. E.

Basal body Hook Filament All o f the above A and B

intracellular cascade o f methylation and phosphorylation D. The intracellular reactions enable the bacteria to move toward nutrient chemo attraclants and away from repellants. E. None o f the above

31 .The number o f rings that make up the basal body o f flagella in gram-positive organisms is: A. 2 B. 4 C. 6 D. 5

35. Which o f the following are common to the cell walls o f Gram-negative and Grampositive bacteria? A. Peptide cross-links between polysaccharides. B. A wide variety o f complex lipids. C. Rigid polysaccharide framework. D. A and C E. None

32.Most bacteria are designated as either gram-negative or gram-positive, based on: A. B. C. D. Components o f the cell wall. Shapes Color. Composition o f capsule.

36. All o f the following are found within the cell wall o f Gram-positive cells EXCEPT; A. B. C. D. Proteins Lipopolysaccharides Teichoic acids Polysaccharides

33.The function o f cell walls in bacteria is: A. To provide the general shape o f the cell. B. To protect the cell from osmotic shock. C. To carry the genetic material D. A and B

37. Which one o f the following is FALSE about Teichoic acids o f bacterial cell membranes? A. Chemically they are glycerol or ribitol phophodiesters. B. Membrane-associated Teichoic acids are covalently linked to glycolipids of the cytoplasmic membrane. C. Well-associated Teichoic acids are covalently linked to the glycan chain o f peptido glycan. D. They are found in both Grampositive and Gram-negative bacteria.

34. Which one o f the following statements is not true about movement in bacteria? A. lagella are proteinaceous, helically coiled organs o f locomotion that extend outward from the cytoplasm through the cell wall in to the environment. B. Flagella rotate either clockwise or counterclockwise; allowing a series o f runs and tumbles in response to chemicals in the environment. C. The direction o f movement is controlled by a complex mechanism involving chemoreceptors and an

3 8 . In gram-negative bacteria part o f the endotoxin responsible for nonspecific inflammation including diarrhea, fever, and septic shock is:

A. B. C. D. E.

Core polysaccharide Phospholipid Lipid A Protein None

45. Which one o f the following contains genes for heavy metal and antibiotic resistance? A. B. C. D. Cytoplasmic membrane Nuclear region Plasmids Ribosomes

39.In bacteria the periplasmic space is: A. An area between the cell wall and the cytoplasmic membrane. B. A pore found in the cell wall C. An organelle found in the nucleus. D. The organelle, which contains the genetic material. 46. The proteins found in the Cytoplasmic membrane are engaged in; A. Transportation o f nutrients. B. Secretion o f exotoxins. C. Electron transport and energy formation D. All o f the above Questions[ 4 7-51J Match the nutritional types o f bacteria with the given nutrition types A. B. C. D. E. Auxotrophs Saprophytic Parasitic Chemoautotrophs Photoheterotrophs

Questions [40-44] Match the cellular units with their description. A. Periplasmic space B. Ribosomes C. Cytoplasmic membrane D. Nuclear region E. Plasmids

40. Contains a gel o f several types o f molecules (e .g ., hydrolytic enzymes, periplasmic-binding proteins ) that process molecules before they enter the cytoplasm.

47.Mutated so that they cannot synthesize the same essential nutrients (usually amino acids) as their parent cell. 4 8 .Use light as an energy source.

41. A phospholipid bilayer matrix o f a fatty acid core and glycerol phosphate backbone 42.Cellular units that synthesize protein by translation messenger RNA base sequences in to amino acid protein sequences. 43.rCircular double-stranded pieces o f DNA that are found outside of the bacterial chromosomes. 44. A condensed area containing the bacterial DNA or genome that lacks a nuclear membrane and consists o f a long, double stranded, super coiled, circular DNA molecule.

49.Organisms whose nutrients are obtained from dead or decaying organic matter. 50.Organisms whose nutrients are obtained from and at the expense o f a living organism. 51 .Oxidize organic and inorganic compounds to produce energy. 52. Which one o f the following bacteria can grow at 55 C or greater?

A. B. C. D.

Psychophile Mesophile Thermophile Autotrophs

53.Bacteria that have the ability to grow with or without oxygen are known as: A. B. C. D. Obligate Anaerobes Facultative Aerobes Facultative Anaerobes Obligate Aerobes

A. The bacteria are replicating DNA and enzymes needed for the new environment induced. B. The cells increase in number but not in size. C. The cells are most permeable. D. The number o f cells increases in geometric progression. E. B and D

57.Most Bacteria cells are more susceptible to cell wall inhibitors during A. Death phase B. Stationary phase C. Log phase D. Lag phase

54.Obligate Anaerobes do not tolerate oxygen at all and die in its presence. One reason could be; A. Many strains lack catalase and superoxide dimutase that protect cells from the destructive oxidizing capabilities o f hydrogen peroxide and superoxide ions, which are normally produced under Aerobic conditions. B. The oxygen molecule kills every living cell C. The oxygen molecule inhibits respiration o f the bacterial cells. D. B and C

58.In Death phase o f bacterial growth curve the concentration of viable cells decreases at a geometric rate because; A. There is accumulation o f toxic wastes and autocatalytic enzymes B. The type o f reproduction is changed from binary fission to sexual reproduction C. The growth rate is equal to death rate. D. B and C

55.Bacteria reproduce by: A. B. C. D. Sexual reproduction Mitosis Binary fission Meiosis 5 9. An energy production process that releases energy through direct transfer of high-energy phosphate groups from an intermediate metabolic compound to adenosine diphosphate (ADP) is: A. B. C. D. Oxidative phosphorylation Substrate- level phosphorylation Glucogenesis Fermentation

56. Which o f the following are WRONG about the Lag phase o f bacteria] growth curve?

60. All o f the following are pathways involved in the production o f pyruvic acid in microorganisms EXCEPT:

A. B. C. D.

Em bden-M eyerhofpathway Enter-Doudoroff pathway Hexose monophosphate pathway Lactic acid fermentation

61 .In glycolysis glucose is oxidized to pyruvic acid with a yield of: A. B. C. D. 3 moles o f ATP 2 moles o f ADP 1 mole o f ATP 2 moles o f ATP
66

A. It is transcribed in to RNA that can be translated into protein B. It contains control signals that ultimately control the synthesis o f protein. C. It can be mutated to alter specific characteristics that are encoded by genes. D. It does not directly catalyze biological reactions. E. All o f the above

.Bacterial replication involves:

62. The products o f butyric acid fermentation by Clostridium are: A. B. C. D. Butanol Isopropanol Acetone All o f the above.

A. Duplication o f the DNA, which enables the formation o f two identical daughter cells. B. Processing o f the genetic information to synthesize proteins. C. Synthesis o f RNA from DNA. D. B and C 67.Repression o f enzyme activity inhibits the synthesis o f the enzyme at A. B. C. D. At replication level At transcription level At translation level None

63.All o f the following are electron transport systems EXCEPT: A. Cytochromes B. Ribosomes C. Flavoproteins D. Ubiquinones

64. Which one o f the following statements is FALSE?

6 8. All o f the following are mechanisms by which microorganisms can change their genetic constitution by transfer o f genetic material EXCEPT:

A. Bacteria have only one chromosome. B. In bacteria Duplication o f the genetic material occurs by semi conservative replication C. In bcteria the nuclear material is attached to cell membrane and as the cell grows, it separates the daughter chromosomes D. Genes are RNA segments that are processed in two steps to produce various proteins. 65.The functions o f DNA include;

A. B. C. D.

Transduction Conjugation Translation Transformation

69. The gene transfer mechanism associated with recombinant DNA technology is: A. B. C. D. Transcription Transformation Conjugation Translation

70. Which one o f the following is FALSE about cloning?

A. It involves splicing a gene into plasmid DNA (vector) B. The plasmids do hot contain a gene essential for cellular survival. C. The vectors code for a phenotypic trait that can be used to detect the presence o f foreign DNA. D. The vectors contain at least one replicon and can be replicated within the host even when they contain foreign DNA. 71 .The transfer o f genetic material by bacteriophage (viruses that infect bacteria) is known as: A. B. C. D. Transduction Transcription Translation Transformation

A. Lytic phages enter the cell, replicate, and package their DNA and then lyse the cell to release mature infective virions B. In temperate phages the prophage suppresses the lytic state by synthesizing a protein known as a repressor, which protects the cell from further infection by a virus. C. Some phages can change the cells phenotype, which allows the organism to elaborate materials (exotoxins or virulence factors) that are detrimental to the human host. D. None

74.0ne o f the following causes blindness and sexually transmitted diseases. A. B. C. D. Rickettsia rickettsii Mycoplasma pneumoniae Chlamydia trachomatis Clostridium tetani

72.In lysogenic bacteriophages the viral DNA that does not replicate is known; A. B. C. D. Plasmid Prophage Transposons Triplet codons

75. All o f the following are true about chlamydia EXCEPT: A. They have the ability to generate ATP B. They are obligate intracellular parasites. C. They have a two-phase life cycle D. The infectious form is a dense non replicating cell that is resistant to drying in the environment.

73. Which one of the following statements is FALSE about bacteriophages?

Answers Microbiology
1. Answer: C. Viruses Explanation Viruses are considered as non-cellular, but medically significant entities. Fungi, bacteria and protozoa are cellular organisms as they have cellular organization.

2. Answer: B. Their cells are biochemically the same as that o f eubacteria Explanation Archaera includes prokaryotes with cells that are biochemically different from eubacteria and inhabit extreme hot, cold, pH, or saline environments.

3. Answer: E. All o f the above Explanation Eukarya contains microscopic organisms like fungi, protozoa and algae? along with macroscopic organisms like fungi and algae, plants, and animals.

4. Answer: D. A and B Explanation Fungi are classified into phyla based on the type o f reproductive structures observed or lack o f observable sexual structures.

5. Answer: C. Temperature Explanation Dimorphic fungi exist in either unicellular (yeast) or filamentous (mold) phase depending on the temperature.

. Answer: E. A and C

Explanation Histoplasma and Blastomyces are dimorphic fungi.

7. Answer: A. Type o f motility

Explanation Protozoa are unicellular, non-photosynthetic eukaryotes characterized by type o f motility. Motility organs for Mastigophora - Flagella, Sarcodina - Pseudopodia, Ciliophora - Cilia and Sporozoa - Non motile.

. Answer: E. Ascaris

Explanation All o f the above are Protozoas except Ascaris which is a helminth.

9. Answer: E. All o f the above Explanation Viruses are classified by: 1. Capsid structure 2. Type o f nucleic acid 3. Envelope 4. Presence o f enzymes 10.Answer: B. Prions Explanation Prions are infectious proteins, implicated in mad cow disease and kuru. Sporozoa and Flagellates are Protozoas.

11 .Answer: D. All o f the above

Explanation Bacteria are grouped and named primarily by morphology, Biochemical and metabolic differences, and immunological and genetic relationships.

12.Answer: D. A and B Explanation In cultural morphology o f bacteria each colony originates from a colony-forming unit, consisting o f a single cell or a group o f adherent cells. 13.Answer: B. Staining cannot be used as a classification system. Explanation Because o f their small size and relative transparency, bacteria must be stained to be visible with the light microscope. Staining is also used as a classification system. For example Grams staining is used to classify bacteria into Gram positive and Gram negative. 14.Answer: C. Gram stain

Explanation A differential staining procedure that divides the bacterial cells into either gram-positive (purple) or gram negative (pink) is Gram stain. In Simple stain a single dye is used that colors the cells. In Spore stain heat is used to facilitate the entrance o f the dye to the spore.

15.Answer: A. Acid Fast stain Explanation A staining procedure that stains cells that have an outer layer o f a waxy-lipid (acid fast) but not those that lack this layer material (non acid fast) is Acid Fast Stain.

16. Answer: C. To stain both the cell and the background, allowing visualization o f the unstained capsular material Explanation In Capsule staining two dyes are used to stain the cell and the background, allowing visualization o f the unstained capsular material.

17.

A nsw er: D. Treponema palladium

Explanation Streptococci, Neisseria gonorrhea and Staphylococci are spherical in shape but Treponema pallidium is helical shaped like corkscrew.

18. Answer: B. Staphylococci Explanation Spherical shaped bacteria that exist in clusters are known as Staphylococci. Streptococci exist in chains while sarcinae are found in packets o f four or eight. Vibrios are not spherical instead they are comma shaped bacilli. 19. Answer: D. Fusobacteria-Spherical Explanation : Fusobacteria do not have spherical shape instead they have tapered end and are slightly curved. 20. Answer: D. All o f the above Explanation Bacteria can be classified based upon: ]. The presence or absence o f spores 2. The presence or absence of capsules 3. Arrangement o f flagella and type o f motility 21 .Answer: C. Peritrichaete

Explanation Bacteria can be classified depending on Motility and the type o f flagella. 1. Monotrichous a single flagellum at either pole. 2. Amphitrichous: flagella at both poles. 3. Lophotrichous: a flagellum at either pole. 4. Peritrichous: flagella distributed evenly over the entire cell. 22.Answer: D. They are more complex inside, but less complex outside. Explanation Prokaryotic cells (bacteria) are more complex outside and less complex inside.

23.

Answer: E. All of the above

Explanation: Reasoning Prokaryotic cells lack a true nucleus, a Nuclear membrane and intracytoplasmic membranous organelles (e.g. Plastids, Endoplasmic reticulum

24.Answer: A.70 S Explanation: 70 S ribosomal units mediate Protein synthesis in prokaryotic cells.

25.Answer: A. Polypeptide Explanation The composition o f capsule shell differs between genera and usually is polysaccharide in nature; however, the capsule o f Bacillus anthracis is Polypeptide in nature

26.

Answer: D. It kills the host cells

Explanation The Capsule has several functions; 1. Increases the virulence (degree o f organism pathogenicity) o f a microorganism 2. Prevents phagocytosis o f the organism by macrophages and neutrophils. 3. Aids in adherence o f the organism to host cells But it does not directly involve in killing o f the host cells.

27.Answer: B. Slime layer Explanation If the polysaccharide o f a capsule is nonadherent, it is called a Slime layer.

28.

Answer: A. Loss o f Capsule

Explanation:

Transformation from smooth to rough colonies on bacterial media is indicative o f loss o f Capsule. Concurrently there is a loss o f virulence.

29.Answer: D. B and C Explanation The capsular material is immunogenic, thereby inducing the production o f antibodies, which act as opsonins to enhance phagocytosis (opsonization).

30.

Answer: D. AH o f the above

Explanation The three parts, which comprise flagella, are Basal body, Hook and Filament.

31 .Answer: A. 2 Explanation The number o f rings that make up the basal body o f flagella differ in gram- positive (two) and gram-negative (four) organisms.

32.Answer: A. Components o f the cell wall. Explanation Most bacteria are designated as either gram-negative or gram-positive, based on fundamental differences in the components o f the cell wall.

33.Answer: D. A and B Explanation The function o f cell walls in bacteria is a. To provide the general shape o f the cell. b. To protect the cell from osmotic shock. Bacterial genetic information is arranged on a single super coiled circular strand o f DNA, the nucleoid. It is not kept in the cell membrane

34.Answer: E. None Explanation All o f the above are true.

35.Answer: D. A and C Explanation

Peptidoglycan is the basic layer of the cell wall in gram- Gram-negative and Gram-positive bacteria. Gram-positive cells are deficient in lipids; however, Gram-negative cells are rich in complex lipids (e.g., lipopolysacchride). Both types o f cell walls have cross-links between polysaccharides.

36.Answer: B. Lipopolysaccharides Explanation Lipopolysaccharides are not present in cell wall o f Gram-positive cells.

37.Answer: D. They are found in both gram-positive and gram-negative bacteria Explanation Teichoic acids are found only in Gram-positive bacteria.

38.Answer: C. Lipid A Explanation Lipid A is the toxic portion that can slough off intact cells or be released into circulation upon lysis o f the cell, causing nonspecific inflammation including diarrhea, fever, and septic shock.

39.

Answer: A. An area between the cell wall and the cytoplasmic membrane.

Explanation The periplasmic space is an area between the cell wall and the cytoplasmic membrane

40.Answer: -A 41.Answer: -C 42.Answer: -B 43.Answer: -E 44.Answer: -D 45.Answer: C. Plasmids Explanation Plasmids contain the information for heavy metal and antibiotic resistance.

46.

Answer: D. All o f the above

Explanation The proteins found in the Cytoplasmic membrane are engaged in;

- Transportation o f nutrients. - Secretion o f exotoxins. - Electron transport and energy formation 47. Answer: - A 48. Answer: -E 49. Answer: -B 50. Answer: -C 51. Answer: -D 52.Answer: C. Thermophile Explanation 1. Psychophile: an organism that grow well at 0 C, has optimal growth at 15 C or less and a maximum growth temperature o f 2 0 C 2 . Mesophile: an organism with optim il growth temperature between 20 C and 45 C 3. Thermopile; an organism that can grow at 55 C 4. Autotrophs are organisms, which us e carbon dioxide as their sole or main carbon source.

53.Answer: B. Facultative Aerobes Explanation Obligate Anaerobes do not tolerate oxj/ gen at all and die in its presence, Facultative Anaerobes do not require ixygen but grow better in its presence, Obligate Aerobes are completely depe ndent on oxygen for growth. Oxygen serves as terminal electron acceptor in Aerobic respiratic n. Facultative Aerobes have the ability tc grow with or without molecular oxygen.

54.nswer: A. Many strains lack catalj.:se and superoxide dimutase that protect cells from the destructive oxidizing capabilities o f hy drogen peroxide and superoxide ions, which are normally produced under Aerobic conditions. Explanation Many Obligate Anaerobes strains lack catalase and superoxide dimutase that protect cells from the destructive oxidizing capabilities c f hydrogen peroxide and superoxide ions, which are normally produced under Aerobic con ditions.

55.Answer : C. Binary fission Explanation Bacteria reproduce asexually by Bina ry fission. Mitosis and meiosis are cellular even s involved in sexual reproduction.

56.Answer: E. B and D Explanation In the Lag phase o f bacterial growth the bacteria are rcplicating DNA and enzymes needed for the new environment induced. The cells increase in size but not number. During this phase o f growth, the cells are most permeable. The number o f cells increases in geometric progression in the Log phase.

57.Answer: C. Log phase Explanation: Most Bacteria cells are more susceptible to cell wall inhibitors during the Log phase of their growth. This is because the cell wall is being synthesized rapidly during this phase.

58.Answer: A. There is accumulation o f toxic wastes and autocatalytic enzymes Explanation In the Death phase o f bacterial growth curve the concentration o f viable cells decreases at a geometric rate because there is accumulation o f toxic wastes and auto catalytic enzymes. The type o f reproduction is not changed from binary fission to sexual reproduction or to any type o f reproduction.

59.Answer: B. Substrate- level phosphorylation Explanation Oxidative phosphorylation removes electrons from organic compounds and passes these electrons through a series o f electron acceptors along an electron transport chain, with molecular oxygen. Substrate- level phosphorylation releases energy through direct transfer o f high-energy phosphate groups from an intermediate metabolic compound to adenosine diphosphate (ADP). Fermentation refers to energy-producing oxidative sequences, in which organic compounds serve as both electron donors and acceptors. Glucogenesis refers to the build up o f glucose from varieties o f substrates.

60.Answer: D. Lactic acid fermentation Explanation Lactic acid fermentation is the simplest process in which pyruvate is converted to lactate.

61 .Answer: D. 2 moles o f ATP Explanation In glycolysis glucose is oxidized to pyruvic acid with a yield

o f 2 moles o f ATP.

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

The products o f bacterial butyric acid fermentation are Butanol, Isopropanol and Acetone.

63.Answer: B. Ribosomes Explanation Ribosomes are not electron transport systems they are Cellular units that synthesize protein by translating messenger RNA base sequences in to amino acid protein sequences.

64.Answer: D. Genes are RNA segments that are processed in two steps to produce various proteins. Explanation Bacteria have only one chromosome - a single, continuous (closed), double stranded, circular piece o f DNA. Duplication o f the genetic material occurs by semi conservative replication, in which two strands o f the helix separate and at this point new strands are synthesized, bidirectionally, with the originals serving as templates. In bacteria the nuclear material is attached to cell membrane and as the cell grows, it separates the daughter chromosomes. Therefore, each daughter cell has one original and one new strand. Genes are DNA segments that are processed in two steps to produce various proteins

65.Answer: D. DNA docs not catalyze biological reactions Explanation DNA does not catalyze biological reactions, Enzymes act as catalysts in biological reactions.

66

.Answer: A. Duplication o f DNA..

Explanation Bacterial replication involves duplication o f the chromosomal DNA, which enables the formation o f two identical daughter cells. Processing o f the genetic information to synthesize proteins is known as translation.

67.Answer: B. At transcription level Explanation Repression o f enzyme activity inhibits the synthesis o f the enzyme at transcription level (transfer o f information from DNA to RNA)

68

.Answer: C. Translation

Explanation Translation is the processing of genetic information to synthesize proteins. Transduction, Conjugation and Transformation are mechanisms by which microorganisms can change their genetic constitution by transfer of genetic material.

69.Answer: B. Transformation Explanation The gene transfer mechanism associated with recombinant DNA technology is transformation. 70.Answer: B. The plasmids do not contain a gene essential for cellular survival Explanation Plasmids cannot maintain stability unless they are beneficial to the host, so the plasmid should contain a gene essential for cellular survival -either an enzyme required in a metabolic pathway or a gene that resists certain antibiotics. 71 .Answer: A. Transduction Explanation Transduction is the transfer o f genetic material by bacteriophage (viruses that infect bacteria). Transcription is the process by which information is transferred from DNA to RNA to produce necessary proteins. Translation is the processing o f genetic information to synthesize proteins. Transformation involves the recipient cell taking up cell free, fragmented, (i.e. naked) DNA and recombining genetic elements. 72.Answer: B. Prophage Explanation In lysogenic bacteriophages the viral DNA that does not replicate is known Prophage. Plasmids are circular double-stranded pieces o f DNA that are found outside the bacterial chromosome and transposons are genetic elements carried by plasmids. Triplet codons (three nucleotides) are nucleotide bases used in the transfer o f genetic information to protein synthesis. 73.Answer: D. None Explanation All o f the above are true. 74. Answer: C. Chlamydia trachomatis

Explanation Rickettsia causes Rocky Mountain spotted fever. Mycoplasma pneumoniae is the causative agent o f pneumonia. Chlamydia trachomatis is a bacterium, which causes blindness and sexually transmitted diseases. 75.Answer: A. they have the ability to generate ATP Explanation Lack the ability to generate ATP; hence, they must obtain it from the host cell.

7. Which o f the following direct acting adrenergic agonists affect betaj and beta 2 but not: alpha receptors? A. B. C. D. E. Dobutamine Norepinephrine Epinephrine Isopreterenol Phenylephrine

A. B. C. D. E.

Dobutamine Phenylephrine Epinephrine Terbutaline Salmeterol

12

.Apraclonidine is used A. B. C. D. E. As antihypertensive agent Bronchodilator Cardiac stimulant Glaucoma To lower intraocular pressure during surgery

. Which o f the following is given systemically to treat nasal decongestion?

8

A. B. C. D. E.

Phenylephrine Oxymetazoline Xylometazoline B and C All the above

13.

Which o f the following is NOT correct? A. Prazosin is alphal-selective adrenergic antagonists B. Propranolol is beta2-selective adrenergic antagonist C. Phenoxybezamine is irreversible, nonselective alpha-adrenergic antagonist D. Metoprolol is betal selective adrenergic antagonist E. Beta selective antagonists lose their selectivity at high doses

9. Which o f the adrenergic agonists (sympathomimetic agents) are used in the treatment o f hypertension? A. B. C. D. E. Alphal selective Alpha 2 selective Beta 1 selective Beta 2 selective Beta selective (nonselective beta agonists)

10. Which o f the following is a WRONG match between an adrenergic agonist and its therapeutic application? A. Isoproterenol; bronchodilator and cardiac stimulant B. Dobutamine; systemic bronchodilator C. Epinephrine; treatment of anaphylactic reactions D. Terbutaline: in the treatment o f asthma E. A and D

14. A drug used for topical treatment o f glaucoma is A. B. C. D. E. Prazosin Propranolol Phenoxybenzamine Tolazoline Timolol

15.A drug that is used in the treatment hypertension and symptomatic treatment o f benign prostatic hyperplasia, A. B. C. D. Prazosin Propranolol Phenoxybenzamine Tolazoline

.Which o f the following agents is used to prolong the activity o f local anesthetic agents and in the treatment of glaucoma?
11

E. Timolol

16. Which o f the following statements about labetalol are correct? I. It is a selective alpahl blocking agent II. It is a nonselective beta blocking agent III. It is used in the treatment o f hypertension A. i f l only is correct B. if III only is correct C. i f l and II are correct D. if II and III are correct E. if l, II and III are correct

19. Which one of the following statements about acetylcholine is wrong? A. It is the endogenous neurotransmitter released at neuromuscular junction and at the synapses o f parasympathetic nerves B. It is the most potent cholinergic agonist C. Chemically it is an ester o f acetic acid and the quaternary amino alcohol(choline) D. It is long acting cholinergic agonist E. It is not a satisfactory therapeutic agent

17. Which o f the following is NOT true about the therapeutic application o f propranolol? A. It can be used to reduce the frequency and intensity o f migraine headache B. It is effective in the treatment o f both supraventricular and - ventricular dysrhythmias C. It can be used safely in patients with asthma D. It can be used as a prophylactic agent in angina pectoris E. It can be used in the management of hypertension

20. Which of the following is a direct acting cholinergic agonist? A. B. C. D. E. Methacholine echothiophate physostigmine isoflurophate neostigmine

21 .In peripheral nervous system muscarinic receptors are located at A. B. the ganglia o f parasympathetic nervous system Neuromuscular junctions o f somatic nervous system Parasympathetic postganglionic neuroeffector sites the ganglia o f sympathetic nervous system All but C

18. Which o f the following are therapeutic applications of phenoxybenzamine and phentolamine? A. Relieving vasospasm in Raynauds syndrome B. Management o f hypertensive emergencies resulting from pheochromocytoma C. Management o f hypertensive emergencies resulting from over dosage o f sympathomimetic drugs D. Management o f hypertensive emergencies resulting from over dosage o f MAO inhibitors

C. D. E.

22. Which of the following is NOT true about the therapeutic application of cholinergic agonists? A. The direct-acting agonist bethanechol can be used to initiate

B.

C.

D.

E.

micturition in acute nonobstructive urinary retention Both direct-acting and indirectacting cholinergic agonists are used to cause mydriasis to aid in eye examination The indirect acting agonists can be used in the diagnosis and therapy of myasthenia gravis The indirect acting agonist edrophonium is used in the treatment o f hypercholinergic crisis Physostigmine, indirect acting agonist, may be used in counteracting the toxic effects o f anticholinergic drugs

B. Scopolamine; to induce sedation C. Homatropine; to produce mydriasis and cycloplegia D. ipratropium; to treat bronchospasm associated with chronic obstructive pulmonary disease E. All o f the above

26.A11 the following are adverse effects of cholinergic antagonists EXCEPT A. B. C. D. E. Increased intraocular pressure Dry mouth Urinary retention Diarrhea Mydriasis

23.All the following are correct about cholinergic antagonist EXCEPT A. atropine is the prototypical drug in this group B. they are bulky analogues o f acetylcholine C. the quaternary ammonium antimuscarinic agents are designed to produce more central effect D. they are able to interact with the postganglionic receptors but they do not have intrinsic activity E. none

27. Which o f the following is NOT true about the competitive, nondepolarizing neuromuscular blocking agents? A. They are bulky and rigid molecules B. pancuronium is a competitive nondepolarizing agent, which is a synthetic steroid derivative C. atracurium is a competitive nondepolarizing agent, which is an isoquinoline D. The principal active alkaloid in curare is metocurine E. None

24.The drug o f choice for alleviating motion sickness is A. B. C. D. E. Atropine Scopolamine glycopyrrolate trihexyphenidyl A and B

28. Which o f the following is NOT true about succinylcholine? A. It is a noncompetitive depolarizing agent B. It has slender aliphatic structure C. It has a long duration o f action D. A and B E. None

25. Which o f the following are true matches between a cholinergic antagonist drug and its therapeutic indication? A. Benztropine; controls Parkinsons disease and some nurolepticinduced extrapyramidal disorders

29. All o f the following are therapeutic indications of neuromuscular blocking agents EXCEPT

A. To cause total unconsciousness of the body B. Promote skeletal muscle relaxation and facilitate endotracheal intubation C. Relax the skeletal muscles and facilitate bone replacement and manipulation during orthopedic procedures D. Limit trauma associated with skeletal muscle contraction during electroconvulsive shock therapy E. None

B. Should permit rapid recovery immediately after cessation of administration C. Should induce anesthesia rapidly and smoothly D. Devoid o f adverse effects E. All o f the above

34. Which of the following is CORRECT about the inhalation anesthetics? I They are inhaled as gases or vapors IT They are hydrophilic III They are all organic compounds 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 I, II and III are correct

30.One o f the following is NOT the adverse effect of succinylcholine A. B. C. D. E. Respiratory paralysis Muscle fasciculation with pain Decreased intraocular pressure Increased intragastric pressure Bradycardia

3 5. Which o f the following nonvolatile anesthetics is ultra-short acting? 31 .Which of the following are the adverse effects o f tubocurarine? A. B. C. D. E. Respiratory paralysis Hypotension Histamine release bronchospasm All o f the above A. B. C. D. E. Ketamine -Thiopental Diazepam Morphine All the above

32. General anesthetics induce which o f the following actions? A. B. C. D. Analgesia Loss o f consciousness Amnesia Inhibition of sensory and autonomic reflexes E. All o f the above

36. Which o f the following intravenous anesthetics should not be mixed with other therapeutic agents before administration? A. B. C. D. E. Thiopental Etomidate Propofol Diazepam Morphine

37.Inhalation anesthetics are excreted primarily through 33. Which o f the following are ideal properties o f a general anesthetic? A. A wide margin o f safety A. The kidneys B. The liver C. The lungs
D. The skin

E. A and B

38. Which o f the following agents allow reduction in the concentration o f inhalation anesthetics required to produce anesthesia? A. B. C. D. E. Muscarinic antagonists Skeletal muscle relaxants Muscarinic agonists Analgesics All but C

B. loss o f consciousness C. Temporary loss o f sensation at their administration site D. Complete analgesia o f well-defined parts o f the body E. None

43.Epinephrine is added to many local anesthetic preparations in order to A. Increase the duration o f action o f the local anesthetic B. Decrease the systemic side effects o f the local anesthetic C. Initiate the action o f the local anesthetics D. Help enhance the effectiveness o f the local anesthesia by causing analgesia E. A and B

39. One o f the following nonvolatile anesthetics is administered intramuscularly A. B. C. D. E. Thiobarbiturates Benzodiazepines Ketamine A and B only All the above

40. Which o f the following previously popular volatile anesthetics is no longer in use due to toxicity? A. Chloroform B. Cyclopropane C. Diethylether D. B and C E. All the above 41 .The uncharged, lipophilic form o f a local anesthetic is necessary A. Because it is the active form o f the drug B. For rapid penetration o f biological membranes C. To enhance the duration o f action D. For interaction with the receptors on the surface o f cell membrane E. All the above

44.In order to provide anesthesia for surgery o f the lower limbs and pelvis, the local anesthetics should be A. Injected close to the innervating nerve B. Injected into the epidural space or the subarachnoid space o f the spinal chord C. Applied locally as a cream D. Infiltrated around the tissue site E. Injected intramuscularly

45.The antipsychotic agents that lack the ring nitrogen o f phenothiazines and have a side chain attached by a double bond are A. B. C. D. E. Butyrophenones Clozapine Pimozide Thioxanthenes Molindone

42.One o f the following is NOT the action o f local anesthetics A. Reversible blockage o f nerve impulse conduction 46.Antipsychotic drugs block dopamine receptors in which part o f the brain to elicit antispychotic action?

A. B. C. D. E.

Cortical Limbic Basal ganglia A and B only All the above

E. Bone marrow depression

51 .AH o f the following are used in the treatment o f manic depression and bipolar disease EXCEPT A. B. C. D. E. Chlorpromazine Lithium Valproic acid Carbamazepine None

47.Many antipsychotic drugs have strong antiemetic effect. This is due to the blockade o f A. B. C. D. E. Muscarinic receptors Seretonin receptors Dopamine receptors Hj-histamonergic receptors Alphaj-adrenergic receptors

52.The drug/class o f antidepression and antimaniac drugs, which act by blocking the CNS neuronal reuptake o f biogenic amines A. B. C. D. E. Tricyclic antidepressants MAO inhibitors Selective serotonin inhibitors Bupropion Trazadone

48. Which o f the following is NOT correct about the pharmacological effect o f the atypical antipsychotics such as clozapine? A. They are very weak antagonists at the serotonin receptors B. They can ameliorate a wide range of symptoms better than the classic antipsychotic agents C. Their extrapyramidal effect is less than that o f the classic antipsychotic agents D. All o f the above 49. One o f the following is NOT an extrapyramidal symptom that may occur as a result o f the centrally mediated adverse effect o f antipsychotic drugs? A. B. C. D. E. Akathisia Acute dystonia Akinesia Tardive dyskinesia Poikilothermy

53. An antidepressant drug/class o f drugs, w'hich is approved clinically but has unclear mechanism o f action, A. B. C. D. E. Tricyclic antidepressants MAO inhibitors Selective serotonin inhibitors Bupropion Trazadone

54.The drug/class o f drugs that act mainly by blocking the intraneuronal oxidative deamination o f brain biogenic amines, A. B. C. D. E. T ricyclic anti depressants MAO inhibitors Selective serotonin inhibitors Bupropion Trazadone

50. All o f the following are adverse effects o f antipsychotic drugs EXCEPT A. Drowsiness B. Hyperprolactinemia C. Weight loss

55.The drug/group o f drugs that act by selectively inhibiting the reuptake o f serotonin into the nerve terminal, A. Tricyclic antidepressants B. MAO inhibitors C. Selective serotonin reuptake inhibitors D. Bupropion E. Trazadone

antidepressants, and atypical antidepressants? A. B. C. D. E. Dry mouth Bone marrow depression Constipation Urinary retention All but B

56. Which o f the following antidepressants are agents o f choice for the treatment of endogenous depression? I MAO inhibitors II Tricyclic antidepressants III Atypical antidepressants A. B. C. D. E. only III only I and 1 1 only 11 and III only 1,11 and III
1

60. Which o f the following is/are no longer used for their anxiolytic and sedativehypnotic effect? A. B. C. D. E. Benzodiazepines Imidazopyridines barbiturates Azaspirodecanediones None

61 .Which o f the following benzodiazepines are expected to show short duration of action? I Temazepam II Lorazepam III Oxazepam IV Diazepam A. B. C. D. E. I and II only II and III only I, II, and III only I, II, and IV only 1,11, III, and IV

57.The tricyclic/atypical antidepressant drug that is used to treat enuresis is A. B. C. D. E. Clomipramine Imipramine Fluoxetine Doxepin Fluvoxamine

58. Which o f the following should be avoided in a patient taking MAO inhibitors? A. B. C. D. E. Sympathomimetic agents Wine Cheese Sausage All the above

62 .IV solutions o f diazepam are prepared using propylene glycol. This is because A. Propylene glycol enhances the action o f diazepam B. Diazepam is insoluble in aqueous solutions C. Diazepam is unstable in aqueous solutions D. Propylene glycol prolongs the biological half-life of diazepam E. B and C

59. Which o f the following adverse effects is shared by MAO inhibitors, tricyclic

63. Which o f the following is NOT true about the structure activity relationship of barbiturates? A. Chemically barbiturates are 5,5disubstituted derivatives of barbituric acid B. Two side chains in position 5 are essential for sedative-hypnotic activity C. Decreasing the urinary pH, increases the excretion o f barbiturates D. The presence o f phenyl and ethyl groups in position 5 makes the barbiturates to be long acting E. None

A. They act by inhibiting the release neurotransmitter GABA B. They act by binding to and activating GABA receptors C. They act by increasing the efficiency o f GABAergic synaptic inhibition D. They act by blocking GABA receptors E. A and B

67. Which o f the following are actions o f benzodiazepines? A. B. C. D. E. Hypnosis Anesthesia Anticonvulsant Muscle relaxation All o f the above

64. Which o f the following are correct about the barbiturates, which have branched side chains, unsaturated side chains, or side chains longer than an ethyl group? A. These barbiturates have increased metabolic rate B. They have shorter onset o f action C. They have short duration o f action D. They are more potent E. All o f the above

6 8 .All the following are correct about the pharmacological action of azaspirones/buspirone EXCEPT

65. Which o f the following is NOT true about the ultra-short acting barbiturates? A. They are the most effective sedative-hypnotics B. The oxygen in C2 is replaced by sulfur C. Thiopental is the prototype drug in this class D. They are highly lipophilic drugs E. They are effective in facilitating the induction o f anesthesia

A. They do not interact with the GABA-chloride ionophore receptor complexes B. Buspirone appear to exert its anxiolytic effects by acting as partial agonist at 5-HTIA receptors C. Buspirone has minimum abuse liability D. Buspirone enhances the depressant effect o f alcohols and other CNS depressant drugs E. A and C

69.One of the following is NOT correct about the pharmacology o f barbiturates. A. They bind to the GABA-chloride ionophore complex at a site different from that o f benzodiazepines B. They are more selective in their action than the benzodiazepines

.Which of the following is CORRECT about the pharmacological action o f benzodiazepines?

66

C. Unlike benzodiazepine, they increase the duration o f the GABAgated channel openings D. They induce hepatic microsomal drug-metabolizing enzyme activity E. They may act as respiratory depressants

C. Long-acting barbiturates D. Chloral hydrate E. Benzodiazepines

74.All the following adverse effects are associated with the use o f benzodiazepines EXCEPT A. CNS depression, drowsiness, sedation B. Leukopenia C. Nausea, vomiting, diarrhea D. Paradoxical excitement, insomnia, rage reactions E. Liability to abuse and dependence

70. Which o f the following is NOT true about chloral hydrate? A. It is commonly used to induce sleep in pediatric or geriatric patients B. It induces the hepatic microsomal drug metabolizing enzyme activity C. It is relatively cheap drug D. Its metabolites do not show any activity E. It may be used as a preanesthetic for minor surgical and dental procedures

75.Intravenous diazepam, phenytoin, and Phenobarbital are used in the management of A. B. C. D. E. Tonic-clonic seizures Absence (petit mal) seizures Status epilepticus Psychomotor seizures All the above

71 .The drug, which is not effective against panic disorders but is used for generalized anxiety states is: A. B. C. D. E. Buspirone Zolpidem Long-acting barbiturates Chloral hydrate Benzodiazepines

76. Which o f the following is NOT effective against absence (petit mal) seizures? A. B. C. D. E. Phenobarbital Clonazepam Phenytoin Valproic acid Ethosuximide

72. One o f the following Drug/drugs may be used as antiepileptics A. B. C. D. E. Buspirone Zolpidem Long-acting barbiturates Chloral hydrate Benzodiazepines

77. Which o f the following are associated with the use of antiepileptic drugs? A. B. C. D. E. Confusion, ataxia, dizziness Allergic reaction GI symptoms Blood dyscriaisis AH the above

73.A drug, which may be used to induce sleep but cannot be used clinically for its anxiolytic activity is: A. Buspirone B. Zolpidem

78. Which o f the following antiepileptic drugs are associated with arrhythmias and gingival hyperplasia? A. B. C. D. E. Carbamazepine Hydantoins Barbiturates Valproic acid Succinimides

A. B. C. D. E.

amantadine bromocriptine ropinirole pergolide pramipexole

83.The anticholinergic agents act as antiparkinsonians because A. They stimulate the release o f dopamine in the caudate-putamen B. They inhibit the degradation of dopamine in the brain C. They act as agonists at the dopaminergic receptors D. They block the excitatory cholinergic system E. All but B

79. Which antiepileptic drug is associated with the birth defects, neural tube defects, which is caused as a result of administration o f the drug during pregnancy? A. B. C. D. E. Carbamazepine Phenytoin Valproic acid A and B only All the above

84. Amantadine is indicated for the treatment o f all o f the following EXCEPT A. B. C. D. E. Idiopathic parkinsonism Tardive dyskinesia postencephalitic parkinsonism Arteriosclerosis parkinsonism None

80. What is the prototypical dopaminergic antiparkinsonian agent? A. B. C. D. Benztropine Levodopa Bromocriptine Pramipexole

81 .Which o f the following increases the efficiency o f levodopa by inhibiting the degradation o f levodopa derived dopamine in the brain? A. B. C. D. E. Carbidopa Tolcapone Selegiline A and B Band C

85. Which o f the following should NOT be used in the treatment o f extrapyramidal effects that result from the use o f neuroleptic drugs? A. B. C. D. E. Selegiline Anticholinergics Antihistamines Levodopa None

82. All o f the following antiparkinsonian agents act by binding directly and activating dopaminergic receptors mimicking the activity o f striatal dopamine EXCEPT

8 6 .Which o f the following adverse effects is NOT associated with the use o f levodopa?

A. Nausea, vomiting, anorexia B. Tachycardia, orthostatic hypotension C. Dyskinesia

D. Delusion, hallucination, confusion E. Livedo reticularis

D. Meperidine E. A and C

87. All the following are adverse effects o f amantadine EXCEPT A. B. C. D. E. Drowsiness, dizziness, insomnia Urinary retention and ankle edema Dyskinesia Hallucination, confusion None

91 .All the following are mixed agonistantagonist opioids EXCEPT A. B. C. D. Naloxone Nalbuphine Betorphanol Pentazocine

.Which o f the following phenanthrenes have enhanced oral bioavailability but decreased agonist potency?
88

92. Which o f the following is NOT correct about tramadol? A. It is structurally unrelated to natural, semisynthetic, or synthetic opioids B. It has no clear benefits over opiates C. Its metabolite rather than the parent drug itself appears to be the active agent D. It is an analogue o f the endogenous opioid peptides E. B and C

A. B. C. D. E.

Codeine Hydromorphone Hydrocodone Oxycodone All but B

89. Which o f the following is NOT correct about the structure activity relationship o f opioid agonists and antagonists? A. M orphines phenolic hydroxyl group is extremely important for activity B. The methyl group in morphine can be changed without significant change in the agonist property C. Agents that have a free phenolic hydroxyl group and a tertiary amine function are chemically amphoterics with erratic oral absorption D. The analgesic activity depends on a p-phenyl-N-alklypiperidine moiety E. A and D

93.Which o f the following is the action o f opioid agonists? A. B. C. D. E. Analgesia Euphoria Sedation Nausea and vomiting All the above

94.Opioids may be used as

I

.Preanesthetic medicaments II. Adjunct to anesthetic agents III. Primary anesthetic agents A. B. C. D. E. I only I and II only I and III only II and III only L 11 and III

90. Which o f the following opioids is a strong agonist as well as has high oral bioavailability? A. Methadone B. Propoxyphene C. Levorphanol

95. Which of the following opioids are used as antidiarrheals? I.Codeine II. Loperamide III. Diphenoxylate IV. Dextromethrophan A. B. C. D. E. I and II only II and III only Ill and IV only I, II and IV only II, III and IV only

ANSW ERS

Nervous System and Drugs

1. Answer: C. I and II

^Explanation: Direct-acting adrenergic agonists interact directly with adrenergic receptors to elicit a response. Two o f the direct-acting adrenergic agonists, norepinephrine and epinephrine, are endogenous cathecholamines, which are biosynthesized from tyrosine.

D opam ine
2. Answer: B. Replacing the meta (3) hydroxyl group will result in loss o f direct-acting property Explanation: Although the meta (3) hydroxyl group is nccessary for direct a - and p-receptor activity, this is not always the case because drugs in which the meta hydroxyl is replaced by a sulfonamide or a hydroxymethyl group retain their activity.

3. Answer: C. I and II are correct

Explanation: Cathecholamines are inactivated by methylation of the Meta hydroxyl group, which is catalyzed i and by oxidative deamination, which is catalyzed by monoamine oxidase (MAO). N-substitutibn with large groups makes the drugs to be (3-receptor selective.

ch
I

4
I

gh

N H -C H

OH I HO
Adrenaline (Epinephrine):

M ore info: Catecholamines (epinephrine, norepinephrine, and dopamine) cause general physiological changes that prepare the body for phys cal activity (fight-or-flight response). Some typical effects are increases in heart rate, blood pressure, blood glucose levels, and a general reaction^of the sympathetic nervous system.

4. Answer: C. Their structure is very different from that o f the direct-acting adrenergic agonists Explanation: Indirect-acting adrenergic agonists ha^e structures that are similar to that o f catecholamines, but they do not interact directly with adrenergic receptors. Their actions depend on the release o f endogenous catecholamines either by displacement o f stored catecholamines from the adrenergic nerve ending or inhibiting the reuptake o f catecholamines already released.

5.

Answer: B. Circular muscles o f tljie iris; constriction o f the pupil

Explanation: j Postjunctional alpha] adrenergic receptors are found in most vascular smooth muscles, radial smooth muscles o f the iris, pilomotoi: smooth muscles o f the hair follicle, in the heart and in the sphincter o f the GI tract. The effect o f agonists on these receptors is excitatory as a result o f which they cause contraction o f the iris sphincter muscle. This causes mydriasis (i.e., widening of the pupil). More Info:

The adrenergic receptors (or adrenoceptors) are targets of the catecholamines adrenaline and noradrenaline (called epinephrine and norepinephrine in the USA), and are activated by these. There are several types of adrenergic receptors, but there are two main groups: a-Adrenergic and |3-Adrenergic.

Receptor location andfunction: a receptors

a l : Smooth muscles. In blood vessels the principal effect is vasoconstriction. Blood vessels with a l receptors are present in the skin and the gastrointestinal system, and during the fight-or-flight response vasoconstriction results in the decreased blood flow to these organs. This accounts for an individual's skin appearing pale when frightened. In the GI tract, the effect is relaxation. a2 are located in Pre- and postsynaptic nerve terminals and mediates synaptic transmission.

fS receptors pi:
Heart and cerebral cortex. In heart, agonists enhance myocardial contractility and increase heart rate. Also found on juxtaglomerular cells, activation results in renin release. P2: Lungs, smooth muscle, cerebellum, and skeletal muscle. P3: Adipose tissue. Agonists enhance lipolysis (breakdown o f fat stored in fat cells). In lung, agonists cause bronchiole dilation (useful in asthma treatment). In smooth muscle, relaxes walls. Relaxes uterine muscle and promotes release o f insulin.

6.

Answer: B. II and III

Explanation: Stimulation o f beta adrenoceptors causes relaxation o f most kind o f smooth muscles by increasing cAMP formation. Bronchial smooth muscles contain beta2 receptors that cause relaxation. Activation o f these receptors thus results in bronchodilation. In the vascular system, there is beta2 mediated vasodilation, which is mainly endothelium dependent and mediated by nitric oxide release. It occurs in many vascular beds and is especially marked in skeletal muscle.

7. Answer: D. Isoproterenol Explanation: Direct acting adrenergic agonists are those, which primarily act by direct stimulation o f adrenergic receptors. They may be selective to a particular receptor subtype or they may be nonselective in that they can activate a variety o f receptor subtypes. Examples o f those which are selective, include clonidine (alpha2), dobutamine (betal), phenylephrine (alphal) and terbutaline (beta2). Examples o f nonselective agonists include, norepinephrine (all but especially alphal, alpha2, and betal), epinephrine (alp h al, alpha2, b e ta l, and beta2). Isoproterenol a nonselective beta activator has no effect on alpha receptors.

8. Answer: A. Phenylephrine Explanation: Phenylephrine is direct acting alpha! agonist, which is given systemically to treat nasal decongestion. Oxymetazoline and xylometazoline, which are also alpha 1 agonists, are used as topical decongestants because o f their ability to promote constriction o f nasal mucosa.

9. Answer: B. Alpha 2 selective Explanation: Alpha2 selective agonists have a paradoxical ability to reduce blood pressure through actions in local application may cause vasoconstriction. These agents, which include drugs like clonidine, methyldopa, guanfacine, guanabenz. etc, are used as antihypertensives.

10.Answer: B. Dobutamine; systemic bronchodilator

Explanation: ! Dobutamine is a betal selective agonist (and thus does not have effect on the lung) and is used to improve myocardial function in CHF n emergency situations. Isoproterenol is a nonselective beta agonist, which can be used as a bronchodilator and as a cardiac stimulant in shock and cardiac arrest. Epinephrine is nonseleittive alpha and beta adrenergic agonist. It is the preferred agent for treating anaphylactic reactions (because o f its great efficiency at alpha, betal and beta2 rcceptors, since stimulation o f all three is helpful in reversing the pathophysiologic process) and it is also used to treat hypersensitivity reactions. Terbutaline, like the other beta2 selective agonist has both systemic and local bronchodilation effect as a result o f which they have achieved a special place in the treatment o f asthma.

11 .Answer: C. Epinephrine Explanation: Because o f their ability to constrict bjlood vessels and thus reduce blood flow, epinephrine (and also phenylephrine) is used to reduce the diffusion o f local anesthetics away from the site o f administration. This way they can be used to prolong the activity o f local anesthetics and reduce

the total dose. Epinephrine has also the ability to decrease intraocular pressure by enhancing the outflow o f aqueous humor and decreasing the production of aqueous humor through vasoconstriction. Hence, it is used in the treatment o f glaucoma.

12. Answer: E. To lower intraocular pressure during surgery Explanation: Apraclonidine is an alpha2 selective agonist that is used to lower intraocular pressure during surgery.

13.Answer: B. Propranolol is beta2-selective adrenergic antagonist Explanation: Propranolol is a nonselective beta adrenergic antagonist.

14.Answer: E. Timolol Explanation: Timolol, which is a nonselective beta-blocker has the ability to decrease ciliary body production o f aqueous humor and thus can be used in the topical treatment o f glaucoma.

15.Answer: A. Prazosin Explanation: Prazosin causes the relaxation of both arterial and venous smooth muscle, which makes it effective in the management o f hypertension. It is also used to relieve prostatic obstruction and increase urine flow in patients with benign prostatic hyperplasia.

16.

Answer: E. I, II and III are correct

Explanation:

Labetolol is a reversible adrenoreceptor antagonist available as a racemic mixture o f two pairs o f chiral isomers. The SS and RS isomers are inactive, SR is a potent alphal selective blocker, and the RR isomer is a potent beta blocker. Labetalol is used in the management o f
hypertension.

MO

OH

17. Answer: C. It can be used safely in patients with asthma. ( NOT True) Explanation:

Propranolol is a nonselective beta adi energic blocker. Therefore, beta-2-receptor blockade associated with the use o f such as agent commonly causes worsening o f preexisting asthma and
other forms o f airway obstruction with 3ut having these consequences in normal individuals. In fact, a relatively trivial asthma may bee<ome severe after beta blockade.

18. Answer: E. AH o f the above Explanation: All the given choices are the therapeut c applications o f phenoxybenzamine and phentolamine.

19. Answer: D. It is long acting cholin :rgic agonist Explanation: After relaying a nerve impulse, acetylicholine is rapidly broken down by the enzyme cholinesterase. Therefore, it is extremiely short acting, which makes it not suitable to be used as a therapeutic agent.

20.Answer: A. Methacholine Explanation: The direct acting cholinergic agonists bind and activate muscarinic or nicotinic receptors. They are produced by replacing the acetyl gift oup o f acetylcholine with a carbamoyl group or by substituting a methyl group o f the beta carbon. This renders them more tolerant to the action o f acetylcholinesterase and thus long actin:g agents. Examples include methacholine and thanechol. By inhibiting acetlycholinesterase, the indirect acting drugs increase the concentration o f endogenous acetylcholine in the synaptic clefts and neuroeffector junctions, and the excess acetylcholine in turn stimulates cholinergic receptors to evoke increased response. Examples in elude the long acting, irreversible agents, such as isoflurophate and echothiophate, and th e short acting, reversible agents such as physostigmine and neostigmine.

21. Answer: C. Parasympathetic postganglionic neuroeffector sites

Explanation:

Peripheral nervous system muscarinic receptors are present at parasympathetic postganglionic neuroeffector sites. Peripheral nervous system nicotinic receptors are present at the ganglia o f parasympathetic nervous system, neuromuscular junctions o f somatic nervous system, at the ganglia o f sympathetic nervous system.

22.Answer: B. Both direct-acting and indirect-acting cholinergic agonist are used to cause mydriasis to aid in eye examination Explanation: Muscarinic agonists, both direct acting and indirect-acting, instilled into the conjunctival sac causes contraction o f the smooth muscle o f the iris sphincter (which results in miosis) and o f the ciliary muscle (which results in accommodation). As a result, the iris is pulled away from the angle o f the anterior chamber, and the trabecular meshwork at the base o f ciliary muscle is opened up. Both effects facilitate the outflow o f aqueous humor into the canals o f Schlemm, which drains the anterior chamber. This makes them useful in the treatment o f glaucoma.

23.Answer: C. the quaternary ammonium antimuscarinic agents are designed to produce more central effect Explanation: The presence o f quaternary or tertiary nitrogen in these agents determines the spectrum o f activity, in that the quaternary ammonium antimuscarinic drugs have more peripheral effect with reduced central nervous system effect. The tertiary ammonium analogues are used for their effect on the eye and central nervous system since they can cross lipid barriers.

24.Answer: B. Scopolamine Explanation: Certain vestibular disorders respond to antimuscarinic drugs. Scopolamine, an antimuscarinic agent, is one o f the oldest remedies for motion sickness and is still as effective as any other more recently introduced agents. It can be given by injection, mouth or by means o f a transdermal patch.

25.

Answer: E. All o f the above

Explanation: All the given choices are the correct matches.

26. Answer: D. diarrhea

Explanation: Blockade o f muscarinic receptors he.s dramatic effects on the motility and some o f the secretory functions o f the gut. Motility o f GI smooth muscles is affected from the stomach to the colon. In general, the walls o f the viscera are relaxed, and both tone and propulsive movements are diminished. Therefore, cholinergic E.ntagonist could be used to treat diarrhea and may cause constipation as an adverse effect.

27.Answer: D. The principal active ajlkaloid in curare is metocurine Explanation: Curare is an alkaloid extract from the bark o f South American tree (Strychnos and Chondodendron species) that relaxes and paralyzes voluntary muscles. The principal active alkaloid in curare is tubocurarine. Me ocurine is the trimethyl derivative o f tubocurarine. Their most important structural feature is th 5 presence o f a tertiary-quaternary amine in which the distance between the two cations is fix ed at about 14 angstroms twice the length o f the critical receptor binding moiety o f acetylchol me.

28. Answer: C. It has a long duration o f action Explanation: Succinylcholine has extremely brief d uration o f action since it is rapidly hydrolysed by pseudocholinesterase (butyrylcholine:sterase), an enzyme o f the liver and plasma.

29.Answer: A. To cause total unconsiciousness o f the body Explanation: The main aim o f using neuromuscular blocking agents is to cause only skeletal muscle paralysis while the patient remains conscious and capable o f sensation. Before the introduction of neuromuscular blocking drugs, adequate skeletal muscle relaxation could only be achieved by deep anesthesia that was often associated with hazardous depressant effect on various organ systems, especially cardiorespiratory system. The neuromuscular blocking agents have made it possible to achieve adequate muscle relaxation for all surgical requirements without the depressant effects o f deep anesthesia. Therefore, neuromuscular drugs are used not to cause total unconsciousness o f the body but rather to avoid it.

30.Answer: C. Decreased intraocular pressure Explanation: Administration o f succinylcholine is followed by an increase in intraocular pressure that is manifested 1 minute after injection, nlaximum at 2-4minutes, and subsides after 5 minutes. The mechanism for this effect has not bee n clearly defined, but it may involve contraction o f tonic myofibrilis or transient dilation o f ch aroidal blood vessels.

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

Tubocurarine causes all o f the given adverse effects.

32. Answer: E. All o f the above Explanation: In addition to the above, general anesthetics can cause skeletal muscle relaxation in many cases.

33. Answer: E. All o f the above Explanation: An ideal anesthetic drug would induce anesthesia rapidly and smoothly.

34.Answer: A. I only Explanation: Volatile general anesthetics act by interacting with the lipid bilayer o f cell membranes, causing depressed excitability. Therefore, in order to interact with the cell membrane, they must be lipophilic in nature. Volatile general anesthetics include the inorganic agents such as nitrous oxide, and the nonflammable halogenated hydrocarbons (e.g., halothane), and ethers (e.g., methoxyflurane, isoflurane).

35.Answer: B. Thiopental Explanation: In general, the water-soluble intravenous anesthetics, which include the barbiturates (e.g., thiopental), cyclohexylamines (e.g., ketamine), benzodiazepines (e.g., diazepam), butyrophenones (e.g., droperidol), and opioid analgesics (e.g., morphine), are short acting. However, the barbiturates are even ultra-short acting. For example, following intravenous administration, thiopental rapidly crosses the blood brain barrier, and if given in sufficient dosage, produces hypnosis in one circulation time.

36.Answer: C. Propofol Explanation: Propofol, a dialkylphenol, which is prepared as an emulsion, should not be mixed with other therapeutic agents before administration.

37.Answer: C. The lungs Explanation: Because they are volatile gases, inhalation anesthetics are absorbed and primarily excreted

through the lungs.

38.

Answer: D. Analgesics

Explanation: Usually the inhalation anesthetics are administered along with other therapeutic agents that serve different purposes. For example, adminislration o f analgesics allows the reduction in the concentration o f the inhalation anesthetics required to produce anesthesia. Skeletal muscle relaxants are added to cause adequate muscle relaxation during surgery, and antimuscarinic agents to decrease bronchiolar secretions

39.Answer: C. Ketamine Explanation: In general, nonvolatile anesthetics are administered intravenously (e.g., thiobarbiturates, benzodiazepines). However, there are some agents such as ketamine that are administered intramuscularly.

40. Answer: A. Chloroform Explanation: Chloroform is no more used because of its toxicity while cyclopropane and diethylether are not used because o f their flammable and ex >losive properties.

41 .Answer: B. For rapid penetration o f biological membranes Explanation: The cationic form o f the drug is the active form o f the drug that blocks generation o f action potentials at the membrane receptor co(mpIex (cationic drugs cannot readily leave closed channels). This site o f anesthetic actioiji is found on the inner surface o f the membrane. So it is not accessible from the external side o f the cell membrane. Therefore, the anesthetic agent must be able to cross the cell membrane, and tile lipophilic form o f the drug allow diffusion across connective tissue and cell membranes. Once inside the cell, the drug becomes ionized to a chargcd ammonium cation, which is the active form. Moreover, this charged form of the drug is not able to penetrate cell membrane aijid thus remains trapped inside the cell, thereby enhancing the duration o f action.

42.Answer: B. Loss o f consciousnes Explanation: Local anesthetics are capable o f reveitsibly blocking nerve impulse conduction and thus produce a reversible loss o f sensation at the site o f administration as well as a temporary but complete analgesia o f well-defined parts o f the body. However, they do not cause loss o f consciousness.

43.Answer: E. A and B Explanation:

Epinephrine is a vasoconstrictor and when included in local anesthetic preparations, it reduces vascular blood flow at the administration site. This reduces systemic absorption, and hence prolongs the duration o f action and reduces systemic toxicity.

44. Answer: B. Injected into the epidural space or the subarachnoid space o f the spinal chord Explanation: The effect o f local anesthetic agents on a particular body part depends up on the site of application o f the agent. When injected close to the innervating nerve, they produce regional nerve block for relief o f pain; when infiltrated around the tissue, they provide anesthesia for minor operations; when applied locally, they provide anesthesia o f the skin and mucous membrane. And in order to provide anesthesia for surgery o f the lower limbs and pelvis, the local anesthetics should be injected into the epidural space or the subarachnoid space o f the spinal chord.

45. Answer: D. Thioxanthenes Explanation: Thioxanthenes (e.g., thiothixene) lack the ring nitrogen o f phenothiazines and have a side chain attached by a double bond. In general, these compounds are slightly less potent than their phenothiazine analogues. Butyrophenones, o f which haloperidol is the most widely used, has a very different structure from those o f thioxanthene and phenothiazines. Clozapine, pimozide, and molindone are examples o f newer drugs that have varied structures.

Haloperidol O I!

C (CH-,)-, N

HALPER1DOL

46.Answer: D. A and B only Explanation: Antipsychotic drugs block dopamine rec|eptors in cortical and limbic areas o f the brain to elicit antispychotic action.The blockade o f dopamine receptors in the basal ganglia by these agents results in the adverse extrapyramidal effects such as parkinsonism- like syndrome, akathisia and acute dystonic reactions.

47.Answer: C. Dopamine receptors Explanation: The majority o f the antipsychotic drugs! have effects other than their main action, which are related to their interaction with muscarinic receptors, seretonin receptors, H]-histamonergic receptors, Alphar adrenergic receptors.) The strong antiemetic effect is, however, related to the blockade o f dopamine receptors both centrally (in the chemoreceptor trigger zone o f the medulla) and peripherally (on receptors in the stomach).

48.Answer: A. They are very weak antagonists at the serotonin receptors. Explanation: The atypical antipsychotic agents are strong antagonists at the serotonin receptors in addition to their blockade o f dopamine receptors

49.Answer: E. Poikilothermy Explanation: Poikilothermy is the inability to reguljate body temperature, which can fluctuate according to the temperature o f the surroundings. It is also centrally mediated adverse effect o f antipsychotic drugs.

50.Answer: C. Weight loss

Explanation;^

Increased appetite and weight gain (not weight loss) are common adverse effects associated with antipsychotic drugs, which require close monitoring o f food intake.

51 .Answer: A. Chlorpromazine Explanation: Chlopromazine is phenothiazine, which is used in the treatment o f Psychosis. The element lithium, in the form o f carbonate salt, is used to treat depression and dipolar disease, so do the organic compounds Valproic acid and carbamazepine.

52.Answer: A. Tricyclic antidepressants Explanation: By blocking the amine reuptake pumps, tricyclic antidepressants reduce CNS neuronal reuptake o f the biogenic amine and thus prolonging the synaptic availability o f the biogenic amines and hence their action at central aminergic receptors.

53.Answer: D. bupropion Explanation: Bupropion is an antidepressant drug, which is approved for clinical use but its mechanism o f action remains unclear.

54.Answer: B. MAO inhibitors Explanation: MAO inhibitors block the major degradative pathway for the amine neurotransmitters, which permit more amines to accumulate in presynaptic stores and more to be released.

55.Answer: C. selective serotonin reuptake inhibitors Explanation: As their name indicates selective serotonin reuptake inhibitors inhibit serotonin reuptake into the nerve terminals, thus prolonging the synaptic activity o f the amine.

56.

Answer: D. ]I and III only

Explanation: Tricyclic and atypical antidepressants are the agents o f choice in the treatment o f endogenous depression. MAO inhibitors are indicated to treat depression, phobic anxiety and narcolepsy that have not responded to other treatments. Their adverse effects limit their use.

57.Answer: B. Imipramine

Explanation: In addition to their use in the treatment of endogenous depression, many individual tricyclic and atypical antidepressants may be used to treat various disorders. For example, imipramine is used to treat enuresis; clomipramine, fluoxeti ne, and fluvoxamine are used in obsessive-compulsive disorder; and doxepin for anxiety.

58.Answer: E. All the above Explanation: MAO inhibitors, by increasing stores o f cathecholamines, sensitize the patient to indirectly acting sympathomimetics such as tyramine, Which is found in some fermented foods and beverages (such as wine, cheese, sausage), and to sympathomimetic drugs that may be administered therapeutically. Such sensitization can result in dangerous hypertensive crisis.

59.Answer: E. All but B Explanation:

Dry mouth, bone marrow depression, and urinary retention are all symptoms o f antimuscarinic activity, which is sho wn by all the three classes o f antidepressants. Bone marrow
depression is the adverse effect o f onH some tricyclic antidepressants.

60.Answer: C. barbiturates Explanation: Anxiolytics and sedative-hypnotic agients in current use include the highly effective benzodiazepines and the atypical azas pirodecanediones and imidazopyridines. Other classes of eh as the barbiturates, meprobamate and hydroxyzine are no drugs, which were used previously su< longer used due to some o f their limitaitions, which include liability to produce tolerance, physical dependence, severe withdrawal reactions,, and serious toxicity with over dosage.

61.Answer: C. I, II, and III only Explanation: Benzodiazepines with 3-hydroxyl grolup (e.g., temazepam, lorazepam, and oxazepam) are susceptible to metabolism by phase II glucuronidation and thus, are short acting. Benzodiazepines that lack a 3-hydroxyl group (e.g., diazepam) must first undergo phase 1 metabolism, which include N-dealkaylation and 3-hydroxylation. Therefore, these drugs are long acting. Moreover, many long acting benzodiazepines can form phase-I metabolites that are active, with half-lives greater than that o f the pare nt drugs.

CH3

o
OH

Cl
c 6h 5 TEMAZEPAM CH 3

Cl
OXAZEPAM

LORAZEPAM

Cl
C 6H5 DIAZEPAM

62.Answer: B. Diazepam is insoluble in aqueous solutions Explanation: Some benzodiazepines that lack an amino side chain, such as diazepam, are not basic enough to form water-soluble salts with acids. Therefore, IV solutions o f diazepam are prepared by using propylene glycol as a solvent.

63.

Answer: C. decreasing the urinary pH, increases the excretion o f barbiturates

Explanation: Barbiturates and many o f their metabolites are weak acid, and thus, alteration in the urinary pH can affect their excretion. For example, acidifying the urinary pH decrease the ionization o f barbiturates as a result o f which their tubular reabsorption is increased. This decreases the amount o f barbiturates excreted in urine.

64.Answer: E. All o f the above Explanation: Barbiturates, which have branched side chains, unsaturated side chains, or side chains longer than an ethyl group have increased lipophilicity. Increased lipid-solubility increases the rate o f entry o f the drugs to CNS, which explains their rapid onset o f action. It also explains the fact that they leave the CNS rapidly (thus short duration o f action) to other body tissues such as liver (where they are metabolized, and thus increased rate o f metabolism). Increased lipophilicity is also found to increase their potency.

65.Answer: A. They are the most effective sedative-hypnotics Explanation:

Replacement of C2 with sulfur produces barbiturates that are extremely lipidsoluble. This contributes to the rapid en tr (and rapid onset o f action) o f these agents to the CNS. How'ever, this high-lipid solubility is at tie same time a cause for their rapid redistribution from the brain. This process contributes to the r;apid termination o f their major CNS effect (thus the name ultra-short acting). Therefore, these agents are not useful as sedative-hypnotics but are effective in facilitating the induction o f anesthesia.

66

.Answer: C. They act by increasing the efficiency o f GABAergic synaptic inhibition

Explanation: Benzodiazepines act by potentiation GAlBAergic neurotransmission at all levels o f the neuraxis, including the spinal cord, hypothalamus hippocampus, substantia nigra, cerebellar cortex, and cerebral cortex. The interaction of benzodiazepines with GABA causes an increase in the frequency o f chloride channel opening events, leading to a facilitation o f chloride ion conductance, membrane hyperpolarization and ultimately synaptic inhibition. This inhibition leads to decrease in the firing rate o f critical neurons in many regions o f the brain.

67. Answer: E. All o f the above Explanation: In addition to their anxiolytic propertie most benzodiazepines have other CNS action, which includes hypnosis, anesthesia, anticon\ ulsant, and muscle relaxation. They increase the depressant effect o f alcohol and other CNS depressant drugs as well.

. Answer: D. Buspirone enhances the depressant effect o f alcohols and other CNS depressant drugs I 68

Explanation: Unlike benzodiazepines, buspirone do es not have hypnotic, anticonvulsant, or muscle relaxant properties, and it does not enhance the depressant effect o f alcohols and other CNS depressant drugs.

69. Answer: B. They are more selective in their action than the benzodiazepines Explanation: Barbiturates are less selective in theiil actions than benzodiazepines, since they also depress the actions o f excitatory neurotransmitters and exert nonsynaptic membrane effects in parallel with their effects on GABA neurotransmission. This multiplicity o f sites o f action o f barbiturates may be the basis for their ability to induce full surgical anesthesia and for their more pronounced central depressant effects (which resjilts in their low margin o f safety) compared to benzodiazepines.

70. Answer: D. Its metabolites do not show any activity Explanation: Chloral hydrate is inactive by itself. It is biotransfrormed to trichloroethanol, which is responsible for the pharmacological action o f the drug.

71 .Answer: A. Buspirone Explanation: In contrast to benzodiazepines, buspirones anxiolytic effects may take more than a week to become established, making this drug suitable mainly for generalized anxiety state. It is ineffective against panic disorders, which require fast acting anxiolytics.

72.Answer: C. long acting barbiturates Explanation: The use o f barbiturates as anxiolytics is almost completely -an d justifiably- supplanted with benzodiazepines. The long-acting barbiturates continue to be used as antiepileptics.

73.Answer: B. zolpidem Explanation: Like the other imidazopyridines, zolpidem has strong sedative effects with minimal clinical anxiolytic action. It is used in shortening sleep latency and in prolonging total sleep time in patients with insomnia.

74.Answer: B. Leukopenia Explanation: Leukopenia, which is a decrease in the number o f white blood cells in the blood is an adverse effect associated with the use o f chloral hydrate and not with benzodiazepines.

75.Answer: C. Status epilepticus Explanation: Status epilepticus is the occurrence o f repeated epileptic fits without any recovery o f consciousness between them. It is a life-threatening emergency, requiring immediate cardiovascular, respiratory and metabolic management as well as pharmacological therapy. The later is done by intravenous administration o f diazepam, phenytoin or Phenobarbital.

76.

Answer: C. Phenytoin

Explanation:

Phenytoin is one o f the most prescribed hydantoins in the treatment of seizures. It is effective against tonic clonic (grand mal) seizure:; and psychomotor seizures. However, it is ineffective against absence (petit mal) seizures.

77. Answer: E. All the above Explanation: In addition to the above-mentioned adv erse effects, antiepileptic drugs may cause various organ system toxicities including renal and liver failure, pancreatitis, and cardiotoxicity.

78.Answer: B. Hydantoins Explanation: In addition to the general adverse effecjt:s o f all antiepileptic drugs, there are some specific adverse effects associated to each agent. For e:xample, the use of hydantoins is associated with specific arrhythmias and gingival hyperplasia.

79.Answer: C. Valproic acid Explanation: Antiepileptics, in general have the potential to cause birth defects when taken during pregnancy, It is estimated that a pregnant woman taking Valproic acid or sodium valproate has a 1-2% of having a child with spinal bifida, one type o f neural tube defects. Carbamazepine and phenytoin may cause cleft palate, a fissure in the middle of the palate due to failure o f the two sides to fuse during embryonic development.

80.Answer: B. Levodopa Explanation: The prototypical dopaminergic antip;arkinsonian drug is the cathecholamine levodopa. Dopamine does not cross the blood-brain barrier and if given into the peripheral circulation has no therapeutic effect in parkinsonism, iwever, levodopa, the immediate metabolic precursor o f dopamine, does penetrate the brain, w here it is decarboxylated to dopamine. Benztropine is the anticholinergic antiparkinsonian agent,:, which is structurally related to atropine. Bromocriptine is an ergoline, which acts directly on the dopaminergic receptors. Pramipexole is a newer nonergoline dopamine agonist.

81.Answer: C. Selegiline Explanation: Selegiline, a selective inhibitor o f mo noamino oxidase B retards the breakdown o f dopamine; as a consequence, it enhances and prolongs the antiparkinsonism effect o f levodopa. Tolcapone is a selective inhibitor o f COMT, and in doing so it reduces the conversion o f levodopa to the inactive 3-O-methyldopa, which may also inhibit levodopa uptake into the brain. Carbidopa, an analogue of levodopa, is a peripheral dopa dec irboxylase inhibitor, which is not able to cross the brain blood barrier. Therefore, it decreases the decarboxylation and subsequent inactivation o f

levodopa in the peripheral tissue, while not affecting the conversion o f levodopa to dopamine in the brain.

82.Answer: A. amantadine Explanation: Amantadine, an antiviral drug, was by chance found to have antiparkinsonism properties. It appears to act by stimulating the release o f dopamine from intact striatal dopaminergic terminals.

83.Answer: D. They block the excitatory cholinergic system Explanation: Anticholinergics block the excitatory cholinergic system, thus reducing the functional imbalance between dopamine and acetylcholine in the striatum. Examples include trihexylphenidyl, benzotropine.

84.

Answer: B. Tardive dyskinesia

Explanation: Tardive dykinesia is a disorder characterized by a variety o f abnormal movements that develop after long-term neuroleptic drug treatment. The exacerbations in the movement disorders produced by levodopa plus other clinical observations suggest that tardive dyskinesia is related to increased dopaminergic function, but its precise pharmacological basis is unclear. Therefore, it is to be expected that the use o f amantadine, an agent that stimulates dopamine release, would aggravate the condition. Hence, amantadine could be used to treat drug induced extrapyramidal effects with the exception o f tardive dyskinesia.

85.Answer: D. Levodopa Explanation: Levodopa is contraindicated in psychotic patients. Therefore, it should not be used to treat extrapyramidal effects that result from the use o f neuroleptic drugs, since it may aggravate the mental disorders for which antipsychotic drugs were prescribed originally. If treatment is necessary selegiline, anticholinergics, or antihistamines could be used effectively (except in case o f tardive dyskinesia). These drugs are also indicated as adjunctive therapy for all types o f parkinsonism.

86

.Answer: E. Livedo reticularis

Explanation: Livedo reticularis, which is mottling o f the skin on the extremities, is an adverse effect associated with the use o f amantadine or bromocriptine.

87.Answer: C. Dyskinesia

Explanation: Dyskinesia, which comprises a group of nvoluntary movements that appear to be fragmentation o f the normally smoothly controlled limt and facial movement, is a condition associated with the use o f levodopa and bromocriptine.

88

.Answer: E. All but B

Explanation: Substitutions at the C3 and C 6 hydroxyl group o f the prototypical drug morphine significantly alter pharmacokinetic properties. Methyl substitution at C3 reduces susceptibility to first-pass hepatic metabolism o f the molecule by glucuronide conjugation at this position. Therefore, drugs such as codeine, hydrocodone, and oxycodone have enhanced oral bioavailability. However, these agents have decreased agonist potency.

89.Answer: B. The methyl group in morphine can be changed without significant change in the agonist property Explanation: Relatively small molecular change in the structure o f the prototypical opioid morphine can result in drastic changes in the actions and pharmacokinetic properties o f the opioids, such as converting an agonist to antagonist or tlo a compound with both agonist and antagonist effect-i.e. mixed agonist-antagonist. Replacement o f the methyl group on the nitrogen atom with larger groups results in antagonist opioids.

90.Answer: E. A and C Explanation: Methadone and propoxyphene are botli bisphenyl derivatives o f heptylamine that have excellent oral bioavailability. However, while methadone is a strong agonist, propoxyphene is only moderately agonist. Levorphanol, a morphinan, is synthetically prepared opioid analgesic closely resembling morphine. It has strong agonist property and has high oral bioavailability. Meperidine, which is a phenylpiperidine derivative is a strong agonist but should be given parenterally.

91.Answer: A. Naloxone Explanation: Mixed agonist-antagonist opioids arelthose that block the actions o f agonists at some receptor subtypes while directly stimulating olher receptor subtypes to produce agonist effect. All the above drugs show mixed agonist-antagonist properties except nalaxone, which is pure antagonist.

92. Answer: D. It is an analogue o f the endogenous opioid peptides Explanation: Tramadol is a newer synthetic opioic analgesic agent, which is structurally unrelated to natural, semisynthetic, or synthetic opioids. I)t is not an analogue o f the endogenous opioid peptides.

93.Answer: E. All the above Explanation: Opioid analgesics have the ability to mimic the action o f the endogenous opioid peptides in that they raise the pain threshold and increase pain tolerance, an action that is mediated through the subtype o f opioid receptors. After a dose o f morphine, an opioid agonist, a typical patient in pain or an addict experience euphoria (a pleasant floating sensation and freedom from anxiety and distress). Drowsiness and clouding o f mentation are frequent concomitants o f opioid action. The opioid analgesics can activate the brain stem chemoreceptor trigger zone to produce nausea and vomiting. Other CNS effects o f opioid analgesics include, respiratory depression, cough suppression and miosis.

94.Answer: E. I, II and III Explanation: The opioids are frequently used as premedicantion drugs before anesthesia and surgery because o f their sedative, anxiolytic and analgesic properties. They are also used intraoperatively both adjunct to other anesthetic agents and, in high doses, as the primary anesthetic agents, most commonly in cardiovascular surgery and other types o f high-risk surgery where a primary goal is to minimize cardiovascular depression.

95.Answer: B. II and III only Explanation: The mild to moderate opioid agonists are used in the treatment o f diarrhea (loperamide and diphenoxylate) and as antitussives in cough suppression (codeine and dextromethorphan).

>. i

New Product Development

Try to put well in practice what you already know. In so doing, you will, in good time, discover the hidden thing, you now inquire about. ^ ^ ( .<)urmaal

1. Which o f the following is NOT TRUE about new chemical entity? A. Can be obtained from organic synthesis, molecular modification, or isolation from plants. B. According to FDA, NCE is an API that has not been approved for marketing in the US. C. NCE is the component that produces the pharmacological activity, although its clinical, toxicological, physical and chemical properties are unknown. D. All NCE are finally developed into a dosage form. E. None

D. In some cases it may be possible to start the phase I before IND application is submitted. E. Clinical testing takes pace after IND application is submitted

4. The formulation used during phase II A. Should be o f the same dosage form and same dosage strength as the one used during the initial clinical studies B. Should have the same type and amount o f ingredients as the one used during the initial clinical studies C. Should have absolute bioequivalency with the one used during the initial clinical studies D. Should be bioequivalent to the one used during the initial clinical studies E. Should be pharmaceutical equivalent to the one used during the initial clinical studies 5. Which phases o f the product development process include patients with the diseases or condition for which the drug was developed? A. All stages except preclinical and phase I B. Phase I and phase II C. Phase II only D. Phase 111 and phase II E. Phase III and phase IV

2. In the preclinical stage o f the development o f drug products containing new chemical entities A. The NCE is biologically characterized for pharmacologic and toxicological effects and potential therapeutic application. B. The subjects during this stage are only whole animals C. The final formulation o f the drug product is decided during this stage D. Once the preclinical studies demonstrate adequate safety and efficacy, the drug sponsor can file an investigational new dug application with the FDA and no more o f the nonhuman studies would be necessary afterwards.

3. During the phase I clinical stage A. Various toxicological studies are planned B. The subjects are healthy volunteers C. The purpose o f doing phase I clinical trials is to determine the safety and dosage.

. After the FDA grants the market approval o f the drug:

6

A. Any change to the product is prohibited B. No more clinical studies are required C. Additional clinical studies are required only to determine if the drug can be used for a new indication.

D. It is possible for the drug product to be removed from the market. E. C and D

7. Scale-up activities can occur: A. Only after FDA grants market approval B. After phase III C. After NDA is submitted and before FDA grants market approval D. After large-scale, multicentered clinical studies are performed with the final dosage form developed in phase II. E. After phase V

A. Can only be developed after the patent expiration o f the brand drug product. B. Should contain the same type and amount o f the active ingredient as the brand drug product. C. The generic product should be o f the same dosage form as the brand product D. Should necessarily be therapeutically equivalent as the brand drug product. E. Should not be expected to give the same clinical response as the brand drug product since the clinical studies are done in healthy individual instead o f patient volunteers.

8 . Which o f the following activities do not occur during phase II?

A. Dose-response studies and pharmacokinetic studies B. Development o f the final drug formulation is developed C. Side effects are monitored in large population and thus, new toxic effects might be identified D. Therapeutic index is determined E. None

11 .A generic drug product may differ (without further study) in its physical appearance (size, color, shape) from the brand drug product in case o f A. B. C. D. E. Only tablets and liquid orals Only semisolids and transdermals All dosage forms except tablets Only tablets All dosage forms except parentrals

9. Which o f the following is NOT TRUE about product line extension? I. physical form or strength o f the dosage forms is changed II. the use o f the dosage forms is changed III. can only be done during phase II when the final drug formulation is developed A. B. C. D. E. I only is correct Ill only is correct I f l and III are correct If II and III are correct I f l, 11 and III are correct

1 2 .To get the market approval o f the generic drug product, a manufacturer must submit

10. Which o f the following is NOT TRUE about a generic drug product?

A. An NDA to FDA for review and approval after the completion o f the carefully designed preclinical and clinical studies. B. An ANDA to FDA for review and approval after the completion o f the carefully designed preclinical and clinical studies. C. An ANDA in which non clinical laboratory studies and clinical investigations are omitted, except those pertaining to the drugs bioiavailability.

D. An NDA to FDA, which describe all changes made in the chemistry, manufacturing and controls requirements for the generic drug product. E. None

13. Which o f the following requirements for generic drug product are similar to that for a brand product? I .chemistry II. manufacturing III. controls A. B. C. D. E. I only is correct Ill only is correct If I and III are correct If II and III are correct If I, II and III are correct

B. Preformulation activities are performed during the preclinical, phase I and phase II stages. C. Preformulation studies should include therapeutic studies since these tend to have large influence on the type o f drug product or drug delivery system. D. Preformulation studies are important in the preparation of dosage forms for drug evaluation in human clinical trials and in the development o f a final product submitted to the FDA for marketing approval. E. C and D

16.The following information is obtained during preformulation studies except A. Physical description B. Solubility and dissolution characteristics C. Drug stability profile D. Chemical characteristics E. Pharmacologic property

14. Which o f the following is TRUE about specialty drug products? A. Drug product with a very small change to the active drug product in the brand drug product that give rise to a new therapeutic indication B. A complete safety and efficacy studies made on the specialty drug product must be submitted before approval for marketing C. Specialty drug products are essentially same as the brand drug product except for the delivery system or the therapeutic use. D. Specialty drug products can differ from brand products only in the delivery system. E. All but C

17. A final drug product is developed in the preclinical phase in case of A. Topical drug products for local application. B. Topical drug products for systemic drug absorption. C. Injectables. D. Oral drug products. E. A and B

18. Which o f the following is NOT TRUE about formulation development A. For early clinical studies it is possible to develop only the initial drug formulation. B. When submitting an NDA, the manufacturer must develop the final (marketed) dosage form o f the drug.

15. Which o f the following is NOT TRUE about preformulation? A. During pre formulation all the physical and chemical properties of the drug substance and dosage form are studied

C. The route o f administration is important in determining the modifications needed. D. Since it easily be adjusted, the dose o f the drug is not very important in making modifications. E. None

D. The technology available and the desired systemic levels are very important in developing the final drug product E. All except B

22. When developing oral drug products 19. Which o f the following is true about developing injectable drug product? A. Stability o f the drug in solution is the major concern for the formulator. B. Formulation changes may require acute toxicity studies. C. Bioavailability studies are required whenever formulation is changed. D. The formulator must choose a final product toward the end o f the process E. A and B A. Prototype forms are often developed during the preclinical phase to assure bioavailability and solubility in the GIT. B. In the early stage o f product development, hard gelatin capsule dosage forms are often developed for phase I clinical trial . C. The final product is developed during the phase II and prior to initiating the phase III trials. D. A, B & C

20. Which o f the following statements about developing topical drug products for local application is not true? A. The final dosage form is usually developed during phase I B. Irritation is a major problem C. The release o f the drug from the matrix is measured in vitro with various diffusion cell models. D. The final dosage form is usually developed during phase 1 1 E. None

23. Which o f the following is/are TRUE about the considerations to be made in the development o f a final dosage form? A. Physical appearance o f the dosage form B. Size and shape o f the package or container C. Production equipment and site D. Country in which the drug is to be manufactured and to which the drug is to be marketed E. All o f the above

21 .Topical drug products for systemic drug absorption A. Include drug delivery through the skin, mucous membrane and rectal mucosa. B. A prototype formulation should be developed at least during the preclinical stage. C. A final topical drug product is developed during phase III.

24.In the solid oral product line extensions where the dosage form to develop is a different dosage strength o f a drug A. Only bioequivalence studies are needed B. Clinical trials are normally required. C. No preformulation studies are required. D. The later three phases o f product development are required E. A and C

25.In the solid oral product line extensions where a modified-release dosage form is to be developed from instant-release dosage form A. Only bioequivalence studies are needed B. Clinical trials are normally required. C. No preformulation studies are required D. All the phases o f drug product development must be done E. B and C

D. Clinical studies and Safety studies E. All o f the above

29. Which o f the following is NOT a combination products? A. B. C. D. E. drug/drug drug/device drug / biologic biologic / device none

26.Regulatory approval for all solid product line extensions are based on the following except A. Stability information B. Analytical and manufacturing controls C. Bioequivalence studies D. Safety studies E. All o f the above

30. The responsibility o f an FDA investigator during preapproval inspection include the following EXCEPT A. Performing a general cGMP inspection relating specifically to the drug product intended for the market. B. Reviewing the development report to verify that the drug product has enough supporting document C. Consulting the chemistry, manufacturing and controls section o f NDA, AADA, or ANDA and determining the capability o f the manufacturer to produce the drug product as described D. Verifying the traceability o f the information submitted in the CMC section to the original laboratory notebooks, electronic information and the batch record. E. Approving the manufacturing o f the drug product.

27.In the solid oral product line extensions where a drug is developed for a new therapeutic indication A. Only bioequivalence studies are required B. Only phase III clinical trials are required C. Only bioequivalence and preformulation studies are required D. New NDA is required E. A & B

28.If the marketed product is a solid oral dosage form and the product line extension is a liquid, regulatory approval necessarily requires A. Bioequivalence studies B. Stability information C. Analytical and manufacturing controls

31.The guidelines for scale-up and post approval changes provide recommendations to sponsors o f NDAs, AADAs, and ANDAs during the following changes A. To make slight changes in the amount o f the active ingredient B. To change the site o f manufacture C. To scale-up or scale-down the batch size o f the formulation

D. To change the manufacturing process and equipment. E. All

E. Use o f different facility to manufacture the drug product.

32.Scale-up and post-approval changes that require annual report to the FDA include the following except A. compliance with an official compendium B. label description o f the drug product (not involving dosage strength or form) C. addition o f an ingredient that affects only the color o f the product D. addition or deletion o f an alternate analytical method E. none

35. Scale-up and post-approval changes that require pre-approval supplement include the following EXCEPT A. establishment o f a new regulatory analytical method B. relaxation o f the limits for a specification C. change in the method o f manufacture o f the drug product D. extension o f the expiration date o f the drug product based on data obtained under a new or revised stability testing protocol that has not been approved in the application E. deletion o f an ingredient that affects only the color o f the product.

33.A manufacturer wants to extend the expiration date o f a drug product based on full shelf-life data obtained from a protocol approved in the application, then A. the extension can be done without informing the FDA B. the extension can be done without approval from the FDA but should reported C. the extension cannot be done without approval from the FDA D. there is no guideline for such changes E. extending expiration is not allowed at all

36.Bioequivalence may be demonstrated by an in vivo bioequivalence study comparing the original and new formulations if the scale-up and postapproval changes A. B. C. D. E. Are considered m inor by the FDA Are considered major by the FDA Require annual reporting Require being effected supplement All but A

37. Which o f the following does NOT match to the word GMP? A. cGMP B. Regulations developed by the manufacturer C. Minimum requirements for manufacturing, processing, packing and storing human and veterinary drugs D. Criteria for personnel, facilities and manufacturing process E. None

34.Scale-up and post-approval changes that require changes being effected (CBE) supplement include the following except A. Container and closure system for the drug product. B. Addition o f a new specification or test method C. Label change to add or strengthen a contraindication D. Use of different facility to
manufacture the drug substance ~

38. The functions of the quality control group within the pharmaceutical manufacturer include the following except A. Responsibility for establishing process and product specifications B. Testing the products and verifying that the specifications are met. C. Determining the systems and facilities are adequate D. Acceptance or rejection o f the incoming raw materials. E. None o f the above

39. The group within the manufacturer which makes sure that all written procedures are followed properly is A. B. C. D. E. quality control group quality assurance group the administration the manufacturing unit B and C

ANSW ERS

New Product Development

1. Answer: D. All N CEs are finally developed into a dosage form. Explanation: A drug substance is the active pharmacological ingredient that produces pharmacological activity. A new chemical entity (NCE) is a drug substance with unknown clinical, toxicological, physical, and chemical properties. The API/NCE may be produced from chemical synthesis, recovery from natural product, enzymatic reaction, recombinant DNA technology, fermentation, or a combination o f these processes. The US FDA considers an NCE as an API that has not been approved for marketing in the US. Many NCE fail to meet official requirements, so that only a few o f them are developed into a dosage form

2. Answer: A. The NCE is biologically characterized for pharmacologic and toxicological effects and potential therapeutic application. Explanation: The subjects during the preclinical stage o f drug development could be whole animals or cell cultures. The final dosage form is decided at alter stages depending upon the type o f dosage form to be developed. For most o f them it is decided during phase 111. Nonhuman studies may continue at nay stage o f the drug development process to obtain addition information about the pharmacology and toxicology o f the drug.

3. Answer: D. In some cases it may be possible to start the phase I before IND application is submitted. Explanation: During this phase o f drug development healthy volunteers are used to determine the drugs safety and dosage and toxicological studies including acute, chronic, subchronic, mutagenicity are planned in various animal species. But this phase can only be started after the IND application is submitted.

4. Answer: D. Should be bioequivalent to the one used during the initial clinical studies Explanation: The formulation used during phase II does not need to be o f the same dosage form, dosage strength or made o f the same type and amount o f non-active ingredients. Nor does it need to be pharmaceutically equivalent to the one used during the initial clinical studies. And no two dosage forms can have absolute bioequivalency.

5. Answer:D. Phase III and phase II Explanation: In the preclinical stage only nonhuman subjects are used. In phase I healthy individuals are used. During Phase II and Phase III the subjects used are patients with the diseases or condition for which the drug was developed.

. Answer: D. It is possible for the drug product to be removed from the market.

Explanation: After the FDA grants market approval o f the drug, product development may continue. The drug product may be improved as a result o f equipment, regulatory, supply, or market demand. Additional clinical studies may be performed in special populations such as the elderly, pediatric, renal-impaired patients, and others to obtain information on the efficacy o f the drug in these subjects. Additional clinical studies are also done to see if the drug could be used for new indication as well. I f the drug is found have unexpected and unacceptable effects,it could be taken out o f the market even if it was approved for market.

7. Answer: C. After NDA is submitted and before FDA grants market approval Explanation: Scale-up is the increase in the batch size form the clinical batch, the submission batch or both, up to the full scale production batch size, using the finished, marketed product. Scale-up activities occur on phase IV after the NDA is submitted and before approval to market the product is obtained from the FDA.

8 . AnswenC. Side effects are monitored in large population and thus, new toxic effects might be identified

Explanation: In phase II, a limited number of patients with the diseases or condition for which the drug was developed are treated under close supervision. Dose-response studies and pharmacokinetics are performed to determine the optimum dosage regimen for treating the disease. Safety is measured by attempting to determine the therapeutic index. A final formulation, which is bioequivalent to the dosage form used in the initial clinical studies, is developed. Chronic toxicity studies are started in two species, which will normally last more than 2 years duration.

9. Answer:A. I only is correct Explanation: Product line extension are dosage forms in which the physical form or strength, but not the use or indication, o f the product changes. Product line extension is usually performed during phase III, IV, or V.

10.Answer: E. Should not be expected to give the same clinical response as the brand drug product since the clinical studies are done in healthy individual instead o f patient volunteers. Explanation: A generic product may be marketed after the patent for the brand product is expired. A generic product should be therapeutically equivalent to the brand name drug product and should contain the same amount o f the drug in the same type o f dosage form. A generic product must be bioequivalent to the brand product and thus, it is expected to give the same clinical response even though the studies are done in healthy individuals.

11 .Answer: D. Only tablets

Explanation: The generic drug product may differ from the brand product in physical appearance (i.e., size, color, shape) or in the amount and type o f excipients only for tablets. A generic drug product may not differ both in qualitative and quantitative composition for liquids, injectables, semisolids, inhalations, and ophthalmic products, unless adequate safety studies have been performed.

12. Answer: C. An ANDA in which non clinical laboratory studies and clinical investigations are omitted, except those pertaining to the drugs bioiavailability. Explanation: Before a drug product is marketed, the manufacturer must submit an abbreviated new drug application (ANDA) to the FDA for approval. Because preclinical safety and efficacy studies have already been performed for the NDA-approved brand product, human bioequivalence studies are generally required for the ANDA instead o f clinical trials.

13.Answer: E. I, II and III are correct Explanation: The chemistry, manufacturing and controls requirements for the generic drug product are similar to those for the brand name drug product.

14.Answer: C. Specialty drug products are essentially same as the brand drug product except for the delivery system or the therapeutic use. Explanation: Specialty drug products are existing drug products that are developed as a new delivery system or for anew therapeutic indication. The safety and efficacy o f the drug product was established in the initial NDA-approved dosage form. For example, the nitroglycerin transdermal delivery system (patch) was developed after experience with nitroglycerin sublingual tablets.

15.Answer:C. Preformulation studies should include therapeutic studies since these tend to have large influence on the type o f drug product or drug delivery system. Explanation: Preformulation is the characterization o f the physical and chemical properties o f the active drug substance and dosage form. Therapeutic indications are not part o f the preformulation studies but (along with the route a f administration) will dictate the type o f drug product or drug delivery system (e.g., immediate release, controlled release, suppository, etc ) that needs to be developed. Preformulation activities are usually performed during the preclinical stage. However, these activities may continue into phases I and II.

16.

Answer: E.Pharmacologic property

Explanation: The information generated during preformulation include: general characteristics (e.g., particle size, crystalline feature, powder flow etc); solubility characteristics (e.g., intrinsic dissolution, pH solubility' profile, solubility in various solvents); chemical characteristics (e.g., surface energy, pKa, stability profile); analytical method development (e.g., development o f

stability indicating method, cleaning method). Pharmacological properties are studied as part o f the preclinical and clinical activities.

17.Answer: C. Injectables. Explanation: A final injectable drug product is usually developed in the preclinical stage.

18.Answer:D. Since it easily be adjusted, the dose o f the drug is not very important in making modifications. Explanation: Formulation is a continuing process. Initial drug formulations are developed for early clinical studies. When the submission o f an NDA is considered, the manufacturer attempts to develop the final (marketed) product. The dose o f the drug and route o f administration are very important in determining the modification needed.

19.Answer:

E. A and B

Explanation: When developing injectable drug product, the stability o f the drug in solutions is the major concern for the formulator. Because few excipients are allowed in injectable products, the formulator must choose a final product early in the development process. If the formulation is changed, bioavailability studies are not required in case o f IV since the drug is injected directly into the circulation. Formulation changes may require acute toxicity studies.

20.Answer: D. The final dosage form is usually developed during phase II Explanation: The final dosage form is usually developed during phase 1 because any major formulation changes may require further clinical trials. Significant problems encounter with locally acting topical drug products include local irritation and systemic drug absorption.

21 .Answer: E. All except B Explanation: Topical drug products for systemic absorption include drug delivery through the skin (transdermal), mucous membranes (intranasal), and rectal mucosa. A prototype formulation is developed for phase I. A final drug product is developed during phase III after the available technologies and desired systemic levels are considered.

22.Answer: D. A, B &C Explanation: During the development o f oral drug product, prototype dosage forms are often developed during the preclinical phase to assure that the drug is optimally available and that the product dissolves in the GIT. In the early stages o f product development, hard gelatin capsule dosage forms are often developed for phase 1 clinical trials. Final product development begins when the drug proceeds during phase II and prior to initiating phase III clinical studies.

23. Answer :E. All o f the above Explanation: In developing a final drug product, a manufacturer must think o f all o f the above mentioned considerations.

24.Answer: E. A and C Explanation: In solid oral product line extensions, the simplest dosage form to develop is a different dosage strength o f a drug in a tablet or capsule. Only bioequivalence studies are needed. Because the original brand drug product information contributes to the body o f knowledge about the drug, no preformulation is needed.

25.Answer:E. B and C Explanation: A modified-release dosage form is more difficult to develop when only an instant-Telease dosage form exists. Clinical studies are normally required in this case. Because the original brand drug product information contributes to the body o f knowledge about the drug, no preformulation is needed.

26.

Answer: E. All o f the above

Explanation: All o f the above are important for regulatory approval for all solid product line extensions.

27.. Answer: D. New NDA is required. Explanation: In the solid oral product line extension where a drug is developed for a new therapeutic indication, a new efficacy studies and a new NDA are required.

28.Answer: E. All o f the above Explanation: All o f the above

29.Answer: A. drug/drug Explanation: Combination products are comprised o f two or more regulated components (i.e., drug/device, drug/biologic, biologic/device, or drug/device/biologic) that are physically, chemically, or otherwise combined or mixed and produced as a single entity. Examples may include an

inhalation steroid (e.g., beclomethasone inhalation aerosol) in which the device component is important for delivery o f the steroid. 30. Answer: E. Approving the manufacturing o f the drug product. Explanation: The responsibilities o f an FDA investigator include all o f the above except approving the manufacturing process. The investigator can only recommend whether to approve the manufacture o f the drug product after the PAL

31. Answer: E. All Explanation: The scale-up and post approval changes are guidelines intended to reduce the number o f changes that require pre-approval by the FDA. These guidelines provide recommendations to sponsors o f NDAs, AADAs, and ANDAs during the following changes in the post-approval period: to make slight changes in the amount o f the excipients to aid in the processing o f the product during scaleup; to change manufacturing site; to scale-up or scale-down the batch size o f the formulation; and to change the manufacturing process or equipment.

32.Answer: C. Addition o f an ingredient that affects only the color o f the product Explanation: Addition o f any kind o f ingredient requires approval from the FDA before they are implemented.

33.Answer: B. The extension can be done without approval from the FDA but should reported Explanation: Extending expiration date based on full shelf-life data obtained from a protocol approved in the application is one o f those changes that are unlikely to have any detectable effect on formulation quality and performance, and thus can be instituted without approval from the FDA, but should be reported annually.

34.Answer: A.Container and closure system for the drug product. Explanation: Changes in container and closure system for the drug product (except a change in contained size for nonsolid dosage form) based upon equivalency to the approved system under a protocol approved in the application or published in an official compendium, can be instituted before approval from the FDA but require annual reporting.

35.

Answer: E. Deletion o f an ingredient that affects only the color of the product

Explanation: Deletion of an ingredient that affects only the color o f the product can be implemented without approval from the FDA but should be reported annually.

36.Answer: B. Are considered major by the FDA Explanation: If the FDA considers the proposed change minor, bioequivalence may be demonstrated by comparative dissolution profiles for the original and new formulation. Annual report and require being effected supplement are two o f the three regulatory documentation through which the FDA must be notified about a proposed change to a drug product.

37.

Answer: B. Regulations developed by the manufacturer

Explanation: GMP, which is also called cGMP, is the minimum requirements for manufacturing, processing, packing and storing human and veterinary drugs. It establishes the criteria for personnel, facilities and manufacturing process to ensure that the finished drug product has the correct identity, strength, quality, and purity characteristics. But GMP is developed by FDA and not by the manufacturer.

38.Answer: C. Determining the systems and facilities are adequate Explanation: Determining the systems and facilities in a pharmaceutical industry is the function o f the quality assurance group in the pharmaceutical manufacturer. The quality control is responsible for establishing process and product specifications. The QC unit tests the product and verifies that the specifications are met. QC testing includes the acceptance or rejection o f the incoming raw materials, packaging components, drug products, water system, and environmental conditions (e.g., heating, ventilation, and air conditioning; air quality, microbial load) that exist during the manufacturing process.

39.Answer: B. quality assurance group Explanation: In addition to determining that the systems and facilities are adequate, the quality assurance group within the manufacturer is the one responsible for ensuring all written procedures are followed so that finished drug products meet the applicable specification for quality.

Organic Chemistry

You were born to win

, but to be a winner, you must plan to win, prepare to win, and expect to win

Z ig Ziglar

1. A. B. C. D. E.

The representation R1-C0-0-R2 refers to the functional group Ester Ether Ketone Aldehyde Quaternary

2. If R], R>, R 3 and R4 refers to alkyl groups, then which of the following notation represents tertiary amine A.

R tf_ R R1- N - R 2 R ,-N -R 2

I B. C.

R4
H
R r D. E. 3. Which of the following structure refers to Benzoyl choride A.
Ov

R,
Rs R,

B. '--ir''
.OH

C. Ci I C -0

\ CH,

Cl

ji
D. E. None

s i

A
4. Ether linkage is NOT found in the drug A. B. C. D. Propranolol Lorazepam Gemfibrozil Naproxen

Cl

~~

E. Fenofibrate Propranolol
COOH H,C

Lorazepam N aproxen

Gemfibrozil O C H * o . A A CHj

X I jC O C
Fenofibrate O 5. The structure ^3^ A. B. C. D. E. Acetic acid Acctic anhydride Acetic hydrazine Acetaldehyde Acetonitrile 0 O

A A

CH3 refers to the name

. As per Bronsted theory, an acid is a group that can: Donate electrons Accept electrons Donate proton Accept proton None

D. Furan E. Propane 9. Which o f the following is NOT an electron withdrawing group Ester Ketone Vinyl Amine Sulfonyl

A. B. C. D. E.

7. The compound that is neutral or positively charged and has a relatively empty orbital for bond making is called as A. B. C. D. E.
8

A. B. C. D. E.

Electrophile Neutrophile Non-polar compound Free radical None

10. Which o f the following statement is WRONG regarding Resonance effect A. Resonance effect involves movement of electrons through a Li bond system B. Resonance effect decreases slowly with distance C. Stabilization increases as the number of atoms over which the charge is dispersed increases

. Which of the following is NOT an aromatic compound

A. Benzene B. Naphthalene C. Phenanthrene

D. Resonance effect doesnt contribute more to electronic effect of a functional group E. None 11. Which o f the following statement is WRONG A. Acid & Basic functional groups provide enhanced water solubility as they allow molecule for ionization B. Hydroxyl groups & Carboxyl groups imparts hydrophilicity to drug molecule C. Alkyl chain imparts lipophilicity to drug molecule D. Aromatic ring imparts hydrophilicity to drug molecule E. Quaternary ammonium groups imparts hydrophilicity to drug molecule 12. Find out the CORRECT statement A. Hydrophilicity of the drug molecule increases its ability to cross cell membrane B. Lipophilicity of the drug molecule increases its water solubility C. Drug possessing either acidic or basic functional group is called as Amphoteric compound D. Drug possessing both acidic & basic functional group is called as Amphoteric compound E. None of the above statements is correct 13. Basic mechanism involved in increasing water solubility of non electrolytes is A. B. C. D. E. Hydrogen bond Ionic bond Ion-dipole Dipole-Dipole None

D. Anti-log constant E. None

of

acid

dissociation

15. Which of the following is more acidic A. B. C. D. E. Carboxylic acid p-dicarbonyl sulfonamide Imide Sulfonyl urea

16. Esterification of the following is often used to produce Prodrug A. B. C. D. E. Carboxylic acid p-dicarbonyl sulfonamide Imide Sulfonyl urea

17. Which of the following is less basic A. B. C. D. E. Hydrazine Imine Amidine Guanidine Amine produces

18. Which hydroxy] group ketone upon oxidation A. B. C. D. E. Primary Secondary Tertiary Quaternary Anyone

19. Acidic & Basic functional groups can form A. B. C. D. E. ionic bonds ion-dipole bonds hydrogen bonds All the above None of the above

20. Which of the following is WRONG statement A. Quaternary ammonium compounds contain permanent positive charge

14. pKarefers to A. Acid dissociation constant B. Log of acid dissociation constant C. Negative log of acid dissociation constant

B. Quaternary ammonium compounds imparts water solubility C. Quaternary ammonium compounds easily passes through cell membrane D. Quaternary ammonium compounds are generally not metabolized but undergo Ndealkylation E. None 21. Abbreviation o f IUPAC A. Internationa] Union of Pure and Applied Chemistry B. Indo-american Union of Pure and Applied Chemistiy C. Indian Union of Pure and Applied Chemistry D. International Union of Pure and Advanced Chemistry E. Italian Union o f Pure and Applied Chemistry 22. The metabolic pathway followed only by secondary amine but not by tertiary amines A. B. C. D. E. Acetylation N-oxidation Oxidative N-dealkyaltion Reduction None

A. B. C. D. E.

Testosterone Fludrocortisone Lovastatin Levodopa None

26. One o f the following statements is WRONG with hydroxyl groups A. Hydroxyl groups can enhance water solubility of drug B. Primary hydroxyl groups can undergo oxidation C. Hydroxyl are often esterified to form prodrugs D. Hydroxyl groups can form iondipole and hydrogen bonds. E. Hydroxyl groups cannot undergo Glucuronization or Sulfation 27. Phenols or Catechols mostly undergo A. B. C. D. E. Air oxidation Reduction Hydrolysis Dehydrogenation None

28. Lactones are A. B. C. D. E. Cyclic amides Cyclic esters Cyclic guanidines Cyclic hydrazines None

23. The drug that contains secondary, tertiary and aromatic amines A. B. C. D. E. Gabapentin Lidocaine Diazepam Procainamide Estradiol guanidine group is

29. Ketones on reduction produces A. B. C. D. E. Esters Amides Alcohols Phenol Amine doesnt contain

24. Heterocyclic present in A. B. C. D. E.

30. Antibiotics which lactam ring is

Btfla-Lactani Ring SinicJufe

Guanethidine Hydralazine Prazosin Quinidine None

25. The drug that contains all the three types of hydroxyl groups (1, 2, 3) is

A. Penicillin G B. Penicillin V

C. Cefadroxil D. Streptomycin E. Ampicillin 31. Upon hydrolysis which of the following produces amines and carboxylic acids A. B. C. D. E. Ketones Lactams Lactones Esters Phenols

E. Oxidation is the major metabolic pathway for Alkanes F. Hydration, Reduction, Epoxidation, Peroxidartion are major metabolic G. pathways for Olefins 36. Charge transfer reactions are shown by A. B. C. D. E. Alkanes Alkenes Alkynes Aromatic hydrocarbons Esters

32. Naphthalene moiety is present in

37. Which o f the following statement is WRONG with Halides A. B. C. D. E. Enalapril Chloramphenicol Ropivacaine Diclofenac Propranolol A. Iodine is the smallest followed by Bromine, Chlorine and Flourine B. Alkyl halides can undergo oxidative dehalogenation C. Aromatic halides generally doesnt undergo metabolism D. Alkyl and Aromatic halides are electron withdrawing functional groups E. Halides are generally hygroscopic in nature 38. IUPAC name of Halothane is

33. Which o f the following groups show lipophilic nature A. B. C. D. E. Primary alcoholic Secondary alcoholic Alkyl groups Carboxylic acid Amines

@
34. Hydrophobic bonding can be shown by A. B. C. D. E. -O H -COOH -NH2 -CH3 None

A. B. C. D. E.
2

35. Which of the following statement is WRONG A. Alkyl groups can form induced dipole-induced dipole bonds & B. hydrophobic bonds C. Alkyl groups are also called as Olefins D. Alkenes are comparatively more reactive than Alkanes

-bromo-2 -chIoro-1,1,3 -trifiuoroethane 1 -brom o-2 -ch 1 oro- ], 1 ,2 -trifluoroethane 2 -bromo - 1 -chloro-1 , 1 ,2 -trifluoroethane 1 -bromo - 1 -chloro-1 ,2 ,2 -trifluoroethane None

39. 2,6-diisopropyl phenol is the IUPAC name of A. Propofol B. Halothane

C. Ketamine D. Enflurane E. Isoflurane 40. 2-(diethyIamine) ethyl paminobenzoate is the IUPAC name of A. B. C. D. E. Benzocaine Procaine Lidocaine Halothane Propofol

A. B. C. D. E.

Phenylethylhydrazine Benzylethylhydrazine Benzylhydrazine Benzen eethy 1 di amin e None

43. IUPAC name of Valproic acid

41. The IUPAC name of the structure QH I ]

CM CH WH is

C II.C H A T k " CHCOOH CH3CH2CHf

VALPROIC ACID

A. B. C. D. E.

Ephedrine Epinephrine Norepinephrine Amphetamine Tyramine

A. B. C. D. E.

2-propyl pentanoic acid 2-ethyl pentanoic acid 1-propyl pentanoic acid 1-ethyl pentanoic acid 2-propyl pentanoic acid

42. IUPAC name of

ANSWERS

Organic Chemistry
1. Answer: A. Ester

Explanation: The functional group ester has the representation RpCO-O-R? o

R1 O R2
Ether

Rj

R1 _Q _R 2
Ketone

Ester

R H

R1

r .,

r|j
$ 4

r2

Ri 0 OH
Carboxylate (R 2 = H in case o f ester)

Aldehyde (R 2 = H in case o f ketone)

Quaternary

Ri, R2, R 3 and R4 may be acyclic (e.g., alkyl) groups or cyclic groups. Examples o f drugs containing the above functional groups include:

OOOH

o
CHj CHJOC

M,'-

00

'

Ac*. f

Y r v ^ A A ^ Ciprofloxacin (ketone group)

8* 1

Gemfibrozil (ether groujjf*

Benzocaine (ester group)

H3C

C .3 OH 3

Paraldehyde (lc](?hyde group) acid group) OH

H3C -4N f

d-TuboCu rarift e :(Q ua ffety ammonium group) One drug only may contain more than one functional group. For example aspirin contains both carboxylic acid and ester functional groups. And also ciprofloxacin contains both ketone and carboxylic acid functional groups. Carbonyl group (C O ) is the integral part o f a large number o f functional groups such as ketones, carboxylic acids,-amides, esters and carbamates.

2.

Answer: B.

Explanation: Tertiary amine means the nitrogen linked to three molecules that can be represented as r
3

F ^ - N R2 This functional group is present in many drugs like

Tertiary amine

Q
primary f ' * " [f

^
secondary amine
Histamine 3. Answer: C.

ra V 1 1
CO^H Procaine (primary amine and tertiary amine)) Cetirizine (tertiary amine)

Explanation: A. 0 N ^OH

B. Cl I ch2

C. Cl
i

D. CzO

JL
Phenyl chloride

Ci

Benzoic acid 4.

Benzyl chloride

Benzoyl chloride

Answer: B. Lorazepam

Explanation: In all the drags Propranolol, Gemfibrozil, Naproxen and Fenofibrate ether linkage is present whereas in Lorazepam it is absent. Ether functional groups contain oxygen bound on both sides by either alkyl or aromatic carbons. In drug molecules like Naproxen ether group is present at terminal position (methoxy) whereas in drugs like Propranolol and gemfibrozil it is present as a part o f basic structure. Ether groups can form dipole-induced dipole interactions and can function as hydrogen bond acceptors. Methyl and ethyl ethers can undergo O-dealkylation whereas larger generally do not undergo metabolism. Diethyl ether (ethers existing as organic solvents) can form peroxides and may explode. But generally this property is not observed in drug molecules.

Me Me
\/

Propranolol (ether link and Naphthalene ring)

Lorazepam
O

Gemfibrozil (ether link)

CHj

et
CM I Naproxen (ether link and Naphthalene ring)

:O A X
CHj

'C H ,

j HjC

Fenofibrate (ether link)

5.

Answer: B. Acetic anhydride

Explanation: O //
H,C
0 0

H-jC-

OH Acetic acid H3 C - C = M Acetonitrile

LA
0 '

H g C -C , CHj NH

O II

O
NH, H ,C H

Acetic anhydride O HtC*" ^ C H 3 Acetone

Acetic hydrazine O H4Z ' NH^ Acetamide

Acetaldehyde

Answer: C. Donate proton

Explanation: There are two main theories that explains about acids and bases. They are Bronsted theory and Lewis theory. According to Bronsted theory an acid is a group that can donate a proton (a hydrogen ion), and a base is a group that can accept a proton. Since a proton has no electrons, the base must be able to provide a pair of electrons to from a new bond. According to Lewis theory an acid is a group that can accept an electron pair and therefore must have an empty orbital. Groups that can donate an electron pair are called as Lewis bases. 7. Answer: A. Electrophile

Explanation: An electrophile is one that has an empty orbital available for bond-making that is relatively low in energy and itjnay be neutral or positively charged. There are three classes o f electrophiles: Lewis

acid electrophiles, sigma-bond electrophiles, and pi-bond electrophiles. Examples o f electrophiles include alkyl halides, alkyl sulfonates, C = N 5 C 0 , C N 5 CH3 etc A nucleophile is a compound that has a relatively high energy pair o f electrons available to make a new bond. A nucleophilic atom may be neutral or negatively charged. There are three classes of nucleophiles: lone-pair nucleophiles, sigma-bond nucleophiles, and H-bond nucleophiles Alcohols (ROH), alkoxides (RO'), amines (R 3 N), metal amides (R 2 N ), halides (X"). thiols (RSH), sulfides (R 2 S), and phosphines (R 3 P) are all examples o f lone-pair nucleophiles Free-radicals are those which contain odd number o f electrons. Not all reactions involving free radicals are chain reactions, and not all chain reactions involve free radicals, but the set o f freeradical reactions and the set o f chain reactions overlap enough that the two subjects are almost always discussed together. A chain reaction consists o f three parts: initiation, propagation and termination.
8

. Answer: E. Propane.

Explanation: An extra amount o f stability or instability is associated with a compound that has a cyclic array o f continuously overlapping p-orbitals. Such a compound may have a ring with alternating single and multiple bonds, or the ring may contain both alternating bonds and one atom with a lone pair or an empty orbital. If there are an odd number o f electron pairs in the cyclic array of orbitals, then the compound is especially stable (as compared with the corresponding acyclic system with two additional H atoms), and it is said to be aromatic. If there is an even number o f electron pairs, then the compound is especially unstable, and it is said to be antiaromatic. If there is no cyclic array o f continuously overlapping p orbitals, then the question o f aromaticity doesnt apply, and the compound is nonaromatic. The simplest case o f an aromatic compound is benzene. Each o f the C atoms in benzene is sp2hybridized, so each has a p-orbital pointing perpendicular to the plane o f the ring. The six porbitals make a cyclic array. Each C atom contributes one electron to its p orbital, so there is a total o f three pairs o f electrons in the system. Because three is odd, benzene is aromatic. There are many aromatic hydrocarbons other than benzene. Many are made up o f fused benzene rings. All have an odd number o f pairs o f electrons in a cyclic array o f orbitals.

Benzene .0 .

Naphthalene
H

Phenanthrene

Indole
..N.

xN/ X

\\
Furan 9.

\ j
Pyrrole Thophene Pyridine Answer: D. Amine

Explanation:

Functional groups that come under clcctron-withdrawing include: carbonyl based groups (esters, aldehydes, amides, ketones, carboxylic acids etc.), nitro, nitrile (cyano), sulfinyl, sulfonyl, halo, quaternary ammonium, vinyl, phenyl etc. Electron-donating groups include alcohols, ethers, amines and alkyl groups. 10. Answer: D. Explanation: Resonance effect involves movement o f electrons through a ubond system. In contrast to field and inductive effects, resonance effect decreases more slowly with distance. Stabilization increases as the number of atoms over which the charge is dispersed increases. Resonance effect contribute more extensively to overall electronic effect o f a functional group than do field or inductive effects. 11. Answer: D. Explanation: Acid & Basic functional groups, Hydroxyl groups and Quaternary ammonium groups impart hydrophilicity to drug molecule and thereby provide enhanced water solubility as they allow molecule for ionization. Alkyl chains and Aromatic rings impart lipophilicity to drug molecule and are likely to increase drugs ability to cross cell membrane. 12. Answer: D. Drug possessing both acidic & basic functional group is called as Amphoteric compound Explanation: Hydrophilicity o f the drug molecule increases water solubility. Lipophilicity o f the drug molecule increases ability to cross cell membrane. Both are important in drug absorption hence balance between hydophilicity and lipophilicity o f drug is important. 13. Answer: A. Hydrogen bond 14. Answer: C. Negative log o f acid dissociation constant Explanation: Groups which function as acids must have a proton that can be removed in the presence o f a base. When an acid donates a proton, a new species called the conjugate base o f the acid is formed which has a charge one unit less than that o f the acid from which it is derived. E.g., Acetic acid, which is electrically neutral, dissociates to a proton and its conjugate base, acetate ion, which has a charge o f -1. An equilibrium is established between the acid and its conjugate base. The equilibrium constant, which is known as the acid dissociation constant (Ka), is a property o f the acid under study. Since Ka values are generally exponential numbers, it is convenient to use -logK a which is referred to as the pKa o f the acid. Smaller, the pKa value o f an acid, the stronger it is. The pKa scale runs from 0 to 14. The equilibrium constant for a base dissociation is called Kb o f that base. As with K a values, it is more convenient to use -logKb which is referred to as the pKb o f the base. Smaller the pKb values stronger the base. The pKb scale runs from 0 to 1. pKa (acid) + pKb (conjugate base) = 14. 15. Answer: A. Carboxylic acids

Explanation: Carboxylic acid, p-dicarbonyl, sulfonamide, Imide, Sulfonyl urea and tetrazole are the common examples o f acidic functional groups. Out o f these carboxylic acids tend to be more acidic. The increasing order o f acidity is amide (pKa neutral) < N-arylamide (pKa 12-13) < phenol (pKa 9-10) < imide (pKa 9), sulfonamide (pKa 9) < N-arylsulfonamide (pKa 6-7) < carboxylic acid (pKa 4-5) < sulfonimide (pKa 4). For an acid as the pKa value decreases acidit increases. These can form salts when combined with bases and are also often esterified to form Prodrugs that are inactive as such but upon biotransformation will be converted as active drug moieties. They can undergo decarboxylation reactions and also can undergo conjugation with glucuronic acid, glycine and glutamine. 16. Answer: A. Carboxylic acids Explanation: Carboxylic acids are often esterified to form Prodrugs that are inactive as such but upon biotransformation will be converted as active drug moieties. 17. Answer: B. Imine Explanation: Out o f Hydrazines, Imines, Amidines, Guanidines and Amines; Imines tend to be less basic whereas guanidines are more basic and basicity o f the remaining two lies in between. 18. Answer: B. Secondary Explanation: Primary hydroxyl groups upon initial oxidation produce aldehydes and later convert to carboxylic acids. Secondary hydroxy] groups produce ketones whereas tertiary hydroxyl groups are usually not oxidized. Hydroxyl groups can also undergo conjugation reactions. Qxi dati on H3 CCH2 OH Pnmary alcohol (Ethanol) ^
h 3c c h = o

OH H3C c = o Aldehyde (Acetaldehyde)

O xidation

19. Answer: D. Explanation: Acidic & Basic functional groups can form ionic bonds, ion-dipole bonds and hydrogen bonds. They can impart hydrophilicity to drug molecule due to their ability to form hydrogen bonds and capable o f ionization thereby enhancing water solubility.

20. Answer: C. Explanation: Quaternary ammonium compounds are neither acidic nor basic but contain a permanent positive charge. Quaternary ammonium compounds impart water solubility and are not free to cross the cell membrane as they have ionic charge. They can participate in ionic and ion-dipole bonds. Quaternary ammonium compounds generally wont undergo metabolism but can undergo Ndealkylation. 21. Answer: A. International Union o f Pure and Applied Chemistry Explanation: IUPAC: International Union o f Pure and Applied Chemistry. The International Union o f Pure and Applied Chemistry (IUPAC) maintains several commissions that deal with the naming of chemical substances. In general, the approach o f IUPAC is to present rules for arriving at names in a systematic manner, rather than recommending a unique name for each compound. Thus there are often several alternative IUPAC names, depending on which nomenclature system is used, each o f which may have advantages in specific applications. Organizations such as the Chemical Abstracts Service and the Beilstein Institute that prepare indexes to the chemical literature must adopt a system for selecting unique names in order to avoid excessive cross referencing. Chemical Abstracts Service uses a system which groups together compounds derived from a single parent compound. Thus most index names are inverted (e.g., Benzene, bromo rather than bromobenzene; Acetic acid, sodium salt rather than sodium acetate). 22. Answer: A. Acetylation. Explanation: Common metabolic pathways for primary amines are oxidative deamination, acetylation and Noxidation. Common pathways for secondary and tertiary amines are oxidative Ndealkylation and N-oxidation. Acetylation is the metabolic pathway followed only by secondary amines. Aromatic amines can undergo acetylation, whereas aromatic heterocyclic nitrogens can undergo N-oxidation or N-dealkylation. 23. Answer: D. Procainamide

Procainamide (2, 3 and aromatic amines)

Lidocaine (2 and 3 amines)

Gabapentin ( , o amine)

h 3c

HOh o (f

y-

1
OH

Albuterol (2 amine) Diazepam (3 amines) Estradiol (No amine group)

24. Answer: C. Prazosin sN H N H Lj

hr

)
Guanethidine (Guanidine group) Hydralazine (Hydrazine group)

Prazosin (hetero cyclic guanidine group)

Quinidine (quinoline nitrogen)

25. Answer: B. Fludrocortisone

Testosterone (secondary hydroxyl group)

Fludrocortisone

h 9.
ch3 A A
-

^ ''T -'J
,0 .

X.X-

*OHi

HjC

A . ^CHj

.o

3
Levodopa (catechol and 10 amine)

CHj

Lovastatin (lactone ring (cyclic ester), secondary hydroxyl group)

26. A nswer: E.

Explanation: Hydroxy] groups can enhance water solubility o f drug due to their ability to form hydrogen bonds. Hydroxyl groups can undergo oxidation. Primary hydroxy] groups upon initial oxidation produce aldehydes and later convert to carboxylic acids. Secondary hydroxyl groups produce ketones whereas tertiary hydroxyl groups are usually not oxidized. Hydroxyl groups can also undergo conjugation reactions. Hydroxy] groups are often esterified to form prodrugs. Hydroxyl groups can form ion-dipole and hydrogen bonds. 27. Answer: A. Air oxidation Explanation: Phenols are the compounds in which the hydroxyl group is directly attached to aromatic ring. If two hydroxyl groups are attached to aromatic ring then it is called as Catechol. Like alcohols, phenols can form ion-dipole and hydrogen bonds. Phenol or Catechol group containing drugs are susceptible to air oxidation and to oxidation in presence o f ferric ions. Phenols can also undergo conjugation reactions (Phase II reactions) like Glucuronization, Sulfation, aromatic hydroxylation and O-methylation.

Catechol (ortho-catechol) 28. Answer: B. Cyclic esters

Phenol

Resorcinol (meta-catechol)

Hydroquinone (para-catechol)

Explanation: Cyclic esters arc called as Lactones whereas cyclic amides are called as Lactams. These functional groups can form hydrogen bonds with enzymes, receptors, transport proteins, water molecules and other groups. Like ketones, esters and lactones act as hydrogen bond acceptors whereas amides and lactams act as either hydrogen bond acceptors or donors. These can undergo hydrolysis as a part o f their metabolism. Esters and lactones are more susceptible to hydrolysis

than amides and lactams and produces alcohols and carboxylic acids whereas amides and lactams produce amines and carboxylic acids upon hydrolysis. Lactams may also undergo N-dealkylation. Cyclic guanidine is found in Prazosin and guanidine in Guanethidine drug. Cyclic and noncyclic hydrazine group is found in Hydralazine drug. O
h 3c
0

c o c h 2c h 3

Ethyl acetate (ester group) O

Dihydrofuran-2(3H)-one (Lactone ring; cyclic ester)

0

Butyramide (amide group) 29. Answer: C. Alcohols

Pyrrolidin-2-one (Lactam ring; cyclic amide)

Explanation: Ketones, even though lipid soluble and very stable, are able to form hydrogen bonds (with certain amines and alcohols) and ion-dipole bonds. Ketones primarily undergo reduction to produce alcohol. 30. Answer: D. Streptomycin Explanation: EXCEPT Streptomycin all the drugs Pencillin G, Pencillin V, Cefadroxil and Amoxycillin contain lactam ring in their structure. Cefadroxil is a cephalosporin derivative whereas others are P-lactam derivatives. Streptomycin is an amino glycoside derivative that doesnt contain lactam ring in its structure.

Penicillin-G (Benzyl penicillin, lactam ring)

Penicillin V (Phenoxymethyl penicillin, lactam ring)

Cefadroxil (lactam ring)

Ampicillin (lactam ring) Streptomycin

31. Answer: B. Lactams Explanation: Cyclic esters are called as Lactones whereas cyclic amides are called as Lactams. These can undergo hydrolysis as a part o f their metabolism. Esters and lactones produce alcohols and carboxylic acids whereas amides and lactams produce amines and carboxylic acids upon hydrolysis. Ketones primarily undergo reduction to produce alcohol. Drug substances containing Phenols or Catechols are susceptible to air oxidation and to oxidation in presence o f ferric ions. Phenols can also undergo conjugation reactions (Phase II reactions) like
OH

o ! j H 3C ' , 0 '~ % .
0

,..N0 2

b ...

Ci.

A
T
C) H

-X

A
v -;
OH

N* if j HjC'

C H j "

Enalapril (phenyl ring and pyrrolidine ring)

Chloramphenicol (phenyl ring)

Ropivacaine (phenyl ring and piperidine ring)

O H OCHjCMCH^MCHCH^

Diclofenac (two phenyl rins)

p r0 pran 0 i0j (Naphthalene ring) Naproxen (Naphthalene ring)

Glucuronization, Sulfation, aromatic hydroxylation and O-methylation. 32. Answer: E. Propranolol Explanation: Enalapril contains phenyl ring and pyrrolidine ring. Chloramphenicol contains phenyl moiety. Ropivacaine contains phenyl and piperidine moieties. Diclofenac contains two phenyl moieties. Propranolol and Naproxen contains Naphthalene moiety in their structure. 33. Answer: C. Alkyl groups Explanation: Acidic functional groups, Basic functional groups, Hydroxyl groups, Phenols and Quaternary ammonium salts impart hydrophilic nature to the drug substance owing to their potential for ionization and thereby increase water solubility. Where as aromatic ring moieties, alkyl groups impart lipophilic nature and thereby increase their ability to cross cell membrane.' 34. Answer: D. -C H 3

Explanation: Groups like -O H , -C O O H and -N H 2 can form hydrophilic bonds whereas alkyl groups like -C H 3 can form hydrophobic bonds. 35. Answer: B. Explanation: Alkyl groups are saturated hydrocarbon chains that may be alicyclic (non aromatic) or aliphatic (attached to aromatic ring). They can form induced dipole-induced dipole bonds (Van der waals interactions) and hydrophobic bonds. They primarily undergo oxidation getting oxidized either at the terminal or penultimate carbon atoms. Alkenes (unsaturated alkyl groups) are also called as Olefins. They can undergo Hydration, Reduction, Epoxidation and Peroxidartion. Alkenes are comparatively more reactive than Alkanes. 36. Answer: D. Aromatic hydrocarbons Explanation: Aromatic hydrocarbons are analogs o f either benzene or naphthalene. Phenyl group is the benzene attached to drug molecule. Like alkyl groups and alkenes (olefins), aromatic hydrocarbons can form induced dipole-induced dipole bonds (Van der waals interactions) and hydrophobic bonds. Aromatic hydrocarbons can also form charge transfer interactions. Electron rich aromatic rings (electron donating groups) can form dipole like interactions with electron poor aromatic rings (electron withdrawing groups). They primarily undergo hydroxylation, epoxidation and diol formation. Esters and their cyclic forms lactones can form hydrogen bonds and can function as hydrogen bond acceptors. 37. Answer: A. Explanation: Fluorine is the smallest followed by Chlorine, Bromine and Iodine. Alkyl and aromatic halides are electron-withdrawing functional groups and are generally hygroscopic in nature. Alkyl halides can undergo oxidative dehalogenation whereas aromatic halides generally doesnt undergo metabolism. 38. Answer: A. 2-brom o-2-chloro-l,l,l-trifluoro-ethane 39. Answer: A. Propofol.

H C Ci Cl I F [2 -(ortho-chlorophenyl)- 2 (methylamino)cyclohexanone]

(2 ,6 -diisopropyl phenol)

Halothane (2-bromo-2-chIoro, 1 , 1 -trifluoro-ethane)

f
CI f

F
f F Enflurane [2 -chloro - 1 (difluoromethoxy), 1 ,2 -trifluoro-ethane]

C
1
F

Isoflurane [2 -chloro-2 (difluoromethoxy), 1 , 1 -trifluoro-ethane)

40. Answer: B. Procaine.

0

CH-i

CH3

^N
N CHj

C
Procaine [2 -(diethylamine)ethyl p-aminobenzoate] 41. Answer: A. Ephedrine. 42. Answer: A. Phenylethylhydrazine Explanation: Benzocaine (Ethyl p-aminobenzoate)

ch3

Lidocaine [2 -diethylamino-2 , 6 -acetoxylidine]

L uL ^ rP

:'f;e e n r c,ure is

* * -

n - * . - , h,c

Phenelzine (Phenylethylhydrazine) 43. Answer: A. 2-propyl pentanoic acid. Explanation: IUPAC name o f valproic acid is 2-propylvaleric acid or 2-propyl pentanoic acid.
CH3C H jC h 2c h COOH
c h 3c h 2 c h 2

Valproic acid

Pharmaceutical Care

Success is simple. Do whats right, the right way, at the right time. Arnold H. Glasgow

1. Which o f the following is central to the practice o f pharmacy? A. B. C. D. E. physicians patients specialist pharmacist generalist pharmacist all the above

B. In pharmaceutical care, the pharmacist is not responsible for dispensing C. In pharmaceutical care requires redesign o f the professional work flow under the pharmacists supervision and responsibility. D. Pharmaceutical care is an outcome oriented practice E. B and C

2. According to the definition of pharmaceutical care, the pharmacist is involved in I. II. III. designing therapeutic plan implementing therapeutic plan monitoring therapeutic plan

5. In the traditional pharmacy practice, the primary focus o f the pharmacist is A. prescription order B. physicians C. other health professionals apart from physicians D. the patient E. all the above

A. i f l only is correct B. if III only is correct C. i f l and II are correct D. if II and III are correct E. i f l , II and III are correct

6 . The area o f pharmacy practice where the pharmacist or pharmacy department is involved in a practice where the patients are faceless' is called

3. In the so called focused area o f practice, the pharmacist role includes which o f the following A. specific drug monitoring B. monitoring drug therapy for a specific disease state C. specific disease state monitoring D. drug management E. all o f the above

A. B. C. D. E.

clinical pharmacy patient counseling pharmaceutical care pharmaceutical services A and C

7. Which o f the following is NOT an essential component o f pharmaceutical care? A. pharmacist-patient relationship B. documentation o f pharmaceutical care C. pharmacists workup o f drug therapy D. pharmacist-physician relationship E. none

4. Which o f the following is NOT true about pharmaceutical care? A. the role o f pharmacist in pharmaceutical care involves primary disease prevention, prevention o f drug related problems, management o f chronic diseases, management o f common acute diseases and triage o f patients.

8 . Which o f the following is NOT correct about pharmacist-patient relationship?

I. it is important to put a face and personality with the clinical picture II. pharmaceutical care depends on a collaborative effort between pharmacist and patient 311 .a pharmacist may care a patient depending on the reports o f the patient without actually seeing the patient A. B. C. D. E. i f l only is correct if III only is correct i f l and 1 1 are correct if II and III are correct i f l , II and III are correct

11 .In the CORE pharmacotherapy plan, the letter 4C indicates for A. B. C. D. E. care condition clinical pharmacy cure all but C

12. One o f the following is NOT a component o f desired patient outcomes for a given condition when planning CORE pharmacotherapy A. B. C. D. morbidity quality o f life economic therapeutic effect to achieve the desired outcome E. behavior

9. All the following are correct about pharmacists workup o f drug therapy (PWDT) EXCEPT A. the provision o f pharmaceutical care is centered around PWDT B. PWDT contains the thought processes necessary for pharmaceutical care C. It is strictly necessary that the PW DT be used as the chart note for pharmacist intervention D. A pharmacy student or a pharmacist entering a new field o f pharmacy practice should be encouraged to write out a complete PWDTs E. None

13. When planning a regimen in CORE pharmacotherapy, for an existing therapy, the pharmacist is expected I. to evaluate the current drug regimen for its potential to achieve the desired end points and to meet the patients individual needs revise regimen as appropriate to list therapeutic option most likely to achieve the desired end points

II. III.

10. Which o f the following are components o f PWDT? A. data collection B. identifying PRIME pharmacotherapy problems C. identifying the CORE pharmacotherapy plan D. B and C E. All the above

A. i f l only is correct B. if 111 only is correct C. i f l and II are correct D. if II and III are correct E. i f l, II and III are correct

14. When evaluating efficacy parameters, one ensures whether

A. adverse effects are being avoided B. allergies are being avoided

C. therapeutic end points or patient outcomes are being achieved D. toxicity are being avoided E. all the above

15. Which o f the following PRIME pharmacotherapy problems are classified as pharmaceutical based problem? A. patient not receiving a prescribed drug, device or intervention B. no indication for a current drug, device, or intervention C. indication for a drug, device, or intervention but none prescribed D. routine monitoring such as labs, and screening missing E. A and D

A. prevention o f recurrence B. Lowering BP to a lower level such a s 140/90 C. eliminate symptoms D. prevent progression o f diabetic nerve disease E. B and C

19. Which o f the following is NOT an intervention option that can be taken by a pharmacist to resolve or prevent actual or potential problem? A. observing, reassuring, or following without taking any action B. changing the prescribed drug therapy regimen C. counseling or educating the patient or caretaker D. informing the prescriber E. withhold medication or advising against use

16.Risks to the patient that indicate for pharmacists intervention include A. too much o f correct drug or too little of correct drug B. drug-drug, drug-food, drug-disease interaction C. adverse drug reaction/drug allergy D. wrong drug, device, intervention, or regimen prescribed E. all the above

.The monitoring and follow up portion o f the FARM includes which o f the following
2 0

17. Which o f the following is CORRECT about the handling o f objective and subjective information when formulating a FARM note? A. only objective information is included B. only subjective information is included C. both are included but separately D. both are incorporated into the same section 18. When providing or proposing intervention, which o f the following is an example o f a short-term goal?

A. deciding the parameters to be followed B. how often the monitoring should be done C. determining how the monitoring is to be done D. deciding the time or point to alter therapy if necessary E. all of the following

21 .All the following are examples o f objective data EXCEPT A. B. C. D. E. weight blood pressure lab data duration o f symptoms none

2 2

.Focused disease monitoring incorporates

A. harmaceutical care B. focused drug monitoring C. monitoring the disease without considering the drug D. both pharmaceutical care and focused drug monitoring

26.In order to make the best use o f available therapeutic alternatives, a pharmacist must I. have the ability to use drug information resources effectively the skills to review and critique drug literature be aware o f the psychosocial issues i f l only is correct if III only is correct if l and II are correct if II and III are correct if I, II and III are correct

II. 23. Which o f the following is/are advice(s)given to a patient whenever a new drug is added (either OTC or prescribed) to the therapeutically monitored drug A. possible drug-drug interaction B. possible drug-disease interaction C. the drugs that may affect the course o f the disease for the monitored drug D. drugs that may affect comorbidity conditions o f the disease for the monitored drug E. AH o f the above III.

A. B. C. D. E.

27.The ability to identifying patients at risk for exaggerated or subtherapeutic response helps the pharmacist in A. developing a patient-specific pharmacist care plan B. preparing drug treatment protocols C. adjusting dosage regimen D. proper patient assessment E. A and B

24. Which o f the following is NOT correct about focused disease monitoring? A. it is specialized monitoring for a specific disease monitoring B. the pharmacist has the authority to alter prescriptions C. it is very extensive in time, effort and patient education D. they should be at least performed each time the patient returns for refills E. none

28.Pharmacist role in developing patientspecific pharmacists care plans requires which o f the above clinical skills? A. knowledge o f both innovative and. conventional pharmacology and therapeutics B. developing and updating protocols C. immunization and screening techniques D. planning, directing, and implementing pharmaceutical care activities

25.All the following skills are necessary for a pharmacist to educate and counsel a patient properly EXCEPT A. B. C. D. interpretation o f laboratory tests interview skills ability to motivate and inspire identification and resolution o f compliance barrier E. communication skills

29. Which o f the above clinical skills is necessary for effective management?

A. knowledge o f both innovative and conventional pharmacology and therapeutics B. developing and updating protocols C. immunization and screening techniques D. planning, directing, and implementing pharmaceutical care activities

32.A patients profile is renewed or updated I .whenever a new drug is added to or deleted from the medication regimen I I . when a new disease or condition is diagnosed III .whenever there is clinical intervention A. B. C. D. E. if l only is correct if III only is correct if l and II are correct if II and III are correct if l, II and III are correct

30.For a pharmacist to be able to deliver preventive services to the community, s/he must be skill full at A. knowledge o f both innovative and conventional pharmacology and therapeutics B. developing and updating protocols C. immunization and screening techniques D. planning, directing, and implementing pharmaceutical care activities

33. Which of the following underlines the importance o f pharmaceutical care in todays pharmacy practice A. increased medication errors B. increased use o f prescription and nonprescription drugs C. increased number, complexity and potency o f prescription and nonprescription drugs D. the need to integrate pharmacist into the health care system E. all o f the above

31.Documentation o f pharmaceutical care is necessary for A. demonstration o f clinical competence B. communication among health care providers C. reimbursement o f professional services D. continuity o f the care

Answers Pharmaceutical Care and Disease State Management

]. Answer: B. patients. Explanation: Although the practice o f pharmacy includes a wide variety o f settings and targets different group o f the community such as the patient population, physicians, pharmacist and other health professionals, central to the practice are the patients.

2. Answer: E. I, II and III. Explanation: Pharmaceutical care describes specific activities and services through which an individual pharmacist cooperates with a patient and other professionals in designing, implementing and monitoring a therapeutic plan that will produce specific outcomes for the patient.

3. Answer: E. all o f the above Explanation: In the focused areas o f practice, the pharmacist is engaged in drug monitoring for a specific drug or for therapy for a specific disease state, disease monitoring for a specific disease state, and in the management o f disease or drug therapy by protocol.

4. Answer: B.In pharmaceutical care, the pharmacist is not responsible for dispensing Explanation: Provision o f pharmaceutical care does not imply that the pharmacist is no longer responsible for dispensing. It may, however, require the redesign o f professional workflow in such a way that technical works are done by technicians under the supervision and responsibility o f the pharmacist. Pharmaceutical care involves designing therapeutic plans based in strategies that anticipate various potential drug related problems to provide a continuous patient care in order to achieve desired outcomes.

5. Answer: A. prescription order. Explanation; In the traditional pharmacy practice, the primary focus o f the pharmacist is the prescription order or an OTC request. In clinical pharmacy, the focus is on physicians and other health professionals. In pharmaceutical care, however, the patient is the primary focus for the pharmacist.

. Answer: D. pharmaceutical services

Explanation; Pharmaceutical service is a practice in which the activities o f the pharmacy or pharmacy department are performed for faceless patients or charts (i.e., there is no input from the patient or caretaker).

7. Answer: D. pharmacist-physician relationship. Explanation: The essential components o f pharmaceutical care are pharmacist-patient relationship, pharmacists workup of drug therapy, and documentation of pharmaceutical care.

. Answer: B. Ill is correct

Explanation: The importance o f putting a face and personality with the clinical picture is a key component of pharmaceutical picture. This is because a pharmacist cannot care a patient depending on the reports o f the patient without actually seeing the patient. S/he cannot empathize for words on a paper. Therefore, pharmaceutical care depends on a collaborative effort between pharmacist and patient.

9. Answer: C. It is strictly necessary the PWDT be used as the chart note for pharmacist intervention. Explanation; The PWDT is too lengthy to be used as a chart note for pharmacist intervention. Therefore, either o f the two abbreviated format (i.e., FARM or SOAP) should be used for practical purposes. However, a pharmacy student or a pharmacist entering a new field o f pharmacy practice should be encouraged to write out complete PWDTs as a training or orientation exercise.

10. Answer: E. all the above. Explanation: Although the forms or methods used for the PWDT may vary, the components are essentially the same and include collecting, synthesizing, and interpretation o f data; developing or identifying the CORE pharmaceutical plan; and identifying PRIME pharmacotherapy problems that serve as indicators for pharmacist intervention.

11 .Answer: B. condition. Explanation: The acronym CORE stands for the components o f pharmacotherapy plan, which is one o f the components o f PWDT. The letter C stands for the condition (i.e., the need o f the patient).

12.Answer: D. therapeutic effect to achieve the desired outcome.

Explanation: The patient outcomes (also called POEMS: Patient-Oriented Evidence That Matters) have the following components: mortality, morbidity (which may be related to disease process or the medication/treatment plan), behavior, economic, and quality o f life. The therapeutic/ pharmacological effect that is expected to achieve a desired outcome is represented by a therapeutic end point, which is DOES: Disease-Oriented evidence.

13.Answer: C. I and 11 only Explanation; When planning a regimen for an existing therapy, a pharmacist is asked to work with a patient with one or more agents already prescribed for the disease process or problem. Therefore, in such cases all the pharmacist has to do is to evaluate the current drug regimen for its potential to achieve the desired end points and to meet the patients individual needs and revise the regimen as appropriate. Incase o f an initial therapy, however, the pharmacist is asked to work with a patient with a new diagnosis or is asked to develop an initial treatment plan. In this case, the pharmacist is expected to list therapeutic options most likely to achieve the desired end points and select the option best suited to the patients medical, physical and financial well being.

14.Answer: C. therapeutic end points or patient outcomes are being achieved Explanation; When evaluating efficacy parameters, the aim is to ensure that therapeutic end points or patient outcomes are being achieved. In evaluating toxicity parameters, however, the aim is to ensure that adverse effects, allergies, and toxicity are not occurring.

15.Answer: E. A and D Explanation; Pharmaceutical based problems include a situation when a patient is not receiving a prescribed drug, device, or intervention, or when routine monitoring such as labs, and screening are missing. A situation where there is no indication for a drug, device, or intervention, or where there is an indication for a drug, device or intervention but is none prescribed, is classified as mismatch between medications and condition or patient needs.

16.Answer: C. adverse drug reaction/drug allergy.

Explanation; Risks to the patient that indicate for pharmacists intervention are adverse drug reaction/drug allergy and potential for overlap o f adverse effects. Drug-drug, drug-food, and drug-disease interactions are classified separately as interaction problems. A situation where too much o f a correct drug, too little o f a correct drug and a wrong drug, device, intervention or regimen is prescribed are problems o f efficiency.

17. Answer: D. both are incorporated into the same section. Explanation; When formulating FARM note, findings include both objective and subjective information and both are incorporated into the same section (i.e., the findings are not separated into subjective and objective).

18.Answer:E.

B and C. Lowering BP to a lower level such as 140/90 and eliminate symptoms.

Explanation: Short-term goals are those, which are intended to be achieved within a short period o f time such as eliminating symptoms, lowering blood pressure to a specific level within short specified time, managing acute asthma flare-up without requiring hospitalization. In long-term goals, the proposed or provided intervention will have a relatively long lasting effect. Examples include prevention o f recurrence, maintaining BP below some level for a long period o f time.

19.

Answer: B. changing the prescribed drug therapy regimen.

Explanation: In pharmaceutical care, changing a prescribed drug therapy regimen is not within the authority of the pharmacist. A pharmacist can change prescription in rare, special cases only. Other interventions options include making recommendations to the patient or caretaker, and making recommendations to the prescriber. It is always necessary to state the reason for a specific intervention.

20. Answer: E. all of the following Explanation: All the above are included in the monitoring and follow up portion of the FARM. It also includes defining the intent o f the monitoring, deciding for how long the monitoring is to be done, and determining the anticipated or desired findings.

21 .Answer: D. Duration o f symptoms. Explanation: Objective data is the patient-specific objective information that gives a basis for, or leads to, the recognition o f a pharmacotherapy problem or indication for pharmacist intervention. These findings are easily duplicated or quantified. Examples include weight, height, blood pressure, lab data, etc. Duration o f symptoms is an example o f subjective type information, which are findings that are open for individual interpretation. But they serve the same purpose as the objective information. Other examples o f subjective information include the patients statement o f complaint, and severity o f symptoms.

22.Answer: D. both pharmaceutical care and focused drug monitoring. Explanation:

Focused areas o f practice are areas o f specialty practice in which pharmacists are increasingly being recognized fro their therapeutic and management expertise. There are different categories o f activities described by the type and extent o f specialty activities. Activities o f a particular category or level are additive to or augment those o f the previous ones. Thus, focused disease monitoring incorporates and expands the activities o f both pharmaceutical care and focused drug monitoring.

23. Answer: E. All o f the above Explanation: A patient is counseled about strategies on how to minimize adverse effects, whenever s/he returns for refill o f the monitored medication.

24.Answer: B. the pharmacist has the authority to alter prescription. Explanation: Normally, a pharmacist does not initiate changes in the pharmacological therapies. Recommendations are relayed to the medical provider, who then directs the pharmacist concerning specific regimen adjustments.

25.

Answer: A. interpretation of laboratory tests.

Explanation: Interpretation o f laboratory results is a skill, which is necessary to design a patient-specific pharmacist care plan. Other important patient education and counseling skill is the ability to develop and implement a patient education plan based on initial education assessment.

26.Answer: C. I and II are correct Explanation: Proper selection of therapeutic alternatives requires the ability to use drug information resources effectively and the skill to review and critique drug literature. Moreover, the pharmacist should be able to construct a comparative analysis to support therapeutic decisions. Being aware o f the psychosocial issues (along the ability to do physical assessment and identify barriers to adherence) help the pharmacist to make proper assessment o f the patient.

27.Answer: C. adjusting dosage regimen. Explanation: Dosage adjustment requires the ability to identify patients at risk o f exaggerated or sub therapeutic response, applying pharmacokinetic principles to determine patient-specific dosing, and the skill o f ordering and interpreting relevant tests at correct time intervals to assess dosage adjustment.

28.

Answer: A. knowledge o f both innovative and conventional pharmacology and therapeutics.

Explanation: Developing patient-specific pharmacist care plan requires recognition, prevention and management o f drug interactions, knowledge o f pharmacology and therapeutics, interpretation of lab results, knowledge o f community resources, and communication and rapport with community medical provider.

29.Answer: D. planning, directing, and implementing pharmaceutical care activities. Explanation: In order to effective in the management o f pharmaceutical care, a pharmacist must be able to plan, direct, and implement pharmaceutical care activities within various practice environments, such as community pharmacy, ambulatory care setting, managed and contractual care, home health services, long term care facilities, inpatient hospital practice, and others. In addition the pharmacist must be skill full in allocating resources.

30.Answer: C. immunization and screening techniques. Explanation: Immunization, screening, and health and wellness education skills are necessary to enable the pharmacist to provide effective preventive services.

31.Answer: E. all the above. Explanation: It is also important as evidence o f contribution to patient care.

32.Answer: E. I, II, and III. Explanation; A patients profile (data base) is revised and reassessed whenever a new drug is added to or deleted from the medication regimen, a new disease or condition is diagnosed, or the patient undergoes clinical intervention such as surgery.

33.

Answer: E. all o f the above

Explanation: The potential for medication error is increasing (probably due to the increased use o f prescription and nonprescription drugs as well as increased number, complexity and potency o f prescription and nonprescription drugs), and this makes it necessary for one professional group to take the primary responsibility in addressing the issues, rather than various groups or individuals making fragmented efforts. The pharmacist is specifically trained to address this therapeutic issue. Pharmaceutical care activities integrate pharmacists into the health-care system o f the future.

Phrmaceutical Dosage Forms

Begin at the beginning... and go on till you come to the end: then stop. Lewis Carroll

1. Which o f the following statements about pharmaceutical principles and drug delivery system is NOT correct? A. Pharmaceutical principles deal with the underlying principles that allow a drug to be incorporated into pharmaceutical dosage form B. Pharmaceutical principles apply to drugs that are extemporaneously prepared and to those that are manufactured for commercial distribution C. The dynamic interaction among the drug, its formulation matrix, its container, and physiological milieu o f the patient is the subject o f pharmaceutical principles D. Drug delivery system concepts embrace the drug (or prodrug) and formulation matrix E. None

4. Which o f the following statements about induced dipole-induced dipole interactions is NOT true? A. they are also called London dispersion forces B. they occur between non polar molecules C. they are responsible for the liquefaction o f non polar gases D. they are not strong enough to effect order in a molecule E. B and D

5. One o f the following is NOT a van der Waals force A. B. C. D. dipole-dipole interaction dipole-induced dipole interaction ion-dipole interaction induced dipole-induced dipole interaction E. none

2. All o f the following about the intermolecular forces o f attraction are true EXCEPT A. electron sharing between different atoms can be unequal B. non polar molecules have perfect symmetry C. dipole moment is the product o f distance o f charge separation and the charge
D . interm olecular rep u lsive forces occur w hen o p p osite charges approach each other

. The ideal gas equation is given as 3. PV = nRT II.P V = (g/M)RT III. PR = (g/M)VT A. B. C. D. E. I f l only is correct I f III only is correct I f l and II are correct I f II and III are correct I f l, II, and III are correct

E. B and D

7. All o f the following are pharmaceutical gases EXCEPT A. B. C. D. E. oxygen halohydrocarbons ethylene oxide nitrogen none

3. Which o f the following does not have net dipole moment? A. B. C. D. E. NaOH h 2o CC14 CO All but B

8 . Liquids show greater ordering and molecular arrangement than gases. This is because liquid molecules are held together by

A. it occurs when the relationship between the shear stress and rate o f shear is directly proportional B. most substances o f pharmaceutical importance are Newtonian C. dilute dispersions are Newtonian substances D. according to Newtonian flow, the rate o f shear is the difference in velocity E. between two planes o f a liquid separated by infinitesimal distance. F. None

A. B. C. D. E.

covalent forces ionic forces metallic bonds van der Waals forces B and D

9. Molecules at a liquid surface are pulled down wards and sideways by other molecules, but not upward away from the surface. This results in I. the molecules at the surface are pulled to ward the bulk o f the liquid II. the surface o f the liquid tends to decrease III. liquids tend to assume the shape o f a sphere A. B. C. D. E. I f l only is correct If III only is correct If I and II are correct If II and III are correct If l, II, and III are correct

1 2 .The type o f flow that exhibits an increase in viscosity as the shearing stress increases is

A. B. C. D. E.

dilatant flow sheaT thickening shear thinning pseudoplasticity A and B

13. Which o f the following is a wrong match between a substance and its flow behavior? A. tragacanth; dilatant flow B. concentrated suspensions; shear thickening C. zinc oxide paste; dilatant flow D. methylcellulose colloidal solution, shear thinning E. carboxymethylcellulose; psuedoplacticity

10. If two immiscible liquids A and B (the surface tension o f liquid A is greater than that of liquid B), are brought together, the interfacial tension between the two liquids is expected to be A. smaller than the surface tensions of the individual liquids B. smaller than the surface tension o f A but greater than that o f liquid B C. greater than the surface tension o f liquid A D. equal to the mean o f the surface tensions o f the two liquids E. B and D

14. Which o f the following is NOT true about thixothropic systems? A. when under stress they show shearthinning behavior B. when the shear rate is decreased thixothropic substances immediately regain their initial viscosity C. aluminum hydroxide gel is an example o f a thixothropic system

1 l.O ne o f the following is NOT true about Newtonian flow?

D. When under stress, the structure breaks down and fluidity increases E. A and B

15. One o f the following is NOT correct about crystalline solids and amorphous solids A. crystalline solids have fixed molecular order while amorphous solids lack a regular three dimensional arrangement o f atoms B. unlike crystalline solids amorphous solids do not have distinct melting point C. all crystalline solids are anisotropic D. all amorphous solids are isotropic E. none

18.A solution, which contains a higher concentration o f the dissolved solute than that at the dissolution equilibrium under the same conditions is called A. B. C. D. E. supersaturated solution saturated solution solution o f nonelectrolytes unsaturated solution electrolyte solution

19.One o f the following is NOT an electrolyte A. B. C. D. E. atropine glycerin Hydrochloric acid sodium chloride none

16. Which o f the following is NOT true about polymorphs? A. they have different molecular arrangement B. different polymorphs o f a drug have different physical and chemical properties C. polymorphs do not have pharmacological or pharmaceutical implications D. many drugs show polymorphism E. C and D

20. The colligative properties o f a solution are dependent up on A. nature o f the solute particles in solution B. on the number o f ionic solutes present in the solution C. on the number o f nonionic solutes present in the solution D. on the number o f solute particles in the solution E. A and D

17. Which o f the following is NOT true about phase diagram and phase equilibria? A. phase diagram shows the variation o f the state o f matter as pressure and temperature are varied B. the triple point is the pressure and temperature at which all the three states o f matter coexist C. substances that exist at the triple point are called supercritical fluids D. critical point corresponds to the point above which the liquid and gas phase are indistinguishable E. none 21 .Colligative properties include all the following EXCEPT A. B. C. D. E. lowering o f vapor pressure elevation o f boiling point acidity o f a solution depression o f the freezing point osmotic pressure

22. All o f the following are true about osmosis/osmotic pressure EXCEPT

A. osmosis is the net movement o f solvent molecules through a semipermeable membrane from a pure solvent or from a dilute solution to a more concentrated solution B. osmotic pressure o f a solution is the pressure required to stop osmosis C. solvent molecules in a concentrated solutions have a higher chemical potential than solvent molecules in a more dilute solution D. the presence o f dissolved solute lowers the escaping tendency o f the solvent in proportion to the solute concentration E. the vant H off equation defines the osmotic pressure as a function o f the number o f moles o f solutes and volume o f the solution

B. the law o f mass action can be used to express the equilibrium the dissociation o f strong acid/base C. for some acids/bases, it is possible to have more than one dissociation constant D. during the dissociation o f acids/bases, there is separation o f ions in solution E. none

26. Which o f the following correctly expresses the equilibrium for the dissociation o f a weak base BH+? A. B. C. D. E. Ka = [H+][A-]/[HA] K a - [H+][B]/[B H+] Kb = [OH"][ BH+]/[B] B and C None

23.The acid-base concept that defines an acid as a molecule or ion that accepts an electron pair to form a covalent bond is A. B. C. D. E. Henderson-Hasselbalch equation Lewis theory Arrhenius dissociation theory Acid-base equilibria Lowry-Bronsted theory

27.The relation between the ionized and unionized species o f a weak electrolyte is described by A. B. C. D. E. Degree of ionization Van Slykes equation Lewis theory Henderson-Hasselbalch equation A andD

24. Which o f the following is NOT correct about pH? A. pH = -Jog [H+] ] B. pH = log 1/[H+ C. H+ concentration decreases exponentially as pH decreases D. [H+] = 10'pH E. none

28.In the Henderson-Hasselbalch equation pH = 3.5 + log [A]/[HA], the 3.5 stands for A. the concentration o f the salt o f the acid B. the dissociation constant o f the weak acid C. the solubility constant o f the weak acid D. the negative logarithm o f the dissociation constant o f the acid E. B and C

25.Which o f the following is NOT true about the dissociation o f acids and bases? A. for weak acids and bases, dissociation is a reversible process

29. The degree o f ionization o f weak electrolytes depends on 1. the pH o f the solution

II. the pKa o f the weak electrolyte III. temperature A. B. C. D. E. If I only is correct If III only is correct I f l and II are correct If II and 111 are correct I f l, II, and III are correct

B. C. D. E.

dilution temperature concentration o f buffer constituents all o f the above

33.In an ideal dispersion A. the dispersed particles do not interact B. the dispersed particles are uniform in size C. the dispersed particles do not move at all D. the dispersed particles do not aggregate E. all o f the above

30. Which o f the following statements about buffers is NOT true? A. Buffer solutions are able to resist any change in pH when any amount o f acid or base added B. Buffer can be a mixture o f a weak acid and its conjugate base or a mixture o f a weak base and its conjugate acid C. Buffer solutions are more commonly prepared from weak acids and their salts D. Buffer systems are a special application o f the common ion effect E. A and C

34.The rate o f settling o f the dispersed phase in the dispersion medium is a function o f the following EXCEPT A. particle size B. the viscosity o f the dispersion medium C. the density difference between the dispersed phase and the dispersion medium D. gravitation E. AH of the above

31. All o f the following are true about the buffer capacity EXCEPT A. it is the magnitude o f the resistance offered by a buffer solution to changes in pH B. it is the resistance to a change in pH C. the smaller the change in pH due to the addition o f an acid or a base, the greater the buffer capacity o f the buffer solution D. it is the number o f gram equivalents o f an acid or base that changes the pH o f 1L o f buffer solution by I unit E. none

35. Which o f the following is NOT a practical way o f decreasing the rate of settling o f dispersed particles? A. decreasing particle size o f the disperse system B. minimizing the difference in densities between the particles and the dispersion medium C. avoiding very high particulate concentration D. increasing the viscosity o f the dispersion medium E. none

32. Which o f the following affects the buffer capacity o f a buffer solution? A. ionic strength

36. Which o f the following is NOT true about the particle-particle interactions in dispersed systems? A. electrical charges always exist at the surface of particles in aqueous dispersions B. electrokinetic or zeta potential represents the magnitude o f the charge found at the surface of dispersed particles C. flocculation occurs at high level of zeta potential D. at low level o f zeta potential, attractive forces dominate E. none

A. B. C. D. E.

Temperature dose o f the active ingredient pH radiation all o f the above

40. Which o f the following is NOT true about the first-order reaction? A. Rate is dependent upon the concentration o f one o f the reactants B. Drug concentration decreases exponentially with time C. The first-order rate constant has the unit, concentration/time D. For a first-order reaction, the graph o f the logarithm o f concentration versus time has a slope which is equal to -K/2.303 E. None

37. Which o f the following is NOT true about the stability o f emulsions? A. coalescence in emulsions can be prevented by using surfactants B. creaming causes less stability than cracking C. emulsions can be changed from o/w to w/o or vice versa D. the principles o f Stokes law can be applied to stabilize emulsions E. all but D

41 .Which o f the following is NOT true about ti /2 and t< > o %o f a first-order reaction? A. both o f them are independent o f concentration B. t ]/2 is the time required for 50% o f the initial amount o f the reactant reacts to form product C. t90% is the time required for 90% o f the initial amount o f the reactant to form product D. the relation between t90% and Xm is given as 1^% = 0.152 x E. A and D

38.Stability problems in a dosage form can result in A. formation o f substances that are toxic to the patient B. loss o f large amount o f the active ingredient C. reduction o f the amount o f active ingredient that is bioavailable, as a result o f which the dosage form will have reduced efficiency D. rejection o f a formulation E. All of the above

39.The rate o f degradation o f the active ingredient in a dosage form can be affected by

42. Which o f the following is/are true about the effect o f temperature on reaction rates I. as temperature increases, reaction rate increases II. the effect o f temperature on reaction rate is described by the Arrhenius equation III. as temperature increases more molecules are activated A. I f I only is correct B. If 111 only is correct

B. they have poor absorption from C If I and II are correct D . i f II and III are correct E. I f l , 11. and 151 are correct 43 Which of the following is NOT true about the effect o f pH on the rate of
reactions?

liquid dosage forms C. they are unstable in aqueous solutions D . they have poor water solubility E. all o f the above

47.W hichofthe following is N O T an antioxidant? A. ascorbic acid B. nitrogen C . tocopherols D. sodium sulfite E. butylated hydroxyanisol

at lower pH, H 'a c ts as catalyst

B rate constants are higher at lower or higher pH than at intermediate pH C. at the intermediate pH, the rate is always independent o f the pH D in the semi logarithmic graph ot ate constant versus pH, the inflectioi i point represents the pH of optim im stability E. B and D

48

. Which of the following is/are C O R R E C T about shelf life? I it represents the period of time a

44

. W hich o f the follow in g is a W RON match betw een the factors that affect tl rate o f reaction and their actual effect
the rate o f reaction?

pharmaceutical drug or drug product could be stored before it ,s no longer fit to be used due to chemical or Physical degradation . 11 it represents the period o f time a pharmaceutical drug or drug Product could be stored before it is no longer fit to be used due to physical degradation l l U t represents the period o f time a pharmaceutical drug or drug Product could be stored before it is no longer fit to be used due to physical degradation only A. I f l only is correct B. If HI only is correct C . I f l and II are correct D. I f l l and 1 1 1 are correct E . I f 1,11, and 111 are correct

A . buffer salts; decrease rate of

B. reaction com piexing agents; decrease reaction rate

c . surfactants; increase rate ot re action

D. all but B E. all of the above

45.The most common mode of pharmaceutical degradation is A. B. C. D. E. hydrolysis polymerization photolysis isomerization oxidation

46 Esters are not usually formulate* into aqueous liquid dosage forms. This ij> because A. they have unpleasant taste

49. A drug formulated as a tablet has a rate constant for first-order degradation j .5x 10 h 1 at 75C. Taking the activation energy (Ea) as 30.0K.cal/mol, the shelf life of the drug at room temperature will be

B. C. D. E.

180days 50days 220 days 400days

53. Which o f the following is NOT correct about the USP purified water? A. it can be obtained by reverse osmosis B. it should have a pH between 5 and 7 C. it can be used in the preparation o f parenteral and ophthalmic preparations D. the maximum solid content is lOppm E. A and B

50. Which o f the following is NOT true about the USP/NF definition o f oral solutions? A. they should not contain coloring agents B. they may contain one or more substances C. they are intended for oral administration D. cosolvent-water mixtures may be used to dissolve the components E. none

51.The drawbacks o f oral solutions include all the following EXCEPT A. the active ingredients in solutions are more susceptible to chemical degradation the therapeutic response is generally slower from solution than from tablets or capsules solutions are more heavier and bulkier, and i f the container breaks the product is irretrievably lost solutions are more susceptible to microbial attack none

54. Which o f the following distinguish purified water USP from water for injection USP? I Water for injection can be prepared by simple distillation IT Water for injection can be used for the preparation of parenteral solutions III Water for injection is pyrogen free

B.

C.

A. B. C. D. E.

i f l only is correct i f III only is correct i f l and II are correct if II and III are correct if l, II and III are correct

D. E.

55. Which o f the following need to be packaged in single or multiple-dose container o f type I and II glass? A. B. C. D. E. purified water water for injection sterile water for injection bacteriostatic water for injection C and D

52.An oral solution is a preferred dosage form than tablets in all o f the following EXCEPT A. if the patient has problem with swallowing tablets B. when the drug can cause ulceration if administered as tablets C. i f a longer shelf life is required D. if there is a need for easy adjustment o f the dose o f the active ingredient E. C and D

56.The containers for water for injection should not exceed a capacity o f A. B. C. ^D. 30ml 1L 500ml 130ml

E. 750ml

D. 85% w/v E. 65% w/w

57. Which o f the following do NOT contain antimicrobial agents? ]. water for injection II. sterile water for irrigation HI. bacteriostatic water for injection A. B. C. D. E. ifl only is correct if HI only is correct
ifl and II are correct

61 .Which o f the following statements is NOT true about elixirs? A. elixirs are solutions B. all elixirs contain alcohol C. the alcohol content o f saltcontaining elixirs should be high D. all elixirs have three or more components E. all but A

if II and III are correct if l, II and III are correct

58.The most common oral drug solutic ns are I.

II. III.

syrups elixir aromatic waters if l only iscorrect if III only is correct i f l and II are correct if II and III are correct if I, II and III are correct

62.A11 o f the following are correct about spirits EXCEPT A. they are also called essences B. they have high alcohol content C. they may be used as flavoring agents or they may have their own pharmacological action D. they should necessarily be stored in tight containers E. water should be added to them before dispensing '

A. B. C. D. E.

le tr 59. Which o f the following is NOT about syrups? I .they are solutions that contain hgh concentration o f sugars II. saturated solutions o f syrup are resistant to microbial growth III. they are good solvents o f water soluble drugs A. B. C. D. E. if l only is correct if HI only is correct if l and II are correct if II and III are correct if l, II and III are correct

63.The chemical that is added to tinctures to prevent precipitation that can occur upon storage is A. B. C. D. E. ethanol glycerin fixed oils acetone A o rD

60.The concentration o f sugar in syrup NF (simple syrup) is A. 85% w/w B. 67% w/v C. 75% w/v

64. Which o f the following are true about Fluidextracts I. fluidextracts can only be prepared by percolation, while tinctures can be prepared by percolation or by maceration II. fluidextract are more concentrated than tinctures III. fluidextracts do not contain alcohol

A. B. C. D. E.

i f l only is correct if III only is correct i f l and II are correct if 11 and III are correct if l, II and III are correct

E. to make swallowing easier

69. Which o f the following is NOT true about hydrocolloids? A. they increase the viscosity o f water B. they are self preserved so they do not need preservatives C. most o f them are not compatible with positively charged drugs D. most o f them are insoluble in alcohol E. carboxymethyl cellulose is one example o f hydrocolloids

65. Which o f the following is NOT true about astringents? A. they have the ability to precipitate proteins B. they can be used as antiperspirants C. they can be used to treat wrinkling o f the skin D. they have the ability to reduce cell permeability E. B and C

70. Which o f the following is NOT true about clays? A. chemically they are silicates B. when in aqueous dispersions, they are anionic C. they exhibit thixotropy D. bentonite is more viscous than Veegum at the same concentration E. none

66. One o f the following is NOT an astringent, A. B. C. D. E. aluminum acetate aluminum subacetate calcium hydroxide solution boric acid C and D

67. Which o f the following is NOT antibacterial topical lotion? A. B. C. D. E. benzalkonium chloride calamine lotion strong iodine povidone-iodine none

71 .Which o f the following could be a good reason for preparing emulsions? A. to increase the stability o f drugs B. to make unpleasant drugs more palatable C. to increase the solubility o f some poorly water-soluble drugs D. to prolong drug action E. all o f the above

68. One o f the following is NOT a reason for preparing suspensions, A. to improve unpleasant taste B. to improve the stability o f drugs that are unstable in solution phase C. to make the drugs to act faster than if they were prepared as solutions D. to make ophthalmic and parenteral preparations o f poorly water-soluble drugs

72.In emulsions, the liquid droplets are called A. B. C. D. E. dispersion medium internal phase continuous phase A and C All the above

73. Whether a prepared emulsion is to be o/w or w/o is determined mainly by I. the emulsifying agent used II. the relative volumes of the phases III. the type o f oil A. B. C. D. E. if l 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

D. dioctyl sodium sulfosuccinate E. none

78. Which o f the following is a correct match between the type o f soaps and the type o f emulsion they form? A. B. C. D. E. alkali soaps; w/o emulsions metallic soaps; w/o emulsions polyvalent soaps; o/w emulsions monovalent soaps; w/o emulsions C and D

74.For an ideal emulsion, the maximum concentration o f the internal phase is A. B. C. D. E. 50% 35% 74% 25% 40%

79. If w/o emulsion is to be prepared, which o f the following emulsifying agents would be the preferred one? A. B. C. D. E. Acacia Tragacanth Spans T weens C and D

75. All o f the following will affect the effectiveness o f an emulsifying agent EXCEPT A. B. C. D. E. chemical structure solubility concentration pH all o f the above

80. Which o f the following methods is suitable for the preparation o f emulsions using volatile oils? A. B. C. D. E. nascent soap method bottle method wet gum method dry gum method all but A

76. All the following are natural emulsifying agents EXCEPT A. B. C. D. E. benzalkonium chloride gelatin pectin methyl cellulose none 81 .Which of the following is NOT true about wet gum method o f preparing emulsions? A. it is also called continental method B. acacia is the emulsifying agent used C. the ratio o f oil, water, acacia used to prepare the primary emulsion is 4:2:1 respectively D. in the first step o f preparing the emulsion, two parts of the water is added all at once to the one part of the oil E. none

77.One o f the following is NOT an anionic synthetic emusifier, A. soaps B. sodium lauryl sulfate C nolvoxvethylene sorbitan moleate

Pharmaceutical Dosage Forms

D. they can incorporate large amount

when the mixture is cooled below

a O

82. Al! o f the following are true about the dry gum method o f preparing emulsions EXCEPT A. the ratio o f fixed oil, water, acacia used to prepare the primary emulsion is 4:2:1 respectively B. alcoholic solutions should be added only as dilute solutions C. if electrolytes o f high concentration are to be added to the emulsions, they should be added last and in as dilute a form as possible D. if electrolytes o f high concentration are to be added to the emulsions, they should be added at the very first step E. A and D

C. the two phases should be cooled to about 40C before they are combined D. heat labile and volatile ingredients are added at the end o f the process E. further improving the emulsion stability and homogeneity can be done using hand homogenized or hand blender

85. Addition o f medicinal agent to a performed emulsion is especially difficult if I. the drug to be added is oil soluble and the emulsion is o/w type the drug to be added is water soluble and the emulsion type is w/o the drug to be added is oil soluble and the emulsion is w/o type 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

II.

III. 83. Which o f the following is NOT true about the nascent soap method? A. an equal volume o f water and oil are used to prepare the emulsifying soap B. an o/w or w/o emulsion can be formed using this method C. it is desirable the oil used for the preparing the emulsion to contain large amount o f free fatty acids D. adding acids helps to stabilize the emulsion formed E. none A. B. C. D. E.

86. Which o f the following s NOT true about ointments? A. They are meant for external application B. They are semisolid dosage forms C. Other than serving as vehicles, they do not have other functions D. They can be used for transdermal delivery o f drugs E. None

84. Which o f the following is a wrong procedure in the preparation o f emulsions stabilized using synthetic emulsifying agents? A. water miscible ingredients and oil miscible ingredients are mixed separately B. high melting oil miscible ingredients are mixed before low melting ingredients

87.One o f the following is NOT true about the oleaginous bases. A. they are anhydrous B. they are insoluble in water C. they are not water washable

D. they can incorporate large amour t of water E. they are greasy

when the mixture is cooled below 40C E. solid drugs which are soluble in melted bases are preferably incorporated by this method

88.One o f the following is NOT a constituent o f oleaginous base A. B. C. D. E. petrolatum cetly alcohol hydrogenated lanolin modified petrolatum waxes anhydrous lanolin 91 .Which o f the following is/are true about suppositories? A. they are solid or semisolid dosage forms B. they are intended to be inserted into rectum, vagina, and urethra C. when they are inserted, suppositories should melt or dissolve in the body fluids o f the cavity in order to release the medicament they carry properly D. suppositories can provide systemic medication i f used rectally E. All o f the above

89. Which o f the following is a WRONG procedure when a drug is incorporated into an ointment base by levigation? A. a stainless steel should be used when incorporating iodine or mercuric salts B. water-soluble salts should be incorporated directly into the ointment base C. organic solvents such as ether land chloroform could be used to dissolve drugs for easy incorporation into the bases D. insoluble substances should b i levigated repeatedly on an ointment slab using spatula with broad knd hard blade. E. All o f the above

92. Which o f the following is False about Rectal suppositories A. First pass elimination o f high clearance drugs can be partially avoided when drugs are administered by the recta] route owing to bypassing the liver B. it is useful for nauseous/vomiting patients C. it provides faster drug absorption D. it is useful way to administer medication to children who are unwilling or unable to tolerate the drug by the oral route E. drugs liable to degradation in the GI tract can be administered 93.The weight o f suppositories intended for adults is approximately A. B. C. D. E. 2g H 3g 4g lg

90. Which o f the following is NOT c <>rrect about the fusion method o f incorpon ting medicinal agents to ointment bases? A. it is used for those bases that have solids with high melting poirt B. the oil phase and the ingredients in the water phase should be he ated separately C. if w/o system is desired, the hot oil phase is incorporated into th ? hot water with agitation D. volatile ingredients could onlly be added at the end o f the process

94. The shape o f suppositories to be inserted into the urethra is A. B. C. D. E. oval cylindrical and tapered to the point cone spherical long and tapered

B. water-soluble drug in water-soluble base C. oil-soluble drug in water-soluble base D. oil-soluble drug in oil-soluble base B and D

98.The most commonly used suppository base is A. B. C. D. Wecobee base Witepsol bases Cocoa butter Cocoa butter along with other hydrogenated fatty acids o f vegetable oils E. B and C

95. Which o f the following is NOT true about vaginal suppositories? A. systemic medication can be achieved by this route B. contraceptive agents can be administered by this route C. antiseptics and antibacterial agents can be formulated as vaginal suppositories D. vaginal suppositories weight about 5g E. none

99.Theobroma oil is most suitable for the preparation of A. B. C. D. E. vaginal suppositories rectal suppositories urethral suppositories A and B B and C

96.One o f the following is a WRONG criterion for a satisfactory suppository base. A. B. C. The suppository base should have wetting and emulsifying properties the suppository base should have a wide melting point range the suppository base should be able to melt at temperature just below the body temperature the suppository base should be able to dissolve fast in the fluid at the body cavity the suppository base should not soften below 30oC

D.

100. Which o f the following is are limitations o f theobroma oil as a suppository base? I. it exhibits marked polymorphism II. its melting point is lowered by the addition o f certain substances III. it can absorb limited amount o f aqueous solution A. B. C. D. E. i f l only is correct if III only is correct if l and II are correct if II and 111 are correc if I, II and III are correct

E.

97. Which o f the following combinations provides the fastest onset o f action? A. water-soluble drug in oil-soluble base

101. Which o f the following is NOT true about Witepsol? A. during preparation o f suppositories from Witepsol, there is no need to

B. C. D. E.

lubricate the molds since Witepsol bases solidify rapidly lauric acid is the major component it is derived from coconut oil it does not show polymorphism all the Witepsol are colorless and almost odorless

B. Glycerin C. mineral oil D. theobroma oil E. C and D

106. Which o f the following substances need special care when producing suppositories by the fusion method? I. II. III. A. B. C. D. thermolabile substances insoluble powders volatile substances

102. Which o f the following are False about PEG polymers? A. they are water soluble B. they have fast dissolution process C. they have little effect on the drug release and absorption profile D. various combination o f PEGs may be used to prepare a suppository base of desired consistency and characteristics E. B and C

if I only is correct if III only is correct i f l and II are correct if II and III are correct E. if I, II and III are correct

107. Which o f the following is an advantage o f powders as dosage forms? 103. Which method is used for the commercial preparation o f suppositories A. B. C. D. E. hand-rolling method compression fusion method A and B B and C A. they can mask unpleasant tastes B. they offer great flexibility in compounding C. they are good for dispensing hygroscopic drugs D. dosing is more accurate with powders E. all but C

104. What is the quantity of cocoa butter required to make nine, 2g suppositories of Phenobarbital 1OOmg? The cocoa butter density factor o f phenobarbital is 1.2. Calculate for extra two suppositories. A. B. C. D. E. 21.083g 18.254g 24.256g 15.156g 27.895g

108. All o f the following are size reduction equipments used on a large industrial scale EXCEPT A. B. C. D. E. fluid energy mill tumblers roller mill rotary cutter none

105. In the fusion method o f preparing suppositories, the substance that is used to lubricate the molds is A. Ethanol

109. The comminution technique used for the size reduction o f gummy substances is A. trituration

B. C. D. E.

pulverization by intervention levigation A and B B and C

114. Which mixing method is best suited to mix potent drugs with large quantities of other powders? A. B. C. D. Trituration Levigation Granulation Sifting

] 10. Which o f the following is NOT true about spatulation? A. a spatula is used to mix powders on a sheet o f paper B. it is not suitable for mixing large quantities of powders C. it is a preferred method for the mixing o f powders that contain potent drugs D. it is particularly useful for mixing powders that form eutectic mixtures E. none

E . geom etric dilution

115. The most suitable container for the dispensing of bulk powders intended to be sprayed on the skin is A. B. C. D. E. perforated sifted aerosol wide-mouthed A and B

111. All o f the following substances form eutectic mixtures EXCEPT A. B. C. D. E. silicic acid aspirin camphor
phenacetin

116. Insufflators or blowers are for administering powders intended for all the following EXCEPT A. B. C. D. E. Ears Skin Vagina Throat Nose

phenylsalicylate

112. The method, which is used, both for size reduction and for mixing of powders is A. B. C. D. E. spatulation tumbling levigation trituration sifting

117.

Dentifrices

113. In trituration glass mortar is preferred A. if comminuting hard substances B. for tirutrating colored substances C. if mixing of the substances is desired while comminution D. if liquids are involved during trituration E. all o f the above ~

A. are applied to the tooth sockets B. are used for oral hygiene C. are dissolved in warm water and applied vaginally D. are dissolved in water and the patient drink it E. all but C

118. Which o f the following provides best protection for hygroscopic and volatile drugs? A. Glassine B. white bond

C. waxed paper D. white bond E. C and D

122. Which o f the following is NOT true about the selection o f capsules? A. when selecting the size capsule, it should be such that a properly filled capsule should have its body and cap filled with drug mixture B. it is possible to add a diluents if the dug dose is inadequate to fill the capsule C. lubricant such as magnesium stearate could be added to facilitate filling D. wetting agents could be added to facilitate dissolution E. none

119. Which o f the following is NOT correct about the manufacture o f empty hard gelatin capsule? A. empty hard gelatin capsules are prepared from a mixture o f gelatin, colorants and opacifying agent B. gelatin is prepared by the hydrolysis o f collagen obtained from animal connective tissue, bone, skin, and sinew C. type A gelatin is produced by alkaline hydrolysis, while type B is produced by acid hydrolysis D. the thickness o f the gelatin capsules formed is affected by viscosity of the gelatin solution E. In the process, stainless steel mold pins are dipped into warm gelatin solution upon which the shells are formed. 120. What is the substance, which is used to prevent decomposition o f gelatin during the manufacture o f empty hard gelatin capsules? A. B. C. D. E. Glycerin titanium dioxide carbon dioxide sulfur dioxide mineral oil

123. What is the method used to fill capsule extemporaneously? A. B. C. D. E. gravity fill tamping punch method screw-feed B and C

124. Soft gelatin capsules differ from hard gelatin capsules in that, A. the basic component o f soft shells is not gelatin B. soft shell capsules are plasticized C. soft shell contain preservatives D. coloring agents cannot be added to soft gelatin capsule E. B and C

121. When storing hard gelatin capsules, the humidity should be kept approximately within the limits o f A. B. C. D. E. 5% and 10% 12% and 16% 20% and 30% 25% and 40% 30% and 40%

125. Which o f the following cannot be encapsulated into soft gelatin capsules?

A. B. C. D. E.

dry powders pastes emulsions vegetable oil suspension o f drugs in PEG 4000 and 6000

126. Which o f the following tests are NOT required for conventional capsules in the USP? A. Disintegration B. Dissolution C. moisture content D. content uniformity E. none

130. Which o f the following excipients is added to increase the bulk of the tablet formulation when the drug dosage amount is not enough for compression?

A. Disintegrants B. Lubricants C. Diluents D. Binders E. Flavors

127. Which o f the following is NOT advantage o f oral solid dosage forms over liquid dosage forms? A. B. C. D. they are easy to handle fast onset of action preservatives are not needed they are more stable E. there is no need to mask the taste

131. Calcium salts are not used as diluents in tetracycline formulations. This is because A. calcium salts are expensive B. calcium salts form complex with tetracycline that will affect their absorption from the GI tract C. calcium salts form complex with tetracycline that is very unstable D. calcium salts are unpleasant E. large amount o f calcium salts are required

128. One o f the following is a disadvantage o f tablets as a dosage forms A. it is difficult to produce them on a large scale B. it is difficult to administer an accurate dosage o f medicament C. it is difficult to control the release profile o f drugs form tablets D. it is difficult to compress some drugs into tablets E. none

132. In which o f the tablet manufacturing methods are binders added as solutions? A. B. C. D. wet granulation dry granulation direct compression A and B E. A and C

129. Which o f the following is NOT an ideal property o f a tablet? A. it should have the stability to be useful for long period o f time B. it should be free o f the production defects like chipping, capping etc C. the release profile o f the drug from the tablet should be predictable D. it should be able to withstand the pressure during production E. it should be white colored

133. Which o f the following is NOT true about disintegrants? A. they could affect the dissolution o f a tablet B. all the disintegrants in the formulation should be added to the drug-diluent mixture to make the granules C. they are the ones which assist the fragmentation o f tablets D. clays such as Veegum and bentonite can act as disintegrants

E. none

134. Which o f the following is a WRONG match between an excipient and its function? A. lubricant; reduce friction during compression and ejection B. anti adherents; reduce friction between particles C. glidants; improve the flow o f granulations D. A and B E. B and C

A. increasing the rate disintegration and dissolution B. masking o f unpleasant taste and odor C. improving esthetic qualities o f the product D. improving product stability E. none

139. Which method o f tablet manufacture allows for combination o f two incompatible drugs within the one tablet? A. B. C. D. film coating
dry coating

135. Flavoring and sweeteners are most o f the time used in the manufacture o f A. B. C. D. E. Extended release tablets sugarcoated tablets gelatin coated tablets chewable tablets B and D

enteric coating sugar coating E. air suspension coating

140. Which o f the following is NOT true about the compression-coated tablets? A. it is suitable for moisture sensitive drugs B. it can be used to produce prolonged action C. it can be used to produce repeataction tablets D. it produces m uch thicker and less
uniform tablets than sugar coating

136. Which o f the following is not an adsorbent? A. B. C. D. E. Sorbitol magnesium oxide bentonite silicon dioxide none

E. it can produce tablets with

multiplayer appearance

137. Which o f the following excipients have more than one function? A. B. C. D. E. Mannitol Talc Lactose Sorbitol All o f the above

141. Which o f the following is NOT correct about repeat-action tablets? A. they are multiple compressed tablets B. the outer coat tolerates disintegration at the stomach C. the inner components are soluble in the intestine D. B and C E. None

138. Which o f the following is NOT a benefit that could be gained from coating tablets?

142. Which of the following is/are the reasons for formulating delayed-action and enteric coated tablets? A. to protect drugs that may get degraded by the acid environment in the stomach B. to control the delivery o f some drugs to the intestine where they are absorbed better C. to protect the stomach from some drugs that may have irritant effect on it D. to promote absorption, which is better in the intestine than in stomach E. All o f the above

C. subcoating, seal coating, syrup coating, polishing D. subcoating, syrup coating, seal coating, polishing E. syrup coating, subcoating, seal coating, polishing

146. Which o f the following is NOT a disadvantage o f sugar coating? A. the process takes a lot o f time B. the service o f highly skilled operator is required C. the esthetic quality sugar coated tablets is not pleasing D. there is an increase both in weight and size o f the finished product resulting in higher packaging and shipping costs E. none

143. The materials used for enteric coating include all the following EXCEPT A. B. C. D. E. cellulose acetate phthalate shellac titanium oxide fats waxes

147. One of the following is a disadvantage of film coating o f tablets, A. B. C. D. E. process efficiency is decreased it is not resistant to chipping the coating process is complex use o f organic solvents all o f the above

144. Which o f the following is NOT a purpose o f sugar coating? A. to improve appearance B. to mask unpleasant odor or taste C. to control the release of drugs from tablets D. to protect certain drugs form the degrading effects o f the environment E. none

148. A film coating solutions may contain all of the following EXCEPT A. B. C. D. E. seal coating agent plasticizer volatile solvent surfactant glossant

145. What is the correct order o f the process involved in sugar coating of tablets? A. seal coating, sub coating, syrup coating, polishing B. seal coating, syrup coating, subcoating, polishing

149. Tablets, which are meant to allow the absorption o f medications through the oral mucosa include A. chewable tablets B. buccal tablets C. sublingual tablets D. B and C E. All the above

150. Which tablets would be suitable for the administration o f a medication that may be destroyed by the acidic environment in the stomach and has low absorption from the small intestine? A. B. C. D. E. enteric coated tablets air suspension-coated tablets sublingual tablets buccal tablets C and D

C. lamination; excessive moisture content D. capping, entrapment o f air among the granules E. none

154. The ability o f tablets to tolerate abrasion, during packaging, transportation, and handling is measured by A. B. C. D. E. tablet hardness tester disintegration tester friability tester balance A and C

151. Tablets, which are used to prepare solutions include all the following EXCEPT A. B. C. D. E. chewable tablets effervescent tablets dispensing tablets tablet triturates none

155. The USP tablet weight variation test applies to A. all tablets that weigh 50mg or more B. for tablets that contain 50mg or less o f the drug substance C. only uncoated tablets that weigh more than 1OOmg D. tablets that contain 50mg or more o f the drug substance or when the latter comprises 50% or more, o f the dosage form. E. Tablets that contain lOOmg or more o f the drug substance or when the latter comprises 95% or more, o f the dosage form.

152. Which o f the following is a WRONG match between a tablet manufacturing problem and its description? A. capping; partial or complete separation o f the top or bottom o f the tablets form the main body B. lamination; separation o f the tablet into two or more distinct layers C. picking; adhesion o f tablet material to the die walls D. mottling; non-uniform distribution o f color on the tablet surface E. none

156. The specification for the disintegration o f enteric-coated tablets is A. intact after 1 hour in simulated gastric fluid and then complete disintegration in 2 hours plus specified tim e in simulated intestinal fluid B. intact after 2 hours in simulated gastric fluid and then complete disintegration in 1 hour plus specified time in simulated intestinal fluid C. intact after 1 hour in simulated gastric fluid and then complete

153. Which o f the following is a WRONG match between a tablet manufacturing problem and its cause? A. mottling; difference in color between the excipients B. sticking; excipients with low melting point

disintegration immediately after put in a simulated intestinal fluid D. intact after h alf an hour in simulated gastric fluid and then complete disintegration in half hour plus specified time in a simulated intestinal fluid E. intact after 1 hour in simulated gastric fluid and then complete disintegration in 10 minutes in simulated intestinal fluid

160. Which o f the following is NOT an advantage o f controlled-release dosage form? A. there is a better patient compliance B. the problem o f dose dumping is avoided in case o f controlled-release dosage forms C. the plasma drug level is maintained at a constant, in the therapeutic window range for an extended period o f time D. there is reduced dosing frequency and elimination o f drug accumulation in the body E. unwanted side effects are reduced

157. The part o f aerosol products, which is responsible for conveying the formulation from the bottom o f the container to the valve assembly is A. B. C. D. E. actuator propellant container dip tube valve

J61. Which o f the following is NOT true about coated beads or granules A. they provide drug blood level similar to that o f multiple drug dosing B. the process involves coating of a drug in non-aqueous solvent onto preformed beads or granules C. some pellets are left uncoated to provide an immediate release o f the drug D. the other pellets besides those left uncoated should receive equal coating E. none

158. Which o f the following propellants are no longer in use now? A. B. C. D. E. carbon dioxide nitrogen nitrous oxide chlorofluorocarbons (CFCs) hydroflourocarbons

159. AH o f the following are advantages o f aerosols EXCEPT I.they provide easy and accurate administration o f dosage H. they provide protection for moisture and oxygen sensitive medications III. sterility is maintained even when a dose is dispensed A. B. C. D. E. if l only is correct if 111 only is correct if l and II are correct if II and 111 are correct if], 1 1 and III are correct 162. Which o f the states o f matter could be microencapsulated? A. B. C. D. E. Gases Liquids Solids B and C A, B & C

163. Which o f the following could NOT be used as a film-forming substance in the process o f coacervation?

A. B. C. D. E.

Shellac Glycerin Starches Gelatin cellulose acetate phthalate

164. The drug release rate o f an osmotic system is affected by all the following EXCEPT A. B. C. D. tablet surface area size o f the delivery orifice pH the type o f the semipermeable membrane E. none

165. In the ion-exchange resin system o f sustained-release forms, the drug-resin complex is formulated into I. II. III. IV; A. B. C. D. E. tablets capsules suspensions emulsions la n d II I and IV 1,11 and III II, III and IV II and IV

166. Maximum buffer capacity occurs when A. B. C. D. E. pH >pK a pH< pKa pH = pKa 2pH = pKa (pH)2 = pKa

Answers Phrmaceutical Dosage Forms

1. Answer: C. the dynamic interaction among the drug, its formulation matrix, its container, and physiological milieu o f the patient is the subject o f pharmaceutical principles. Explanation: The dynamic interaction among the drug, its formulation matrix, its container, and physiological milieu o f the patient is the subject o f biopharmaceutics.

2. Answer: D. intermolecular repulsive forces occur when opposite charges approach each other. Explanation: Intermolecular repulsive forces occur when positive charge approaches positive charge and negative charge approaches negative charge. 3. Answer: C.CC14 Explanation: CC14 has a perfect symmetry; therefore, it is non polar and has zero dipole moment. All the others have unequal electron distribution between the atoms as a result o f which, there is a shift in the overall electron cloud. Therefore, they are polar and have nonzero dipole moment. 4. Answer: D. They are not strong enough to effect order in a molecule Explanation: By their own, non polar molecules do not have permanent dipoles. However, in some instances it is possible that the electrons o f the molecule may be aligned in such a position that their distribution in the molecule become asymmetrical. This will make the molecule to have transient dipole moment that is capable o f inducing a dipole in an adjacent molecule, which will result in induced dipole-induced dipole type o f interaction. This kind o f interaction, which is also called London dispersion force has an approximately 0.5-1 kcal/mol and is sufficient to facilitate order in a molecular array. They are also responsible for the condensation o f non polar gases. 5. Answer: C. Ion-dipole interaction Explanation: Dipole-dipole, dipole-induced dipole, and induced dipole-induced dipole interactions make up what chemists commonly refer to as van der Waals forces, after the Dutch physicist Johannes van der Waals. Ions and dipoles are attracted to what another by electrostatic forces called ion-dipole forces; they are not van der Waals forces. 6. Answer: C. I and II are correct

Explanation: The ideal gas equation is the equation, which describes the relationship among the four experimental variables, pressure (P), volume (V), absolute temperature (T), and the number of moles o f gas [which is the equivalent to the number o f grams (g) o f gas divided by the molecular weight o f the gas (M)]. R, the proportionality constant, is called the gas constant. 7. Answer: E.None Explanation: Oxygen is used therapeutically in conditions where the lung is unable to deliver adequate supply to some tissues. Nitrogen, halocarbons and halohydrocarbons are used in aerosol products as propellants. Ethylene oxide is used as sterilizing gas. 8. Answer: D.Vander Waals forces Explanation: The intermolecular forces o f attraction (van der Waals forces, and hydrogen bond in some cases) between liquid molecules are responsible for the greater ordering and molecular arrangement found in liquids. These forces are, however, weaker than covalent and ionic bonds found in solids. So the ordering found in solids is much stronger than found in liquids. 9. Answer: E. I, II and III Explanation: Molecules within a liquid are pulled in all directions by intermolecular forces as a result o f which there is no tendency for them to be pulled in any one way. However, molecules at the surfaces are pulled downward and sideways by other molecules, but not upward away from the surface. As a result, molecules at the surface o f a liquid experience a net inward force that will pull them into the interior o f the liquid bulk. This will make the liquid surface to decrease/contract and the liquids to assume the shape o f a sphere. 10. Answer: A.smaller than the surface tensions o f the individual liquids Explanation: When a substance is adjacent to another substance, as is the case at the interface between two liquids, then there is interfacial tension. When the surfaces o f liquids A and B are separated from each other, they have their own surface tensions. When the two surfaces come into contact with each other to form an interface, an attractive force between molecules o f A and B appears. This attractive force reduces the imbalance in forces o f attraction within each phase. As a result o f this, the interfacial tension between the two liquids will be smaller than the surface tension o f the individual liquids.

11 .Answer: B.most substances o f pharmaceutical importance are Newtonian Explanation: Pharmacists deal more frequently with non-Newtonian material. Liquids and solid heterogeneous dispersions such as colloidal solutions, emulsions, ointments, and liquid suspensions make up this class. 12.Answer: E.A and B

Explanation: Non-Newtonian substances show either shear-dependent or time-dependent viscosity. Shear dependent viscosity in turn include dilatant flow (also referred as shear thickening) or pseudoplasticity (also called shear thinning). Dilatant flow displays increase in viscosity with increasing rate o f shear. On the other hand, in pseudoplasticity, there is a decrease in viscosity as the rate o f shear increases. 13.Answer: A.tragacanth; dilatant flow Explanation: Long chain or linear polymers, e.g., tragacanth, methylcellulose, and carboxymethylcellulose, generally exhibit pseudoplastic flow. Shear thickening is showed by suspensions that have a high solid content o f small, deflocculated particles. 14.Answer: B.when the shear rate is decreased thixothropic substances immediately regain their initial viscosity Explanation: A thixothropic fluid undergoes a decrease in viscosity with time (i.e.. shear thinning), while it is subjected to constant shearing. If the rate o f shear is immediately decreased, the thixothropic fluid does not immediately recover its viscosity. In a thixothropic system, structural recovery is slower than structural breakdown. Thixothropy occurs with heterogenous systems that involve a three dimensional structure o f networks such as gels and magmas. 15.Answer: C. all crystalline solids are anisotropic Explanation: All crystalline solids are anisotropic except cubic crystals which are isotropic(i.e., their properties are the same in all directions). 16. Answer: C. polymorphs do not have pharmacological or pharmaceutical implications

Explanation: Polymorphs have significant pharmacological and pharmaceutical implications since one polymorph of a drug may be active while the other polymorph may show no or only little activity (e.g., steroids). Moreover, one polymorph o f a pharmaceutical ingredient may have physical and chemical properties that render it suitable component o f a formulation while the other polymorph may not have such attributes that it cannot serve the same function as the other (e.g., cocoa butter)

17. Answer: C. substances that exist at the triple point are called supercritical fluids Explanation: Supercritical fluids are substances that exist above the critical point. 18.Answer: A.supersaturated solution Explanation:

A supersaturated solution is one that contains more o f the dissolved solute than it would normally contain at a definite temperature, were the un dissolved solute present. Some salts such as sodium thiosulfate and sodium acetate can be dissolved in larger amounts at an elevated temperature and, upon cooling, fail to crystallize from the solution. 19.Answer: B.Glycerin Explanation: Electrolytes are substances that form ions when in solutions. These substances, when dissolved in water, result in solution that can conduct electricity. Examples include, atropine, sodium chloride, sodium hydroxide, hydrochloric acid etc. Non electrolytes are substances that do not form ions when dissolved in water. As a result they do not conduct electricity. Examples include urea, glycerin, sucrose etc. 20. Answer: D. on the number o f solute particles in the solution

Explanation: Colligative properties are those properties o f a solution that depend up on the number o f solute particles (both ionic and nonionic) in solution and not on the nature o f the solute particles. 21. Answer: C. acidity o f a solution Explanation: Colligative properties are vapor-pressure lowering, boiling point elevation, freezing point depression, and osmotic pressure. 22.Answer: C. solvent molecules in a concentrated solutions have a higher chemical potential than solvent molecules in a more dilute solution Explanation: Solvent molecules are able to transfer from a dilute solution to concentrated solution because they have higher chemical potential in the dilute solution than in the concentrated solution 23.Answer: B. Lewis theory Explanation: According to the Arrhenius dissociation theory, an acid is a substance that liberates H+ in aqueous solution, and a base is a substance that liberates hydroxyl ions(OH-) in aqueous solution. Lowry-Bronsted theory defines an acid as a substance, charged or uncharged, that is capable of donating a proton, and a base is a substance, charged or uncharged, that is capable o f accepting a proton. The Lewis theory extends the acid-base concept to reactions that do not involve protons. If defines an acid as a molecule or ion that accepts an electron pair from another atom and a base as a substance that donates an electron pair to be shared with another atom. 24.Answer: C. H+ concentration decreases exponentially as pH decreases Explanation: As pH decreases, H+ concentration increases exponentially. For example, if pH decreases from 10 to 9, the H+ concentration increases from 10"1 0 to 10'9 , which is 10 times the original concentration.

25. Answer: B. the law o f mass action can be used to express the equilibrium the dissociation o f strong acid/base Explanation: Strong acids/bases dissociate completely when in solution. So there is no equilibrium condition in such cases. Since the law o f mass action is applied to equilibrium conditions, it cannot be used to express the dissociation o f strong acids/bases. 26.Answer: D.B and C Explanation: The dissociation o f a weak base in water can be expressed as BHf <--------- ^ H + + B Therefore, the dissociation constant for this reaction is expressed as Ka = [H+][B]/[B H+] However, more commonly, the dissociation constant for weak base is expressed as B + H20 <--------- OH- + BH+ Kb = [OH~][ BH+]/[B] The dissociation constant for a weak acid HA is expressed as Ka = [H+][A"]/[HA] 27.Answer: D. Henderson-Hasselbalch equation Explanation: Degree o f ionization is used to calculate the fraction o f ionized/unionized species o f weak electrolyte in solution. Van Slykes equation is the equation, which gives the exact representation o f buffer capacity. Lewis theory gives the definition o f bases and acids depending whether they accept-or donate protons. Henderson-Hasselbalch equation gives the relation between the ionized and unionized species o f a weak electrolyte. It is also used to calculate the pH o f buffer solutions. 28.Answer:D. the negative logarithm o f the dissociation constant o f the acid Explanation: The Henderson-Hasselbalch equation for a weak acid is given as pH = pKa + log [salt]/[acid] Therefore, the 3.5 must be the pKa o f HA (a weak acid), and pKa is the negative logarithm o f Ka (the dissociation constant o f a weak acid). So 3.5 is the negative logarithm o f the dissociation constant o f the weak acid. 29. Answer: C. I and II only

Explanation: The degree o f ionization o f a weak electrolyte depends solely on the pH o f the solution and the pKa o f the weak electrolyte. 30. Answer: A. Buffer solutions are able to resist any change in pH when any amount o f acid or base added Explanation:

A buffer solution is capable o f resisting only a significant change in pH when only a limited concentration o f acid or base is added. Buffer solutions are more commonly prepared from weak acids and their salts, since weak bases are often unstable and volatile. 31 .Answer: B. it is the resistance to a change in pH Explanation: The resistance o f a buffer solution to a change in pH is termed as the buffer action. 32. Answer: D. Concentration o f buffer constituents Explanation: Buffer capacity depends upon the actual concentration o f buffer components. This can be expected because as we increase the concentrations o f the salt and acid (in a weak acid buffer), the alkaline reserve and the acid reserve o f the buffer, respectively, increase and thus, the buffer can withstand higher increments o f acid or base without significantly changing its pH. 33.Answer: C. the dispersed particles do not move at all Explanation: The dispersed particles are involved in random movement due Brownian motion. 34.Answer: E. All o f the above Explanation: According to the Stokes law, the rate o f settling o f dispersed particles in dispersed system are dependent on the diameter o f the dispersed particles, the viscosity o f the dispersion medium and on the difference between the densities o f the dispersed particles and dispersion medium, and gravitation. 35.Answer: B. minimizing the difference in densities between the particles and the dispersion medium Explanation: Control o f settling by minimizing the difference in densities between the particles and the dispersion medium is not too practical. 36. Answer: C.flocculation occurs at high level o f zeta potential

Explanation: At high level o f zeta potential, the interparticulate repulsive forces predominate the attractive forces, as a result o f which only little collision between particles occur. Therefore, aggregation (i.e., flocculation) is avoided and the dispersion is said to be deflocculated. 37.Answer: B. Creaming causes less stability than cracking Explanation: The proper choice o f surfactants used at the correct concentration can significantly reduce coalescence by forming interfacial film o f surfactant around the droplets. Creaming is the reversible separation o f a layer o f emulsified particles. Although undesirable, creaming can be overcome by vigorous shaking. Cracking on the other hand is the separation o f the phases into

permanent layers that can never be redispersed. So it is o f greater concern than creaming. According to Stokes law, it is possible to stabilize emulsions and reduce coalescence by reducing the particle size o f the dispersed particles, by minimizing the density difference between the dispersed phase and dispersion medium, and by increasing the viscosity o f the dispersion medium. 38.Answer: E. All o f the above Explanation: The stability o f the active ingredient in a pharmaceutical dosage form is very important since it can determine whether a formulation for a dosage form could be accepted or rejected. This is because stability problems o f the active ingredient can result in the formation o f substances that are unsafe for the patient, and in the loss o f large quantities o f the active ingredient such that the amount o f active ingredient available for absorption is reduced. This can render the dosage form inefficient. 39. Answer: E. all o f the above

Explanation: The degradation rate is the velocity with which the reaction that leads to the degradation o f the active ingredient occurs. It is affected by several factors, which include temperature, pH, solvents and additives used, catalysts, radiation, concentration o f the reactant (dose o f the active ingredient since the active ingredient is a reactant). 40. Answer: C. The first-order rate constant has the unit, concentration/time Explanation: For a first-order reaction, the unit o f rate constant is reciprocal time (i.e., 1/time). 41 .Answer: C. is the time required for T90o /oo f the initial amount o f the reactant to form product Explanation: T90%is the time required for a drug to degrade to its 90% of its initial concentration (i.e., the time required for 10% o f the initial amount o f the drug to react). 42.Answer: E. I, II, and III are correct Explanation: All o f them are true 43. Answer: C. at the intermediate pH, the rate is always independent of the pH

Explanation: In a neutral system, the rate may be independent o f the pH, or it may be catalyzed by both H+and OH'. 44. Answer: D.all but B Explanation: Buffer salts may decrease rate o f reaction by maintaining the most optimum pH, and they may increase the rate o f reaction by acid/base catalyses. Reaction rates can be increased by addition of

surfactants as a result o f micellar catalysis. Although less common, surfactant may also be used to decrease reaction rates. 45.Answer: A. Hydrolysis .

Explanation: . Since most medicinal agents are esters, lactams or amides, which are prone to hydrolysis, the most common way o f drug degradation is hydrolysis. 46.Answer: C. they are unstable in aqueous solutions Explanation: Esters are prone to hydrolytic reaction as a result o f which they are unstable in aqueous solutions. Therefore, they are not formulated as liquid dosage forms. 47.Answer: B. Nitrogen Explanation: Antioxidants are the substances with the ability to react with free radicals by providing electrons and easily available hydrogen atoms. Therefore, they are able to avoid the chain reaction that could have been propagated by the free radicals. Examples o f such substances include ascorbic acid, sodium bisulfite, propyl gallate, tocopherols, butylated hydroxyanisole, butylated hydroxytoluene. Although nitrogen can be used to prevent oxidation by creating an inert atmosphere, by definition it is not an antioxidant. 48.Answer: A. 1 only is correct Explanation: Shelf life represents the period o f time a pharmaceutical drug or drug product could be stored before it is no longer fit to be used due to either chemical degradation or physical deterioration or both.

49.Answer: B.180days Explanation: The shelf life o f a drug is taken as the time required for a drug to degrade to 90% o f its original concentration (t90%). It is calculated by the formula t 9 o%= [2.303/^] [log(l 00/90)] = 0.105/ki, where K] is the first order degradation at the storage temperature (in this case 25C). Therefore, inorder to solve the above problem, K, must be calculated first. To calculate Kj, the following formula can be used Log[k2/k | | = [Ea/2.303R] x [(T2-T i)/T 2Ti], where K2 is the first-order degradation at T2 (in this case 75C). Log [3.5x1 O'2/ K,] = [30.0/(2.303 x 1.987)] x [(348 - 298)/(348x298)] 3.5xl02/K , = antilog (3.16)= 1445.44 K]= 3.5x10'2/ 1445.44 K ,= 2.42x 1 0 'V Therefore, t90%= 0.105/2.42 x 10'5 w ,, = 4338.84hrs = 180.8days

Pharmaceutical Dosage Forms

50.Ans\ver: A. they should not contain coloring agents Explanation: According to the USP/NF definition, solutions may or may not contain coloring, flavoring or sweetening agents 51 .Answer: B.the therapeutic response is generally slower from solution than from tablets or capsules Explanation: In case o f oral solutions, the active ingredient is already in solution and does not need to undergo dissolution; therefore, the therapeutic response is generally faster than if a tablet or capsule dosage form is used for treatment. 52. Answer: C. if a longer shelf life is required Explanation: Solutions may be swallowed by patients who have difficulty taking tablets or capsules, as might be the case with pediatric or geriatric patients. Drugs such as potassium chloride that may cause ulceration to the mucosa in a tablet formulation avoid this side effect when present in solution. The active ingredient, when present in solution, is usually more susceptible to chemical degradation,particularly hydrolysis, than when they are in a solid dosage form. As a consequence, the solution product has a shorter shelf life than the solid formulation. In case o f solution, the dose o f the active ingredient is easily and conveniently adjusted by measuring a different volume. 53. Answer: C. it can be used in the preparation o f parenteral and ophthalmic preparations Explanation: Purified water is used in prescriptions and finished manufactured products except parenteral and ophthalmic preparations

54.Answer: D. II and III are correct Explanation: . Water for injection may be prepared by double distillation or reverse osmosis. Water for injection is pyrogen free and can be used for the preparation o f parenteral solution. 55.Answer: D. bacteriostatic water for injection Explanation: Sterile water for injection should also be stored in containers made from type I or II glass, but they should be single containers. 56.Answer: B.1L Explanation: The containers for water for injection should not exceed a capacity of IL, and the containers for Mcteriostatic water for injection should not exceed a capacity o f 30ml

57.Answer: C. I and II are correct Explanation: Bacteriostatic water for injection IJSP is sjerile water for injection that contains one or more suitable antimicrobial agents. 58.AnsweT: C. I and II are correct Explanation: The most commonly prescribed oral drug! solutions are syrups and elixirs. Other less commonly prescribed oral solutions include tincture?, aromatic waters, fluidextracts and spirits. 59. Answer: B. HI only is correct Explanation: Because o f the strong hydrogen bonding between sucrose and water, syrup solutions have only limited capability to dissolve water-soluble drugs. Saturated solutions o f syrup arc self preserving and resistant to microbial growth. The dilute solutions, however, are excellent media for microbial growth and therefore, preservatives must be added to them. Under excessive heat, sucrose, a disaccharide, may be hydrolysed into the monosaccharides, glucose and fructose by the process known as inversion o f sugar. But during inversion, the syrup becomes sweeter and more susceptible to microbial growth. 60.Answer: D.85% w/v |

Explanation: The most commonly used syrup is syrulp NF, also known as simple syrup, which is prepared by dissolving 85g of sucrose in enough purified water to make 100ml o f the syrup. Therefore, the percentage o f sugar is 85% w/v. 61 .Answer: C. the alcohol content o f ^alt-containing elixirs should be high Explanation: Elixirs are homogenous, one-phase products, and thus, are solutions. To be an elixir, a solution must contain alcohol, but not all solutions that contain alcohol are elixirs. Elixirs are not suitable for salts since the alcohol in the elixir makes the salty taste very noticeable and since salts have limited solubility in alcohol. Therefore, the alcohol content o f salt-containing elixirs should be as low as possible. 62. Answer: E.water should be added to them before dispensing Explanation:

Spirits, also called essences are alcot olic or hydroalcoholic solutions o f volatile substances that
contain 50-90% alcohol. If water is ai add to spirits, the water-insoluble volatile oils will be separated and they may probably be lost. So it is not a correct procedure to add water before dispensing spirits. 63.Answer: B. glycerin Explanation:

Precipitation o f the inactive constituents o f tincture on aging is one o f the problems that can occur during their storage. Glycerin may be added to prevent the precipitation and to increase the solubility o f the active constituents. 64.Answer: C. I and II are correct Explanation: Tinctures are alcoholic or hydroalcoholic solutions o f chemicals or soluble constituents of vegetable drugs and fluidextracts are liquid extracts o f vegetable drugs that contain alcohol as a solvent or preservative or both. So both preparations contain alcohol. Most tinctures are prepared by an extraction process o f maceration or percolation. Fluidextracts, on the other hand are prepared by percolation so that each milliliter contains the therapeutic constituent o f lg o f the standard drug. Therefore, fluidextracts are more concentrated than tinctures and sometimes tinctures are called 100% tinctures. 65. Answer: C. they can be used to treat wrinkling o f the skin

Explanation: Astringents cause constriction, with wrinkling and blanching o f the skin 66.Answer: D. boric acid Explanation: Calcium hydroxide is a mild astringent that is used in lotions as a reactant and an alkalizer. Aluminum acetate and aluminum subacetate are used as wet dressings in contact dermatitis. 67. Answer: B. calamine lotion

Explanation: Calamine lotion is a preparation o f zinc oxide or zinc carbonate used as a mild astringent on the skin 68. Answer: C. to make the drugs to act faster than if they were prepared as solutions Explanation: Since drugs prepared as suspensions must first dissolve before they are absorbed, they cannot act faster than those prepared in solution form. So suspensions are preferred if sustained action o f drugs is desired. Some drugs are unstable in solutions, so in such cases the suspensions can assure stability. A drug with unpleasant taste can be converted into insoluble form and then prepared as suspension. Since suspensions are liquid dosage forms, they are preferred over the solid dosage form o f the same drug since they are easier to swallow. Sometimes, it is difficult to find suitable solvent to prepare ophthalmic and parenteral solutions; in this case suspensions provide a valuable alternative. 69. Answer: B. they are self preserved so they do not need preservatives Explanation: Hydrocolloids also referred to as hydrophilic colloids, have the ability to form bond with water molecules when they come in contact with water. This limits the mobility and fluidity o f water, as a result o f which the viscosity o f water is increased. With the exception o f methyl cellulose(neutral) and chitosan (cationic), all the other hydrocolloids are negatively charged. This

makes them to be incompatible with positively charged drugs such as quaternary antibacterial agents. Hydrocolloids are good media for microbial growth, thus they necessarily require preservatives. 70. Answer: D. bentonite is more viscous than Veegum at the same concentration Explanation: Since Veegum is hydrated to greater extent than bentonite, it forms more viscous preparation at the same concentration. 71 .Answer: E. all o f the above Explanation: Many drugs have better stability when formulated in the form o f emulsions than solutions. Emulsions provide a way administering oil and other unpleasant drugs in more palatable aqueous preparations. Drugs that have limited water solubility can be incorporated in oil phase o f emulsions where they have better solubility. It is possible to incorporate some drugs into emulsions so that they will have prolonged action such as IM injections. Emulsions may also be used to improve the appearance o f some oily topical preparations. 72.Answer: B. internal phase Explanation: In emulsions, the liquid droplets are called internal, dispersed or discontinuous phase. And the other liquid is called dispersion medium, external phase or continuous phase. 73.Answer: C. 1 and II are correct Explanation: Both, the emulsifying agent used and the relative volumes o f the phases, will determine what the final emulsion type will be, the choice o f an emulsifying agent is more important though.

74.Answer: C. 74% Explanation: Theoretically, an emulsion can be prepared with internal phase o f < 74%. 75. Answer: E. all o f the above

Explanation: In addition to the above mentioned factors, physical properties and electrostatic effect affect the effectiveness o f an emulsifying agents. 76.Answer: A. benzalkonium chloride Explanation: Benzalkonium chloride is a cationic synthetic emulsifying agent. Other natural emulsifying agents include acacia, tragacanth, agar and carboxymethyl cellulose. 77.Answer: C. polyoxyethylene sorbitan moleate

Explanation: Polyoxyethylene sorbitan monooleate [a pol /sorbate (tween 80)], is a nonionic synthetic emulsifying agents. 78.Answer: B.metallic soaps; w/o emulsion Explanation: Metallic soaps are hydrophobic, which makds them suitable for the preparation o f w/o emulsions. Alkali soaps are hydrophilic in nature and th us, are used for the preparation o f o/w emulsions, Polyvalent soaps are suitable for the prepara ion o f w/o type o f emulsions as opposed to monovalent ones, which form o/w emulsion:;. 79.Answer: C.Spans Explanation: Both acacia and tragacanth are natural emuliifying agents that form hydrocolloids when added to water and generally produce o/w emulsions. Tweens and spans, both o f them are nonionic synthetic emulsifying agents. However, tweens (polysorbates) are hydrophilic and have high HLB value as a result o f which they tend to form o/w emulsions. Spans (sorbitan esters) on the other hand, are hydrophobic in nature with 1j w HLB value. This makes them suitable for the preparation o f w/o emulsions. 80. Answer: B. bottle method Explanation; The bottle method, which makes use o f a ca sped container to help prevent the escape o f the volatile oils, is the preferred method o f prepiration o f emulsions if volatile oils are involved. 81 .Answer: A. it is also called continental method Explanation: The second name o f the wet gum method of preparing emulsions is English method. Continental method is the second name for dry gum method. 82. Answer: D. if electrolytes o f high concentration are to be added to the emulsions, they should be added at the very first step Explanation: Since emulsions o f high concentration tend to crack an emulsion, they should be added at their most dilute solution and they should be added at the last step o f preparation. 83.Answer: D. adding acids helps to stabili ze the emulsion formed Explanation: Adding o f acids to the emulsifying soaps is not advisable since it can destroy the emulsifying soap and cause the separation o f the emulsion. 84.Answer: C. the two phases should be cc oled to about 40C before they are combined Explanation:

In preparing emulsions using synthetic emulsifying agents, the two phases, in which the ingredients miscible in each phase are previously mixed, are heated to about 70 -80C . Next they are combined with stirring until the resultant emulsion has cooled. 85.Answer: C. I and II are correct Explanation: Addition o f oleaginous drug to w/o emulsion or water-soluble drug to o/w emulsion is not that much difficult provided there is no problem o f interaction. This is because the miscibility o f the additive with the external phase. On the other hand, addition o f water-soluble drug to w/o emulsion and oil soluble drug to o/w emulsion could prove to be quite difficult. 86. Answer: C. Other than serving as vehicles, they do not have other functions

Explanation: Other than being carriers for medications, ointments can be used for their protective action and as emollients to increase the moisture content o f the skin, and make it soft shiny and pliable. 87. Answer: D. they can incorporate large amount o f water Explanation: Oleaginous bases do not contain water, and only small quantities o f water can be incorporated into them. 88.Answer: E. anhydrous lanolin Explanation: Anhydrous lanolin (also called wool fat) is an absorption base and can absorb twice its weight o f water.

89.

Answer: E. All o f the above

Explanation: A hard rubber spatula should be used when incorporating substances such as iodine and mercuric salts since these substances interact with metal spatula. Water-soluble salts should first be dissolved in small quantities o f water and then the aqueous solution is added to a compatible base. Solvents that can be used in levigation should be such that, after they evaporate the solid will remain as fine powder. Organic solvents such as ether and chloroform however, leave crystallized solids when they evaporate. So they are not suitable as levigating aides. Insoluble substances should first be finely powdered using mortar and spatula and then mixed with equal amount o f base until a smooth, grit-free mixture is obtained. 90. Answer: C. if w/o system is desired, the hot oil phase is incorporated into the hot water with agitation Explanation: I f a w/o system is desired, the hot aqueous phase is incorporated into the hot oil phase with continuous agitation. And if o/w system is required, the hot oil phase is incorporated into the hot Aqueous phase with agitation.

91 .Answer: E. All o f the above Explanation: All o f the above are correct. Suppositories can provide systemic medication only when they are inserted into the rectum. 92.Answer: C. it provides faster drug absorption Explanation: Generally, drug absorption from rectal suppositories is slow and erratic in comparison to oral administration. 93.Answer: A. 2grams Explanation: The weight o f suppositories for adult use weight is about 2g. Those intended for child and infant use are smaller. 94.Answer: E. long and tapered Explanation: Urethral suppositories are long and tapered. Vaginal suppositories are oval shaped and those intended for rectal use are cylindrical and tapered to the point. 95.Answer: A. systemic medication can be achieved by this route Explanation: Although some systemic absorption might occur, the purpose o f administering drugs formulated as vaginal suppositories is to achieve local effect.

96.Answer: B. the suppository base should have a wide melting point range Explanation: Suppository bases should have a sharp melting point or a very narrow melting range. Other criteria include inertness and compatibility with a variety o f drugs; nonirritant and nonsensitizing properties; an acid value o f less than 0.2, a saponification value o f 200-245, and an iodine value o f less than 7 if the base is fatty. 97.Answer: A. water-soluble drug in oil-soluble base Explanation: It is easier for water-soluble drugs in oil-soluble base to leave the oily phase into the aqueous mucosal secretions than oil-soluble drug to leave the oily base into the aqueous mucosal secretion. The rate o f transfer o f water-soluble drug form water-soluble base to aqueous mucosal secretion is also slow as is the transfer o f oil-soluble drug n water-soluble base to the aqueous mucosal secretion. 98.Answer: C.Cocoa butter Explanation:

Explanation:

Cocoa butter (theobroma oil) is the most commonly used suppository base. It is solid up to a temperature o f about 32C. At 32C it starts to soften and melts at 34-35C. 99. Answer: B. rectal suppositories Explanation: Theobroma oil is a good suppository base for the preparation o f rectal suppositories. However, its properties are not ideal for the preparation o f vaginal and urethral suppositories, so it is not frequently used in these two cases. 100. Answer: E. 1. II and III are correct

Explanation: Owing to its triglyceride content, cocoa butter exhibits marked polymorphism. Depending up on the fusion temperature, it can crystallize to any o f the four crystal forms, which have properties that may render them unsuitable as suppository bases. Substances like phenol and chloral hydrate tend to lower the melting point o f the cocoa butter when incorporated into it. Its inability to absorb aqueous solutions is also another major disadvantage o f theobroma oil. 101. Answer: C. it is derived from coconut oil

Explanation: Witepsol bases are not derived form coconut oil. Wecobee bases are the ones which are derived form coconut oil. Witepsol bases contain natural saturated fatty acid chains between C n and C 18. 102. Answer: E. B and C

Explanation: Although they are water soluble, PEGs have very slow dissolution process. Since they form complexes with several drugs, PEGs affect the drug release and absorption profile. It is possible to prepare bases o f different properties from mixture o f PEG polymers o f varying proportions.

103.

Answer: C. fusion method

Explanation: Hand-rolling method involves trituration o f the base and other ingredients until a plastic mass is formed. The plastic is then shaped into a cylinder and the final shaping is done with fingertips. In compression method, forcing the mixture o f suppository base and the medicaments into special molds using suppository-making machines makes suppositories. The most commonly used method for producing suppositories on both small and large scale is the fusion method. It is primarily used for suppositories that contain cocoa butter, PEG, and glycerogelatin base. 104. Answer: A.21.083g

Explanation: To calculate the amount o f cocoa butter required, first determine the total amount o f the active ingredient to be used (in this case 100 x 11 = 11 OOmg). This is divided by the cocoa butter density factor for the active ingredient (1100/1.2 = 916.67mg). This is subtracted from the total amount o f cocoa butter required to make the required number o f suppositories [(2000mg x 11) 916.67mg = 21083.33mg or 21.083g]. ^

105.

Answer: C. mineral oil

Explanation: Lubrication is required for cleaning and easy removal o f the suppositories formed. A thin coating o f mineral oil applied to the molding surface provides sufficient lubrication.

106.

Answer: E. I, II and 111 are correct

Explanation: Special care should be made to prevent the damage o f thermolabile materials and the escape o f volatile materials that could happen during the melting stage. Insoluble powders in the melt may settle or float during pouring depending up on their density. This may result in the collection o f the powder on one side o f the suppository resulting in the non-uniform distribution o f the medicinal agent. 107. Answer: B. they offer great flexibility in compounding

Explanation: Masking o f unpleasant tastes is difficult with powders. Although the preparation process may be time consuming, powders offer a lot o f flexibility in compounding solids. Powders are not suited for dispensing hygroscopic or deliquescent powders. Since individual doses are usually extracted from the powder bulk using spoon, there is a variation in spoon fill, as a result o f which there is less accuracy with powders. Other advantages o f powders include good chemical stability and rapid dispersion o f ingredients because o f small particle size. 108. Answer: B. tumblers

Explanation: Tumblers are not size reduction equipments. They are mixers, which have large containers rotated by motorized process. They are used to mix powders on industrial scale.

109.

Answer: B. pulvrization by intervention

Explanation: Pulverization by intervention involves adding a solvent to the material to be reduced. The material is then pulverized after which the solvent is allowed to evaporate. This method is used to size reduce gummy substances that reagglomerate and resist grinding, such as camphor. Trituration involves reducing the substances by rubbing them in a mortar using pestle. Levigation involves adding a non solvent material to the substance to be reduced to form a paste, which rubbed by using pestle in a mortar. 110. Answer: C. it is a preferred method for the mixing o f powders that contain potent drugs

Explanation: Spatulation is not a suitable method for the mixing o f powders that contain potent drugs since homogeneity may not be achieved with this method.

111.

Answer: A. silicic acid

Explanation: Eutectic mixtures are mixtures that have nelting points lower than any o f the individual ingredient. These substances liquefy whe 1i they come in contact with each other. Examples o f such substances include phenol, camphor thymol, menthol, aspirin, phenacetin, phenylsalicylate etc. Silicic acid is the substance that is us :d to prevent eutexia with aspirin, phenylsalicylate and other substances. 112. Answer: D. trituration

Explanation: Trituration , which involves grinding anc rubbing in a mortar using a pestle, is the method that can be used to mix as well as to commin ite powders. 113. Answer: B. for tirutrating colore i substances

Explanation: Since it is easy to clean a glass mortar, il is preferred when colored materials that can stain porcelain or ceramic surfaces. If both co nminution and mixing are required simultaneously, a porcelain or ceramic surface with rough inner surface is the preferred one. 114. Answer: E. Geometric dilution

Explanation: In this method, the potent drug is mixed with equal amount o f the ingredient second in quantity. Next another amount o f the second ingn|d ien t equal in quantity to the already mixed powders is added and mixed. The process is contim ed in this fashion until all the ingredient powders are added. This way it is possible to achieve uniform mixing o f potent drugs with large quantities o f other ingredients. 115. Answer: C. aerosol

Explanation: Bulk powders, which are to be sprayed >n the skin, are dispensed on aerosol containers, Perforated or sifter can is used for exter lal dusting and wide-mouthed containers are for easy removal o f a spoonful o f powder. 116. Answer: B. skin

Explanation: For a convenient application o f powder^ on the skin, a sifter should be used. 117. Answer: B. are used for oral hygiene

Explanation: Dentifrices, or dental cleansing powder 5 arc used for oral hygiene. Powders are applied into the tooth socket by using insufflators or po vder blowers. The powders that are dissolved in warm water and applied vaginally are called c ouche powders. The powders which are dissolved in water and to be drunk by the patient inc lude antacid and laxative powders.

118.

Answer: C. waxed paper

Explanation: Hygroscopic and volatile drugs can be protected best by using a waxed paper, which is a transparent waterproof paper. This can be double-wrapped with a bond paper (an opaque paper with no moisture resistance) to improve appearance o f the completed powder. 119. Answer: C. type A gelatin is produced by alkaline hydrolysis, while type B is produced by acid hydrolysis Explanation: Type A gelatin is produced by acid hydrolysis, while type B is produced by alkaline hydrolysis.

120.

Answer: D. sulfur dioxide

Explanation: The USP allows the addition o f 0.15% o f sulfur dioxide to prevent decomposition o f gelatin during manufacturing. 121. Answer: B. 12% and 16%

Explanation: Finished capsules normally contain an equilibrium moisture content o f ]2%-16%. This moisture content is critical to the physical properties o f the shells, since at lower moisture content (<12%) the shells become too brittle, and at higher moisture content (>16%) they become too soft. 122. Answer: A. when selecting the size capsule, it should be such that a properly filled capsule should have its body and cap filled with drug mixture Explanation: The cap is not meant to contain powder. Its function is just to enclose the body o f the capsule.

123.

Answer: C. Punch method

Explanation: Capsule or extemporanceously filled by Punch method. 124. Answer: E. B and C

Explanation: As with hard gelatin capsules, soft gelatin capsules are prepared from gelatin shells and it is also possible to add dyes. However, soft gelatin capsules are made plastic or elastic by adding glycerin or a polyhydric alcohol (e.g., sorbitol). Moreover, preservatives (e.g., methyl and propyl parabens, sorbic acid) are added to soft gelatin capsules to prevent the growth o f fungi. 125. Answer: C. emulsions

Explanation;

Since emulsions contain water, it is not possible to incorporate them into soft gelatin capsule because water will be released and affect the soft gelatin shell. Other substances that cannot be incorporated into soft shells include water (and other materials with water content greater than 5%), low molecular weight alcohols and liquids with pH out o f the range 2.5-7.5. 126. Answer: A. disintegration

Explanation: Disintegration tests are not normally required for conventional capsules. But enteric coated capsules need to meet the requirements for enteric coated tablets. 127. Answer: B. fast onset o f action

Explanation: Because oral solid dosage forms have to go through the processes o f disintegration and dissolution before they can be absorbed (processes which are not required in case o f liquid orals), their onset o f action is slower than that o f oral liquids. 128. Answer: D. it is difficult to compress some drugs into tablets

Explanation: Sometimes the chemical and physical properties o f some drugs make it impossible for them to be compressed into tablets and even if they are compressed it becomes difficult to avoid such tablet manufacturing problems as capping, lamination, and picking etc. Otherwise tablets can be massproduced quickly and easily, they enable an accurate administration o f the drugs, they can be tailored to have a control on the release profile o f the drugs from them to meet various pharmacological requirements. 129. Answer: E. it should be white colored Explanation: Tablets do not need to be white colored as long as their color characteristics are acceptable to the patient.

130.

Answer: C. diluents

Explanation: Diluents are fillers, which are added to tablet formulations where the quantity o f the active ingredient is small or difficult to compress. 131. Answer: B. calcium salts form complex with tetracycline that will affect their absorption from the GI tract Explanation: Calcium salts form complex with tetracycline that are not soluble. This will affect the absorption o f tetracycline. For this reason calcium salts are not used as diluents for tetracycline formulation. 132. Answer: A. wet granulation

Explanation:

Since dry granulation and direct compression do not involve the use o f liquids, binders could not be incorporated as solutions in these processes. Instead, they are added as dry powders. In wet granulation, however, they can be added as solutions. 133. Answer: B. all the disintegrants in the formulation should be added to the drug-diluent mixture to make the granules Explanation: Some amount o f the disintegrating agent in the formulation should be added to the drug-diluent mixture before the granules are made.This will promote the disintegration o f the granules formed. The remaining amount o f the disintegrating agent is then added to the formed granules before they are compressed to tablets. And this will promote the disintegration o f the tablets 134. Answer: B. anti adherents; reduce friction between particles

Explanation: The purpose o f adding antiadherents to tablet formulation is to aid in preventing adherence o f tablet material to the surface of dies and punches. 135. Answer: D. chewable tablets

Explanation: Both sweeteners and flavoring agents are usually added to chewable tablets and to those tablets intended to dissolve in the mouth such as buccal or sublingual tablets. Effervescent tablets and lozenges may also contain these additives. 136. Answer: A. sorbitol

Explanation: Adsorbents are substances included in a formulation that are capable o f holding quantities o f water in an apparently dry state. Examples: silicon dioxide, bentonite, kaolin, magnesium oxide, magnesium carbonate, etc.

137.

Answer: E . All o f the above

Explanation: Mannitol and lactose ean be used as both fillers and sweeteners. Talc can be used as lubricant or a glidant. Sorbitol is used as filler or as a binding agent. 138. Answer: A. increasing the rate disintegration and dissolution

Explanation: Although it is possible to modify the drug-release characteristics o f tablets by coating them, coating the tablets cannot increase the actual disintegration and dissolution rates. 139. Answer: B. dry coating

Explanation: In dry coating, also called compression coating, the tablet powder is subjected to more than one compression cycle. That is, a tablet is produced by the first compression; this tablet is then subject

to another compression as a result o f which a multilayered tablet or a tablet-within-a-tablet is formed. This method enables two incompatible drugs to be compressed in one tablet. 140. Answer: D. it produces much thicker and less uniform tablets than sugar coating

Explanation: Compression coating of tablets produce thinner and more uniform coating than sugar-coating. 141. Answer: B. the outer coat tolerates disintegration at the stomach

Explanation: In case o f repeat action tablets, the outer layer should disintegrate rapidly in the stomach, whereas the inner part is insoluble in the stomach but soluble in the intestine. 142. Answer: E. All o f the above

Explanation: Delayed-action or enteric-coated tablets are designed to pass unchanged through the stomach to the intestine, where they are disintegrated and the drugs go to solution. These will help protect drugs that may get degraded by the acidic environment o f the drug. It also protects the stomach from the irritant effect o f some drugs, it is also helpful to enhance absorption of some drugs from the intestine, where the surface area is large for better absorption. 143. Answer: C. titanium oxide

Explanation: Materials used for enteric coating should remain intact in the stomach, but break down readily once the dosage form reaches the small intestine. Such materials include cellulose acetate phthalate, shellac, fats, fatty acids and waxes. Titanium oxide is an inorganic material that is used as colorant and opacifier. 144. Answer: C. to control the release o f drugs from tablets

Explanation: Sugar-coating does not provide the control of the release patterns of drugs from tablets, since once in the stomach the coating will be disintegrated just like the conventional tablets do. 145. Answer: A. seal coating, sub coating, syrup coating, polishing

Explanation: Typical sugar coating process encompasses the following steps in their correct order; sealing (waterproofing), subcoating, syrup coating (coloring and smoothing), and polishing. 146. Answer: C. the esthetic quality sugar coated tablets is not pleasing

Explanation: Sugarcoated products are esthetic,pleasing and have wide consumer acceptability. 147. Answer: D. use o f organic solvents

Explanation:

The major advantages of film-coating o f tablets making a preferred process include substantial decrease in the amount o f coating material applied, faster processing time, improvement in process efficiency and output, resistance to chipping, and a simplified process. The use o f organic solvents, which can be toxic, inflammable and pollutants to the environment, is the one thing that limits film coating o f tablets. Fortunately, aqueous dispersions o f polymers that can be used in film coating are now available as alternatives to the organic solvents. 148. Answer: A. seal coating agent

Explanation: Most coating formulations in sugar coating are aqueous. Therefore, they can disintegrate the tablets is they are used directly. So to avoid this they must first be sealed with a polymer-based coating on the surface o f the tablets. In film coating, however, since the solvents used are organic in nature, they cannot disintegrate the tablets. Therefore, seal coating agent is not required in case o f film coating. 149. Answer: D. B and C

Explanation: Chewable tablets are meant to be chewed, disintegrate, and dissolve in the mouth. But they are finally swallowed and the medication will have either local effect or will be absorbed either from the stomach or from the small intestine. In case o f buccal and sublingual tablets, however, the medication is dissolved in the mouth and absorbed through the oral mucosa. 150. Answer: E. C and D

Explanation: Both buccal and sublingual tablets provide the absorption o f medications through the oral mucosa. This means the medication does not need to go to the stomach (where it is destroyed) ot small intestine (where it has poor absorption) for absorption. Enteric coated tablets may be suitable for those that can be destroyed in the stomach. But it is required that the medication has good absorption from the small intestine 151. Answer: A. chewable tablets

Explanation: Tablets, which are used to prepare solutions are first dissolved in water and then administered. They include effervescent tablets, tablet triturates, hypodermic tablets, and dispensing tablets. Chewable tablets are meant to be chewed in the mouth. 152. Answer: C. picking; adhesion o f tablet material to the die walls

Explanation: In picking, materials come o ff the surface o f tablets and sticks to the punch face. Adherence o f granules to the die walls is called sticking. 153. Answer: C. lamination; excessive moisture content

Explanation; Lamination, like capping, is caused by the entrapment o f air among the powder particles. Excessive moisture content could be the cause for sticking or picking.

154.

Answer: C. friability tester

Explanation; Tablet hardness tester measures the force required to crash a tablet. Disintegration tester measures the time required for a tablet to disintegrate completely. Friability tester (or friabilator)is used to test the ability o f tablets to tolerate abrasion, during packaging, transportation, and handling. 155. Answer: D. tablets that contain 50mg or more o f the drug substance or when the latter comprises 50% or more, o f the dosage form. Explanation: If the tablets contain 50mg or less o f the active ingredient, the USP requires for content uniformity test. 156. Answer: A.intact after 1 hour in simulated gastric fluid and then complete disintegration in 2 hours plus specified time in simulated intestinal fluid. Explanation: Enteric-coated tablets are required to pass the acidic environment o f the stomach intact and disintegrate in the small intestine. The USP specification for the disintegration o f enteric-coated tablets is that it should be intact after 1 hour in simulated gastric fluid and then complete disintegration in 2 hours plus specified time in simulated intestinal fluid. 157. Answer: D. dip tube

Explanation: Actuator is a specially designed button fitted to the valve and opens and closes the valve. The propellant provides the proper pressure within the container and expels the drug solution when the valve is released. The valves control the amount o f solution to be delivered and the dip tube allows the solution to enter from the container.

158.

Answer: D. chlorofluorocarbons (CFCs)

Explanation; Because CFCs were found to deplete the ozone layer, they are no longer in use. 159. Answer: E. I, II and III are correct

Explanation: All the three choices are correct 160. Answer: B. the problem o f dose dumping is avoided in case o f controlled-release dosage forms Explanation: Dose dumping is one o f the major problems associated with controlled-release dosage forms. It is defined as the release o f more than the usual fraction o f drug or the release o f drug at a greater rate than the customary amount o f drug per dosing interval, such that potentially adverse plasma

levels may be reached. This can happen if the design o f the controlled-dosage forms fail, since they contain more than one drug doses than in conventional dosage forms. 161. Answer; D. the other pellets beside those left uncoated should receive equal coating

Explanation; Except for those that are left uncoated, the coating thickness on the pellets should be varied so that to achieve sustained release o f the drug. 162. Answer: E. A, B &C

Explanation: All the states o f matter (i.e., solids, liquids and even gases) can be encapsulated into small microscopic capsules. 163. Answer: B. glycerin

Explanation: . A variety o f synthetic and natural polymers can be used as film-formers or coating materials in the process o f coacervation. These include shellac, cthylcellulose, acacia, gelatin, cellulose acetate phthalate, waxes, etc. Glycerin, however, is not a polymer and thus cannot be used as a coating material. 164. Answer: C. pH

Explanation: The drug release rate from an osmotic system is virtually unaffected by the pH o f the environment and is constant as long as the osmotic gradient remains constant. 165. Answer: C. I, II and III

Explanation: Because the drug-resin complex is solid, they can be formulated as tablets, capsules or suspensions in aqueous vehicles, but they cannot be emulsified.

166.

Answer: C. pH = pKa

Explanation: Buffer capacity depends on the value o f the ratio o f the salt to the acid form. It increases as the ratio approaches unity. Therefore a buffer shows its maximum capacity when its pH is equal to its pKa or when [H30 +] is equal to Ka.

Pharmacodynamics
0 W

Flaming enthusiasm, backed by horse sense and persistence, is the quality that most frequently makes for success. Dale Carnegie

1. Pharmacodynamics is A. The science that examines the interrelationship of the physicochemical properties o f the drug and the route o f administration on the rate and extent o f systemic drug absorption. The scienceo f the kinetics o f drug absorption, distribution and elimination. The part o f pharmacology, which deals with what a drug does to the body The science, which deals with the physicochemical properties o f the drug that allow it to be designed into dosage forms A and B

4. Which o f the following considered as potential receptor? A. B. C. D.

can

be

B.

C.

Only the physiological receptors Only adrenergic receptors Any macromolecular component Only the macromolecular components that can bind to agonists E. Only the macromolecular components that can bind to antagonists

D.

5. Which o f the following types o f drugs binds to a receptor and produce an effect similar to that o f endogenous ligands? A. B. C. D. E. Inverse agonist Agonist partial antagonist competitive antagonist noncompetitive antagonist

E.

2. The analysis o f drug action provides A. The basis for rational design of therapeutic agents. B. Insight into the regulation of cellular function. C. The basis for the rational therapeutic use o f a drug. D. The basis to understand the kinetics o f drug absorption, distribution and elimination. E. All but D

6. Drug 'X 5 binds to drug as a result o f which an inactive complex is formed. This type o f antagonism is called A. B. C. D. E. Competitive antagonism Non-competitive antagonism Physiologic antagonism Neutralizing antagonism Partial antagonism.

3. Which o f the following is MOT true about the actions o f drugs A. They are the consequences o f the dynamic interaction between drug molecules and cellular components B. They lead to the alteration in the function o f the cellular components. C. They eventually form the basis o f the cellular responses to the drugs. D. They can impart a new function to a cell E. None

7. Epinephrine and acetylcholine act on the sympathetic and parasympathetic autonomic nervous system, respectively, and their effects are opposite to each other. This type o f antagonism is called A. B. C. D. E. Competitive antagonism Non-competitive antagonism Physiologic antagonism Neutralizing antagonism Partial antagonism.

8. Antagonists can be

A. Drugs, which cannot bind to receptors and thus are devoid of intrinsic regulatory activity. B. Drugs, which can bind to receptors but are devoid o f intrinsic regulatory activity. C. Drugs, which can bind to receptors but are unable to produce any type effect upon the cells D. Drugs, which may not bind to receptors but are somehow able to cause effects by inhibiting the action o f an agonist. E. B and D

12.The type o f interactions exist when a drug binds to its receptor are: A. B. C. D. E. Covalent bonds Ionic bonds Hydrogen bonds All but A A, B and C

13.Which o f the following is NOT true about structure-activity relationship? A. Both the affinity o f a drug for its receptor and its intrinsic activity are determined by its chemical structure. B. Since relatively minor modifications in the drug molecule may result in major changes in pharmacological properties, it is always advisable not to make any change to the structure o f the drug molecule. C. Minor modifications o f structure also can have profound effects on the pharmacokinetic properties o f drugs D. The type o f interaction and the binding affinity between the drug molecule and the receptor can influence the duration reversibility o f the drug action.

9. Which o f the following is NOT true about competitive antagonism? A. it involves the selective binding of the antagonist to a particular type of receptor in such a way as to prevent the binding of the agonist B. both the agonist and antagonist have similar chemical structure C. it is not reversible D. the antagonist does not have the ability to activate the receptor E. none

10. Chemically receptors could be one of the following EXCEPT A. B. C. D. E. Proteins Glycoproteins Lipids Nucleic acids None

14. Which o f the following is not true about signal transduction by cell-surface receptors? A. Ligand binding is necessary for a signal to be triggered B. Second messengers or effectors are required to propagate signal for one cell to another C. Ligand binding o f receptors may cause the receptor to interact with cytoplasmic effectors D. Integration o f multiple signal transducing events along the receptor-effector system can change the cellular phenotype E. None

11 .Receptors could be present in which of the following locations? A. B. C. D. E. Cell membrane In side the nucleus Nucleus membrane Within the cytoplasm All o f the above

15.Which of the following are true about intracellular receptors? A. they are soluble in the cellular fluid B. they are able to bind to DNA C. they are involved in the transcription of specific genes D. thyroid hormone and steroid hormones act through these receptors E. all o f the above

19. Which o f the following is correct about the quantal dose-response curve? A. It describes the relationship between the number o f patients exhibiting a defined response produced by a specified dose o f a drug. B. Describes the relationship between the magnitude of the effect o f a drug in an individual and the doses o f the drug. C. Describes the relationship between drug effect and log dose response D. It allows to make comparison of the efficacy o f different drugs E. None o f the above

16. Which o f the following are true about Down regulation o f receptors A. It is caused by continuous prolonged exposure o f receptors to agonists that disrupt the homeostatic equilibrium. B. It affects the levels o f receptors C. Can cause the target cells to become desensitized D. The effect o f subsequent exposure to the same concentration o f the drug is reduced E. All o f the above

20

.The relationship between the magnitude o f the effect o f a drug in an individual and the doses o f the drug is best described by A. B. C. D. E. a graded dose-response curve a quantal dose-response curve dose-response relationship frequency distribution curve log dose-response curve

21 .The log dose-response curve 17. Which o f the following statements best describes the word hyperreactivity? A. sudden administration o f high doses o f a drug B. repeated administration o f a drug C. long term exposure followed by abrupt cessation D. gradual increase in the dose E. A and C A. allows for the comparison o f the potency and efficacy among different drugs only if the drugs have the same mechanism o f action B. allows for the comparison o f only the potency o f drugs with the same mechanism of action C. allows for the mechanism o f only the efficacy of drugs with the same mechanism of action D. allows for the comparison o f the potency and efficacy o f different drugs regardless o f the mechanism o f action E. It describes the relationship between the number o f patients exhibiting a defined response produced by a specified dose o f a drug.

18. Which o f the following show colligative drug effects? A. B. C. D. E. antimctabolites anesthetic agents cathartics antacids C and D

2 2

.In the log dose-response curve, the efficacy o f a drug is determined by A. B. C. D. E. by the half the height o f the curve by the height o f the curve by determining ED50 from the curve by determining the 50% o f Emax C and D

26.The relative measure o f the safety and effectiveness o f a drug is the ratio o f TD 50 to ED50. The pharmacological term used to indicate this ratio is known as

23.According to the log dose-response curve, which o f the following is true about efficacy and potency A. the higher the curve, the greater Emax but the lower the efficacy B. the smaller the ED50, the greater potency C. the larger the ED50 , the greater potency D. the lower the curve, the greater Emax but the lower the efficacy E. B and D the the the the

A. B. C. D. E.

pharmacological efficacy pharmacological toxicity ratio therapeutic index median effective ratio median toxic ratio

27.In genera] the therapeutic index will be greater when A. Both TD50 and ED50 are large B. TD50 large but ED50 small C. Both TD50 and ED50 are equal and greater D. ED50 large but TD50 small E. Both TD50 and ED50 are equal and small

24.A physician may prescribe carbidopa along with Levodopa to increase the half life o f levodopa and the duration o f its anti Parkinsonian effect. This way o f enhancing o f drug effect is known as A. B. C. D. E. synergism addition Potentiation partial antagonism competitive antagonism

28. The margin o f safety is the ratio o f A. B. C. D. E. ED 10 to TD90 TD25 to ED75 ED75 to TD25 TD0.1 to ED99.9 ED99.9 to TDO.I

29. Which o f the following are true about alkaloids? A. they are nitrogen-containing compounds obtained primarily from plants B. all o f them are not basic compounds C. they possess pharmacological activity D. colchicines is an alkaloid E. All o f the above

25. When two different drugs with the same effect are given together, producing a drug effect that is greater in magnitude than the sum o f the individual effects o f the two drugs, the phenomena is called A. B. C. D. E. Synergism addition noncompetitive antagonism competitive antagonism potentiation

30.One o f the following natural products is obtained from plant source.

A. B. C. D. E.

somatostatin estradiol digitoxin insulin all o f the above

35. Which o f the following are requirements for a systemically active drug to exhibit its action? A. the drug must pass various membrane barriers B. the drug must be removed from the active site and metabolized to a form that is easily excreted by the body C. the drug must penetrate to the active site D. the drug must interact with the receptor E. all o f the above

31 .Which o f the following statements about peptides and polypeptides is incorrect? A. they are polymers o f amino acids B. they are obtained from either animal or human sources C. they are inactive if administered orally D. they have relatively long half-life E. none

32.The group o f natural products that consist o f a sugar moiety bound to a non sugar (aglycoside) moiety by means o f a glycoside bond is known as A. B. C. D. E. Glycosides polysaccharides vitamin antibiotics hormones

36.Drug absorption, metabolism, utilization, and excretion all depend upon

I . drugs physico chemical properties II. hosts physiological properties III. hosts biochemical properties

33. All o f the following vitamins are water soluble except A. B. C. D. E. thiamine retinol riboflavin niacin biotin

A. B. C. D. E.

I f l only is correct If III only is correct I and II are correct II and III are correct 1,11, and III are correct

37.Which o f the following are true about the physicochemical properties o f drugs? A. polarity and acid-base nature are the most important properties B. drugs polarity is expressed by partition coefficient C. partition coefficient = [drug] lipid / [drug] aqueous D. ionic character and hydrogenbonding capabilities determine water solubility E. all o f the above

34.0ne o f the following synthetic products has a chemical structure closely resembling those o f active natural products. A. B. C. D. E. thiazide diuretics antibacterial sulfonamides Ampicillin phenothiazine antipsychotics barbiturates

38.The water solubility o f a drug is important for which o f the following reasons

A. B. C. D. E.

dissolution in GI tract preparation o f parenteral solutions preparation o f ophthalmic solutions adequate urine concentration all o f the above

A. B. C. D. E.

carboxylic acid group phenolic group sulfonamide acid group imine nitrogens imide group

39.. Lipid solubility o f a drug is important for I. II. III. IV. penetration through the lipid bilayer in the GI tract penetration through the bloodbrain-barrier preparation of IM depot injectable formulations enhanced pulmonary absorption within the respiratory tract la n d II 1 ,11, and III II and III I, II and IV I, II, III, and IV

43. Which o f the following is NOT a strong base? A. B. C. D. E. ammonia magnesium hydroxide quaternary ammonium hydroxides calcium hydroxide A and C

44.Acetic acid has a pKa o f 4.76. At a gastric pH o f 2.1, which o f the following species will be the dominant?

A. B. C. D. E.

I CH3COOH

II CH3COO III H+ A. B. C. D. E. I f l only is correct If III only is correct If I and II are correct If II and III are correct I f 1,11, and III are correct

40.Which o f the following dissociation constants represents a stronger acid?

A. B. C. D. E.

x10 IxlO ' 2 lx l O' 3 IxlO ' 4 IxlO ' 5

45.Which o f the following would be expected to have a best absorption from the stomach? A. B. C. D. E. strong acid strong base weak acid weak base neutral molecule

41.All o f the following are strong acids, EXCEPT A. B. C. D. E. hydrobromic acid sulfuric acid acetic acid iodic acid perchlotric acid

46.All o f the following salts are weak electrolytes EXCEPT A. B. C. D. mercuric halides cadmium halides lead acetate sodium chloride

42. Organic acids contain one or more of the following functional group EXCEPT

E. all o f the above

47.Which o f the following is NOT true about organic salts? A. they are formed by combining drug molecules with small hydrophilic or lipophilic organic compounds B. water-soluble organic salts are used to increase dissolution C. lipid-soluble organic salts are used to enhance bioavailability D. timolol maleate is an example of water-soluble organic salt E. procaine penicillin is an example of lipid-soluble organic salt

A. the lock-and-key theory postulates a completely complementary relationship between the drug molecule and a specific area in the receptor B. the induced-fit theory allows for mutual conformational changes between the drug and its receptor C. occupational theory o f response postulates, for a structurally specific drug, the intensity of the pharmacological effect is directly proportional to the number o f rcceptors occupied by the drug D. according to the induced-fit theory, conformational changes in the receptor molecules are translated into biological responses E. All o f the above

48. Which o f the following are CORRECT about the effect o f dissolution o f salts on the pH o f aqueous medium? A. salts o f strong acids and basic drugs dissociate in aqueous medium to yield an acidic solution B. salts o f strong base and acidic drugs dissociate in aqueous medium to yield alkaline solution C. salts o f weak acids and weak bases dissociate in an aqueous medium to yield neutral solutions D. salts o f weak acids and weak bases dissociate in an aqueous medium to yield acidic or basic solutions
E. all o f th e above

51 .One o f the following statements about the structurally specific agonist is NOT correct

49. Which o f the following are structurally nonspecific drugs? A. B. C. D. E. most general anesthetics some hypnotics some bactericidal A,B and C none

A. The ability o f the drug to bind to a specific receptor is primarily dependent upon the drugs physical properties and chemical structure. B. Often only a critical portion o f the drug molecule (the pharmacophore), rather than the whole molecule, is involved in receptor site binding. C. Drugs with similar critical region but different in other parts show similar qualitative pharmacological activity D. The better the drug fits the receptor site, the greater the observed biological response E. None

52. The isomers, which contain at least one asymmetric, or chiral, carbon atom are called A. geometric isomers B. conformational isomers C. enantiomers

50. Which o f the following are true about receptor site theory?

D. optical isomers E. conformers A. B. C. D. E. I f 1 only is correct If HI only is correct 1 and II are correct 11 and III are correct I,II, and III are correct

53. Which o f the following statements about] enantiomers are true ? A. enantiomers have identical physica and chemical properties B. an equal mixture o f D and enantiomers is optically inactive C. enantiomers can have largo difference in potency, receptor fit ,biological activity, transport an 1 metabolism D. enantiomers are mirror images o f one another. | E. All o f the above

57.Which o f the following are true about characterization o f reversible inhibition o f enzyme activity A. A state o f equilibrium between bound and free drug B. free association and dissociation o f the drug with enzymes C. a stable covalent interaction between the drug and the enzyme D. A and B E. all o f the above

54.One o f the following statements aboju diastereomers are true A. they have different physical a id chemical properties B. they have some stereochemical centers that are opposite and some that are identical C. they are stereoisomers that neither mirror images superimposable D. they have at least two chiral centrt E. All o f the above

58.Inhibition o f nucleotide occurs when there is interference in the biosynthesis of I. II. III. A. B. C. D. E. purine pyrimidine folate

'

I f l only is correct I f III only is correct I and II are correct II and III are correct 1,11, and III are correct

55.Coenzymes can activate enzymes by 59.Which o f the following is a wrong match between a nucleotide and its antagonist? A. B. C. D. E. purine ; 6 -mercaptopurine purine ; thioguanine pyrimidine; 5-flourouracil pyrimidine; trimetrexate none

A. induction o f enzyme synthesis B. allosteric bonding C. complexation D. stereochemical interaction E. C and D

pro|tem

56.Inhibition or decreased enzyme activity can result from drugs that interact with I. apoenzyme 1 1 . coenzyme 60.Drugs that can damage and destroy DNA include

A. intercalating agents B. alkylating agents that inhibit C. compounds topoisomerases D. compounds that produce free radicals E. C and D 61 .Which o f the following act by inhibiting the sodium-potassium pump?

A. B. C. D. E.

digitalis glycosides quinidine local anesthetics omeprazole A and D

ANSWERS Pharmacodynamics

1. Answer: C. The part o f pharmacology, which deals with what a drug does to the body. Explanation: Pharmacodynamics the part o f pharmacology that deals with what the drug does to the body (i.e., it deals with those events that follow the interaction o f the drug with the receptor or other sites of action). It also studies the relation o f the drug concentration or amount at the site o f action (i.e., the receptor) and its pharmacological response as a function o f time.

2. Answer: E. All but D Explanation: Analysis o f drug action does not tell about the kinetics o f its absorption, distribution and elimination. It explains what happens after the drug comes into interaction with the cells. By doing so it provides the basis for both the rational therapeutic use o f drugs and the design o f new agents. It also provides fundamental insight into cellular regulations.

3. Answer: D. Thet can impart a new function to a cell. Explanation: The actions o f drugs result from their interaction with cellular components o f the cells. Such interaction alters the function o f the pertinent components and thereby initiates biochemical and physiological changes that are characteristics o f the response to the drug. But most drugs cannot impart a new function to a cell. They merely modulate ongoing functions (although gene therapy may challenge this principle).

4. Answer: C. Any macromolecular component Explanation: Potentially any functional macromolecular components may serve as a drug receptor. The physiological receptors are a particularly important group o f receptors that normally serve as receptors for endogenous regulatory ligands (e.g., Hormones or neurotransmitters). Adrenergic receptors are examples o f physiological receptors.

5. Answer: B. Agonist. Explanation: Drugs, which produce responses that resemble the effects of the endogenous molecules when they bind to a receptor, are called agonists. For example, bethanechol directly stimulates cholinergic receptors for catecholamines.

Pharm acodynam ics

D. optical isomers

III. whole enzyme complex

. Answer: D. Neutralizing antagonism

Explanation: Neutralizing antagonism occurs when two drugs bind with each other to form an inactive compound.

7. Answer: D. Neutralizing antagonism Explanation: Neutralizing antagonism occurs when two drugs bind with each other to form an inactive compound.

. Answer: E. B and D are true

Explanation: Antagonists are drugs, which can (in case o f partial and physiologic antagonists) or may not (in case o f neutralizing antagonists) bind to the receptors, but are themselves devoid o f intrinsic regulatory activity. However, they are capable o f causing effects by inhibition o f an agonist.

9. Answer: C. it is not reversible Explanation: In competitive antagonism, the two drugs compete with each other since the receptor can bind only one drug molecule at a time. Therefore, at a given agonist concentration, the agonist occupancy will be reduced in the presence o f the antagonist. However, because the two are in competition, raising the agonist concentration can restore the agonist occupancy. So competitive antagonism is a reversible process.

10.Answer: C. Lipids Explanation: Chemically receptors could be proteins, glycoproteins or nucleic acids, but not lipids.

11 .Answer: E. All o f the above Explanation: Receptors could be found embedded at the surface o f the cell and the nucleus membrane. They could also be found within the cell cytoplasm as well as in side the nucleus.

12.Answer: E. A, B and C Explanation: The bindings of drugs to their receptors involve a variety o f interactions, including hydrophobic interactions and Van der Waals forces with ionic, hydrogen and covalent bonds.

13.Answer: B. Since relatively minor modifications in the drug molecule may result in major changes in pharmacological properties, it is always advisable not to make any change to the structure o f the drug molecule. Explanation: It is true that modifications in the drug molecule may result in major changes in pharmacological properties o f the drug, but changes in molecular configuration need not alter all actions and effects o f a drug equally. Therefore, it is sometimes possible to develop a congener with a more favorable ratio o f therapeutic to toxic effect, enhanced selectivity among different tissues or cells, or more acceptable secondary characteristics than those o f the parent drug.

14.Answer: B. Second messengers or effectors are required to propagate signal for one cell to another Explanation: Cell-surface receptors are composed o f extracellular domains that bind the ligands (drugs or physiological molecules). The ligand binding serves as a triggering signal that can be propagated in the target cells through intracellular regulatory molecules, known as second messengers or effectors. Ligand binding o f receptors often leads to interaction o f the receptors with the cytoplasmic effectors, which in turn become activated. Integration o f the multiple signal transducing events along the receptor-effector system might change the cellular phenotype or gene expression, leading to new protein synthesis.

15.

Answer: E. all o f the above

Explanation: Thyroid hormone, steroid hormones, vitamin D, and the retinoid act through binding cytoplasmic receptors, which translocate into the nucleus. These receptors are soluble, DNA-binding proteins that regulate the transcription o f specific genes.

16. Answer: E. All o f the above Explanation: Down regulation o f receptors is caused by continuous prolonged exposure o f receptors to agonists and results in the decreased level o f receptors. The vanishing receptors are taken into the cell by endocytosis. Down regulation causes the target cell to become desensitized and therefore increased concentration o f the drug is required to produce an effect o f the same magnitude as the initial exposure with a smaller drug concentration. Receptor desensitization is an unwanted complication when drugs are used clinically but it can be exploited. Fro example, gonadotrophinreleasing hormone is used to treat endometriosis or prostate cancer, given continuously, this hormone paradoxically inhibits gonadotrophin release (in contrast to the normal stimulatory effect o f the physiological secretion, which is pulsatile).

17.Answer: C. long term exposure followed by abrupt cessation. Explanation: ~

Hyperreactivity or supersensitivity to receptor agonist is expected when target cells are subject to long-term exposure to receptor antagonist followed by abrupt cessation o f the administration of the drug. This can involve up-regulation through synthesis o f new receptors.

18.Answer: E. C and D. Explanation: Colligative drug effects are characterized by a lack o f requirement for highly specific chemical structure. Volatile general anesthetic agents with diverse structures are lipophilic and interact with the lipid bilayer o f cell membranes, resulting in depressed excitability. Cathartics, such as magnesium sulfate and sorbitol act by increasing the osmolarity o f intestinal fluids and thus, changing the distribution o f water.

19. Answer: A. It describes the relationship between the number o f patients exhibiting a defined response produced by a specified dose o f a drug. Explanation: The quantal dose-response curve describes the relationship between the number o f patients exhibiting a defined response produced by a specified dose o f a drug. This relationship often follows a Gaussian distribution and therefore, the majority o f the patients will respond to a specific dose, while a small number o f patients will need a dose greater than this specific dose and some other small number o f them will require a dose smaller than the specific dose for their minimum response.

20.Answer: A. a graded dose-response curve. Explanation: The graded dose-response curve describes the relationship between the magnitude o f the effect of a drug in an individual and the doses o f the drug. In general, a low drug dose produces a small effect and larger doses produce greater effect, until a maximum is reached. It also allows the comparison o f the efficacies and potencies o f different drugs.

21 .Answer: A. allows for the comparison o f the potency and efficacy among different drugs only if the drugs have the same mechanism o f action. Explanation: The log dose-response curve describes the relationship between the drug effects and the log o f the dose. This curve facilitates comparison o f potency and efficacy among different drugs with the same mechanism o f action (and thus they have the same slopes).

22. Answer: B. by the height o f the curvc. Explanation: In the log-dose response curve, efficacy o f a drug is determined by the height o f its curve; the higher the curve for the drug, the greater the Em ax and efficacy. The ED 50 is used to compare the potency o f two drugs. The smaller the ED 50 the greater the potency.

23.Answer: B. the smaller the ED50, the greater the potency. Explanation: According to the log dose-response curve, the efficacy o f a drug is determined by the height o f the curve; the higher the curve, the greater the Emax and efficacy. And the potency o f two drugs can be compared by determining their ED50, which is the dose o f each drug producing 50% o f the corresponding maximum effect. The smaller the ED50, the greater the potency.

24.Answer: C. Potentiation Explanation: Potentiation occurs when one drug, lacking an effect by itself, increases the effect o f another drug that is active. For example, carbidopa is an analogue o f dopa. When carbidopa blocks the degradation o f dopa and is given with dopa, it prolongs the half-life o f dopa and the duration o f the anti-Parkinsonian effect.

25.Answer: A. Synergism Explanation: Examples o f drugs that show such a property are penicillin and gentamycin. These drugs are synergistic in their antipseudomonal activities. Addition occurs when two different drugs with the same effect are given together, resulting in a drug effect equal in magnitude to the sum o f the individual effects o f the two drugs. For example, trimethoprim and sulfamethoxazole inhibit different steps in-the synthesis o f folic acid, resulting in the suppression o f bacterial growth.

26.Answer: C. therapeutic index Explanation: The therapeutic index o f a drug is a relative measure o f the safety and effectiveness in laboratory studies. It is the ration o f the minimum dose that is toxic for 50% o f the population (TD 50 or median toxic dose) to the minimum dose that is effective for 50% o f the population (ED 50 or median effective dose).

27.

Answer: B. TD50 large but ED50 small

Explanation: In general, the grater the TD50 or the smaller the ED50, the greater the therapeutic index, and thus the drug is safer when used at the therapeutic dosage.

28.Answer: D. TD0.1 to ED99.9 Explanation: The margin o f safety is a more practical term to describe the relative safety and effectiveness o f a drug. It is the ratio o f the minimum toxic dose for 0.1% o f the population (TD0.1 or minimal

toxic dose) to the minimum effective dose for 99.9% o f the population (ED99.9 or minimal effective dose).

29. Answer: E. all o f the above Explanation: Alkaloids are nitrogen-containing compounds obtained primarily from plants through extraction and purification, which possess pharmacological activity. The majority o f alkaloids are basic compounds (e.g., morphine and atropine. However, some are neutral amides (e.g., colchicines).

30.Answer: C. digitoxin Explanation: Digitoxin is a glycoside obtained from the plant foxglove. Somastostatin is a 14 amino acid peptide obtained either from animal or human source. Estradiol is a steroid, which is also obtained either from animal or human source. Insulin is a hormone and is obtained through recombinant DNA technology.

31.Answer: D. they have relatively long half-life. Explanation: Peptides and polypeptides are polymers o f amino acids, are obtained from animal or human source and are smaller that proteins. The amino acid distinction between these three classes is vague and often varies from one source to another. Naturally occurring peptides have little to no oral activity and short half-life. Somatostatin, a 14 amino acid peptide; glucagon, a 29 amino acid polypeptide are some examples.

32.Answer: A. Glycosides Explanation: Glycosides are organic substances consisting o f a sugar moiety bound to a non sugar (aglycone) moiety by means o f a glycoside bond (i.e., a bond between the anomeric carbon o f the sugar and a hydroxy group on the aglycone). They can either be plant (e.g., digitoxin) or microbial (e.g., streptomycin, doxorubicin) origin.

33.Answer: B. retinol Explanation: Vitamins are organic substances that are present in foods and are essential to normal metabolism. They can be either water-soluble or lipid-soluble. Water-soluble vitamins include thiamine (B l), riboflavin (B2), niacin (B3), pyridoxin (B6), cyanocobalamin (B12), ascorbic acid (C), folic acid, pantothenic acid, and biotin (H). Lipid soluble vitamins include retinol (A), ergocalciferol (D), atocopherol (E), and phytonadione (K).

34.Answer: C. Ampicillin

Explanation: Ampicillin has a chemical structure, which resembles the naturally occurring antibiotic penicillin. All the others are synthetic products that are completely new obtained by screening synthesized materials for drug activity.

35.Answer: E. all o f the above Explanation: Systemically active drug must enter and be transported by body fluids. It must pass various membrane barriers, escape excessive distribution into sites o f loss, and penetrate to the active site. At the active site, the drug molecule must orient itself and interact with the receptor to alter function. Moreover, the drug must be removed from the active site and metabolized to a form that is easily excreted by the body.

36.Answer: E. I, II, and III are correct Explanation: Drug absorption, metabolism, utilization, and excretion all depend upon the drug's physicochemical properties, and the hosts physiological and biochemical properties. A drugs physicochemical properties can be altered via the synthesis o f chemical analogues, whereas the hosts properties usually cannot be altered.

37.

Answer: E. all o f the above

Explanation: Two o f the most important physicochemical properties o f a drug molecule are its polarity and its acid-base nature. Drug polarity is a relative measure of a drugs lipid and water solubility and is usually expressed in terms o f a partition coefficient. The partition coefficient of a drug is defined, as the ratio o f solubility o f the compound in organic solvent to the solubility o f the same compound is an aqueous environment. Water solubility depends primarily upon ionic character and hydrogen-bonding capabilities.

38.Answer: E. all o f the above Explanation: Water solubility is not required for a drug to bind to plasma proteins. It is lipid solubility is important for a drug to have enhanced plasma protein binding.

39.Answer: E. I, II, III, and IV. Explanation: Lipid solubility is enhanced by nonionizable hydrocarbon chains and ring systems. Lipid solubility is required for penetration through the lipid bilayer in the GI tract, penetration through the blood-brain-barrier, preparation o f IM depot injectable formulations, enhanced pulmonary

absorption within the respiratory tract. It is also important to enhance topical potency (seen with topical glucocorticoids) and to enhance plasma protein binding.

40.Answer: A. IxlO"1 Explanation: Ionization of acids and bases plays a role with substances with dissociate into ions. The ionization constant (Ka) indicates the relative strength o f the acid or base. The larger the value o f Ka, the stronger the acid, and the smaller the value of Ka, the weaker the acid. 41 .Answer: C. acetic acid Explanation: Strong acids are those, which are completely ionized when in solution. Examples o f strong acids include hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, iodic acid, and perchloric acid. Weak acids are those, which ionize only partially. Acetic acid does not ionize completely when in solution, so it is a weak acid.

42.Answer: D. imine nitrogens Explanation: Imine nitrogens are examples o f basic functional groups. Other acidic functional groups include P-carbonyl group, tetrazole ring, and sulfonic acid group.

43.Answer: A. ammonia Explanation: Strong bases, which include sodium hydroxide, magnesium hydroxide, calcium hydroxide, quaternary ammonium hydroxides, potassium hydroxide, and barium hydroxide, are completely ionized when in solution. Almost all other bases, including organic bases are weak (i.e., they ionize partially). Since ammonia ionize only partially it is a weak base.

44.Answer: A. I only is correct Explanation: The ionization of acetic acid takes place as follows; CH 3 COOH = CH3COO' + H + According to Le Chateliers principles, which states that when a stress is applied on an equilibrium reaction, the reaction will move in the direction that tends to relieve the stress, if acetic acid is placed in acidic medium, the equilibrium will shift to the left producing more o f the unionized species. I f acetic acid is placed in alkaline medium, the reverse will happen.

45.Answer: C. weak acid Explanation:

Strong acids and strong bases always exist in ionized form. A weak base exists mainly in ionized form in acidic media, while a weak acid exists mainly in unionized form. A neutral molecule will have ionization that lay between a weak acid and a weak base. Since the unionized form o f a drug is able to cross the lipid cellular membrane, the weak acid will be expected to have a better absorption from the stomach. A weak base is absorbed better from the small intestine, where the pH is alkaline.

46.Answer: D. sodium chloride Explanation: With a few m inor exceptions (mercuric and cadmium halides and lead acetate), all salts are strong electrolytes. .

47.

Answer: C. lipid-soluble organic salts are used to enhance bioavailability

Explanation: Organic salts are made by combining drug molecules with either small, hydrophilic organic compounds (e.g., succinic acid, citric acid) or lipophilic organic compounds (e.g., procaine). Water soluble organic salts are used to increase dissolution and bioavailability, as well as to aid in the preparation o f parenteral and ophthalmic preparations (e.g, timolol maleate). Lipid soluble organic salts are primarily used to make depot injections (e.g., procaine penicillin).

48.Answer: E. all o f the above Explanation: Salts o f strong acids and basic drugs dissociate in aqueous medium to yield an acidic solution.

49.

Answer: D. A,B and C

Explanation: Structurally nonspecific drugs are those for which the drugs interaction with the cell membrane depends more on the drug molecules physical characteristics than on its chemical structure. Usually the interaction is based on the cell membranes lipid nature and the drugs lipid attraction. Most general anesthetics, some hypnotics and some bactericidal agents act through this mechanism.

50. Answer: E. all o f the above Explanation: Receptor-site theory describes the pharmacological activity o f structurally specific drugs. The lock-and-key theory postulates a completely complementary relationship between the drug molecule and a specific area in the receptor molecule (i.e.. the active, catalytic, site). This theory does not account for the conformational changes in either drug or receptor molecules and is an oversimplification o f a complex process. The induced-fit postulates a complementary relationship between the drug molecule and its active site; however, it provides for mutual conformational changes between the drug and its receptor. Conformational changes in the receptor molecules are

then translated into biological responses. This theory explains many more phenomena (e.g., allosteric inhibitors) than the lock-and-key model. The occupational theory o f response further postulates that, for a structurally specific drug, the intensity o f the pharmacological effect is directly proportional to the number of receptors occupied by the drug.

Tl receptor
{Th *!ecir5

{the

Dib 4nt (Tits "key" fits l i t lock*}

51 .Answer: A. The ability o f the drug to bind to a specific receptor is primarily dependent upon the drugs physical properties and chemical structure. Explanation: The ability of a drug to bind to specific receptor, while not independent o f the drugs physical characteristics, is primarily determined by the drugs chemical structure. The drugs chemical reactivity plays an important role, reflected in its bonding ability and in the exactness o f its fit to the receptor.

52.Answer: D. optical isomers Explanation: Stereoisomers can be divided into three main groups, Optical isomers, geometric isomers, and conformational isomers.

Chirality refers to the "handedness" (right or left handed) o f molecules which occur in two forms, mirror images which cannot be superimposed upon each other. Such molecules are called enantiomers (Optical Isomers). Optical isomers contain at least one asymmetric, or chiral, carbon atom (i.e., *a carbon atom that is covalently bonded to four different substitutes).
< COOH

C 'C O O H ">

NH2

- +

.........

ch

3 ")
D-alanine

L-alanine

Conformational isomers, also known as rotamers or conformers, are nonsuperimposable

orientations o f a molecule that results from the rotation atoms around single bonds. Remember that enantiomers are optical isomers that are mirror images o f one another.

*chiral carbon atom in conform ational isom ers.

H CH,

H,
Coafoim&tiosal isom eis; HMeree&rerEti fe ysingle 'bona rot&tians.
H CH 3

c n .fin - r " T ~ H
UCH/ not readily Br
C o afig m atlo aal isom era;

Geometric isomers are (cis-trans isomers) occur as a result o f restricted rotation around a
chemical bond, owing to double bonds or rigid ring system in the molecule.

C'is

Trans

53. Answer: E. all o f the above Explanation:

Enantiomers are optical isomers that are mirror images o f one another. Enantiomers have
identical physical and chemical properties except that one rotates the plane polarized light in a clockwise direction (dextrorotatory, designated D or +) and the other in a counterclockwise direction (levorotatory, designated L or -). Enantiomers can have large differences in potency, receptor fit, biological activity, transport, and metabolism. These differences result when the drug molecule has asymmetric interaction with a receptor, a transport protein, or a metabolizing enzyme.

54. Answer: E. All o f the above Explanation: Diastereomers are stereoisomers, which are neither mirror image nor superimposable.
CHO CHO

H H -

O H OH CHjOH

HOH -

H
OH

ChfeOH
D-Threose

D-Erythrose

A drug must have at lest two chiral centers in order to exist in diasteremers. Unlike enantiomers, in which all stereochemical centers are opposite, diastereomers have some stereochemical centers that are identical and some that are opposite. Diastereomers possess different physicochemical properties and. thus, differ in properties such as solubility, volatility, and melting points. 55.Answer: E. C and D Explanation: Coenzymes play a role in optimizing enzyme activity. They include vitamins (particularly the vitamin B complex) and cofactors (mainly metallic ions such as sodium, potassium, magnesium, calcium, zinc and iron). Coenzymes activate enzymes by complexation and stereochemical interaction. Activation or increased enzyme activity can also result from induction o f enzyme protein synthesis by drugs such as barbiturates, phenytoin and other entiepileptics, rifampin, antihistamines, griseofulvin, and oral contraceptives. Moreover, a drug can enhance enzyme activity by allosteric binding, which triggers a conformational change in the enzyme system and, thus, alters its affinity for substrate binding.

56.Answer: E. I, II, or III Explanation:

A p o en zy m e is th e protein com p on en t o f an en zym e, to w h ich the coen zy m e attaches to form an activ e en zy m e.

Inhibition or decreased enzyme activity can result from drugs that interact with the apoenzyme, the coenzyme, or even the whole enzyme complex. The drug might modify or destroy the apoenzymes protein conformation, react with the coenzyme (thus reducing the enzyme systems capacity to function), or bind with the enzyme complex (rendering it unable to bind with its substrate).

Bound FAD Apoenzyme

.

Enzvme
rf

Substrate

1 C'

57.Answer: D.A and B

Explanation: Reversible inhibition results from a noncovalent interaction between the drug and the enzyme. It is irreversible inhibition that results from stable, covalent interaction between the enzyme and the drug. In this case, the drug is not able to dissociate once it is bound to the enzyme. 58.Answer: C. 1 and II are correct Explanation: Inhibition o f nucleotide biosynthesis occurs when folate, purine, and pyrimidine antimetabolites interfere with the biosynthesis o f purine and pyrimidine building blocks. 59.Answer: D. pyrimidine; trimetrexate Explanation: Trimetrexate (and methotrexate) are folic acid analogues that inhibit the synthesis o f purine and thymidylate by inhibiting the enzyme dihydrofolate reductase. Thioguanine and 6-mercaptopurine are analogues o f purine, which act as antagonists in the synthesis o f purine bases. 5-flourouracil is pyrimidine analogue that inhibit the synthesis o f thymidylic acid by inhibiting the synthesis o f thymidine synthetase. Both, the purine and pyrimidine analogues are not active until they are converted to their respective nucleotide. 60.Answer: E. C and D Explanation: Intercalating and alkylating agents (and antimetabolites) interfere in the in DNA replication and function. Compounds that inhibit topoisomerases and those that produce free radicals, on the other hand are capable o f damage and destroy DNA molecules. 61.Answer: A digitalis glycosides Explanation: Digitalis glycosides inhibit the cell membranes sodium potassium pump, inhibiting the influx of potassium ion and the out flow o f sodium ion. Omeprazole inhibit the hydrogen-potassium pump (located in parietal cell membranes), thus decreasing the efflux o f protons into the stomach.

Sterile Products

E n c o u r a g e d p e o p le a c h ie v e th e b est; d o m in a te d p e o p le a c h ie v e se c o n d b est n e g le c te d p e o p le a c h ie v e th e le a st.

1.

All o f the following dosage forms are sterile products except irrigating solutions ophthalmic preparations parenteral preparations soft gelatin capsules none o f the above

5.

All o f the following are true, except one. Identify the false statement.

A. B. C. D. E.

2.

septic techniques

A. Refer to the methods used for sterilizing B. Refer to the procedures used during preparation that maintain the sterility o f pharmaceutical dosage forms. C. Refer to the procedures used after preparation used to effect sterility to the dosage froms D. Refer to the techniques o f achieving sterility to sterile preparations. E. All o f the above

A. tonicity is directly related to the osmotic pressure exerted by a solution B. adjustment o f the tonicity is particularly important for formulations intended for parenteral routes o f administration C. only isotonic solutions should be injected into the body D. sometimes it is possible to inject hypertonic solutions E. B and D 6. Which o f the following is isotonic with blood 0.9% CaC12 solution 0.45% NaCl solution 0.9% NaCl solution 9% NaCl solution 4.5% KC1 solution

A. B. C. D. E.

3.

Which o f the following is correct about parenteral preparations?

7.

Hypotonic solutions

A. they are injected through one or more layers o f the skin B. they should be absolutely sterile because they bypass the protective barrier o f the body C. their stability is easily affected by the pH o f the solution D. aseptic techniques are required for their preparation E. all o f the above

A. have a greater osmotic pressure than blood B. cause shrinkage o f cells C. cause hemolysis D. can be administered through a large vein E. B and C

8.

Which o f the following is true about hypertonic solutions?

4.

Pyrogens are

A. metabolic products o f live microorganisms B. metabolic products o f dead microorganisms C. cause fever if injected to the body D. A,B&C E. Bacteria

A. they have greater osmotic pressure than the blood B. they should be administered through a large vein so that they will directly go to the lungs C. they should be administered through a large arteries to ensure rapid dilution

D. because they can cause phlebitis, hypertonic solutions should not be administered as such E. all o f the above are true except C

12. HEPA filtered rooms are generally classified as A. B. C. D. E. Federal class Federal class Federal class Federal class Federal class 10,000 1,000 100 100,000 1000,000

9.

Clean rooms are

A. areas specially constructed and maintained for the proper storage o f sterile products B. important for the manufacturing o f sterile drug products C. areas where packaged drug products are sterilized D. are intended to protect the operators from infection E. all o f the above

13. Which of the following is a correct statement about positive-pressure airflow? A. the air pressure inside the clean room should be greater than outside the room B. the positive-pressure airflow system ensures that the air coming to the clean room is filtered C. the air pressure inside the clean room should be less than out side the clean room D. the positive-pressure airflow prevents the exchange o f air between two adjacent rooms E. A and D

10. Which o f the following is not a requirement that has to be met by a clean room? A. B. C. D. HEPA filter Positive-pressure airflow Counters Airflow with uniform velocity along vertical lines E. Walls and floors, which do not have cracks and crevices and have rounded comers

14. The walls and floors o f clean rooms should A. B. C. D. have no cracks or crevices have round comers be nonporous and washable epoxy painting should be used if required E. all o f the above

11. HEPA filters remove all airborne particles, which are A. 3mm or larger with an efficiency o f 99.99% B. 0.3mm or larger with an efficiency o f 99.97% C. between 0.3-3mm with an efficiency o f 99.98% D. 0.3mm or larger with an efficiency o f 99.97% E. 3mm or larger with an efficiency o f 99.97%

15. Which of the following is a correct statement about laminar flow hoods? A. they create an aseptic environment for the preparation o f sterile products B. a class o f 10,000 environment exists inside a certified laminar flow hood

C. they are indispensable components in the manufacture o f sterile pharmaceutical preparations D. unlike the clean rooms, laminar flow hoods do not require HEPA filters E. all of the above

19. Which o f the following methods can be used to achieve sterilization? A. B. C. D. E. Thermal method chemical method radioactive method mechanical method all o f the above

16. Which o f the following is not true about the horizontal laminar flow? A. They were the first hoods to be used by pharmacies for the preparation of sterile pharmaceutical preparations. B. Airflow in horizontal hoods moves across the surface o f the work area C. They do not provide protection to the operator D. Allows for the re-circulation of purified air filtered by HEPA

20. The most widely used and reliable method o f sterilization is A. B. C. D. E. moist heat sterilization radioactive sterilization filtration gas sterilization dry heat sterilization

17. Which o f the following is/are true about vertical laminar flow hoods? A. provide protection to the operator against potential hazards from the products being prepared B. a portion o f the HEPA-filtered air is circulated a second time through the HEPA filter. C. vertical laminar flow hoods protect the operator from chronic, concentrated exposure to hazardous materials. D. Vertical laminar flow hoods requires highly efficient air filters E. All o f the above

2 1 . D uring m oist heat sterilization, the ob jects to be sterilized are exp o sed to saturated steam under pressure at w h ich o f the given b e lo w tem perature and tim e?

A. B. C. D. E.

100 C, 1hour 121 C, 15 minutes I l l C, 30 minutes 160 C, 120 minutes A and D

22. Which method is more suitable to sterilize surfaces and porous materials? A. B. C. D. E. dry heat sterilization moist heat sterilization gas sterilization radioactive sterilization mechanical sterilization

18. Which of the following tests is used to ensure that no particle larger than 0.3 mm passes through the HEPA filters. A. B. C. D. E. particle counter test DOP particle test DOP smoke test Particle size analyzer B and D

23. What is the most commonly used gas for achieving chemical sterilization?

A. B. C. D. E.

carbondioxide oxygen ethylene oxide helium butane

27. Which o f the following is not a reason for reduced popularity o f ampoules as packages o f parenteral preparations? A. it is not suitable for multiple dosing B. the need to filter solutions before use C. once opened, it cannot be resealed with assurance that sterility has been maintained D. inability to maintain sterility until the time of use E. none o f the above.

24. Which of the following sterilizing methods remove rather than destroy microorganisms? A. B. C. D. E. heat sterilization mechanical sterilization radioactive sterilization chemical sterilization A and B

28. Which o f the following is not an advantage o f vials? 25. Which o f the following is not true about the screen (membrane) filters? A. membrane filters are 1-200mm thick films B. they could be made o f stainless steal C. a mesh o f millions o f microcapillary pores o f varying size filter solutions by a process o f physical sieving D. screen filters have a higher flow rate than depth filters. E. They could be used to filter particles as well as microbes A. can hold multiple doses B. drug product is easier to remove from vials C. no risk o f glass particle contamination during opening D. allow for the packaging of drugs unstable in solution as un reconstituted powders which can be reconstituted with a diluent before use. E. Vials avoid the risk of contamination from multiple withdrawals.

26. Which o f the following is not the function o f particulate filters? A. Remove particles o f glass, particles, rubber and other contaminants B. reduce the risk o f phlebitis associated with the administration o f reconstituted powders C. ensures complete microbial removal D. could be used as in-line filter to remove particulates or microorganisms from an intravenous solution during infusion. E. all o f the above

29. One o f the most commonly used drug diluents for reconstitution o f solid drugs packaged in vials is. A. B. C. D. E. Sterile water for injection Sterile sodium chloride for injection potassium chloride for injection A and B All o f the above

30. Which o f the following reduces the risk of microbial contamination by eliminating the need to enter the vial twice?

A. B. C. D. E.

ampules using lyophilized powders prefilled syringes double chamber vials infusion solutions

35. What are the common materials used for packaging parenteral products? A. B. C. D. E. glass plastic polymers rubbers stainless steel A and B

31. What is the system in which the drugs come in vials that may be attached to an IV bag for reconstitution and administration? A. B. C. D. E. double chamber vial ADD-vantage Prefilled cartridges Monovial safety guard system Single-dose plastic bags for IV infusion

36. Which o f the following is not one o f the advantages plastic polymers provide over glasses when used as parenteral packages? A. B. C. D. E. durability easier storage and disposal reduced weight improved safety less interaction with the parenteral preparation

32. Prefilled syringes are designed for A. emergency cases B. eliminating the need to enter the vial twice C. for intermittent infusion o f fluids or drugs D. multiple dosage

37. The route o f administration o f Insulin is A. B. C. D. E. intramuscular subcutaneous intradermal IV None

33. Narcotics (eg, morphine, meperidine) are commonly available in A. B. C. D. E. ampules infusiom solutions prefilled cartridge prefilled syringe double chamber vials

38. What is the maximum volume o f a solution that can be administered via the intramuscular route? A. B. C. D. E. 5ml 2.5ml 1ml 10ml 3ml

34. Small volume parenterals are those having a volume A. B. C. D. E. less less less less less than than than than than Hit. 500ml 250ml 100ml 75ml

39. What is the most common and most important parenteral administration route? A. intramuscular B. IV C. Intracardial

D. Intrathecal E. Intraspinal 44. The route o f parenteral drug administration into a joint space is called A. B. C. D. intrasynovial intrathecal intra-articular intrarterial

40. What is the special feature o f IV route o f administration? A. it can be used for delayed absorption B. it can deliver drugs directly to the heart C. it allows an immediate therapeutic effect by delivering the drug directly into the circulation D. it can be used to do skin tests E. None o f the above

45. Which route o f administration is frequently used during childbirth? A. B. C. D. E. epidural hypodermoclysis intraspinal intrathecal IV

41. Which o f the routes o f parenteral administration is suitable for skin tests? A. B. C. D. subcutaneous intramuscular intradermal IV

46. Which o f the following is not correct about the IV admixtures? A. these preparations consist o f only one sterile drug product added to an IV fluid B. they are suitable for drugs intended for continuous infusion C. drugs that may cause irritation or toxicity when given as a rapid direct IV injection are prepared as IV admixtures D. usually dextrose or sodium chloride solution alone or in combination are the IV fluids o f choice when preparing IV admixtures E. IV admixtures can be administered for longer time than IV injections

42. Which o f the following is not true about the intra-arterial route o f administration? A. it involves injection directly into an artery B. it is possible to deliver a high drug concentration to the target organ C. generally it is used for radioopaque materials, thrombolytic agents and some antineoplastic agents D. it is suitable for drugs intended for prolonged or delayed absorption E. none o f the above

43. Local anesthetics are frequently administered via which route during surgical procedures. A. B. C. D. subcutaneous IM IV Intrathecal

47. Which o f the following fluids used in preparation and administration o f parenteral products: A. B. C. D. sterile sodium chloride sterile water Ringer's solution dextrose solutions

48. Which o f the following is/are the uses o f IV fluids? A. Useful as vehicles in IV admixtures B. Used as a basis for correcting body fluid disturbances C. provide a caloric source in parenteral nutrition D. in adjusting electrolyte imbalance E. All o f the above 49. In what percentage is the dextrose solution used as vehicle in IV admixture? A. B. C. D. E. 10% 5% 7.5% 2.5% 1%

B. C. D. E.

25% 50% 15% 20%

53. What solution o f sodium chloride is termed as half-normal saline A. B. C. D. E. 0.9% 9% 18% 0.45% 4.5%

54. Which o f the following is/are the use/s o f bacteriostatic sodium chloride for injection? A. vehicle in IV admixture B. fluid and electrolyte replacement C. multiple reconstitution o f various medications D. parenteral nutrition E. all o f the above

50. Dextrose solution should be used cautiously in patients with A. B. C. D. E. arthritis hypertension diabetes mellitus malaria chronic asthma 55. Which o f the following is not true about the Ringers solution? A. they are appropriate for fluid and electrolyte replacement B. they are commonly administered to post-surgical patients C. they are often used combined with dextrose D. the absence o f sodium lactate from Ringers solution is the only difference between lactated Ringers solution and Ringers solution E. It contains sodium, potassium and calcium chlorides

51. Instability could be a problem if the drug combined with the D5W is A. B. C. D. E. water soluble sensitive to alkaline condition acid-sensitive light sensitive an antibiotic

52. What is the limit o f Dextrose concentration beyond which it must be administered through a central vein. A. 10%

56. The main extracellular cation in the body is A. B. C. D. calcium potassium sodium magnesium

D. magnesium phosphate 57. Which o f the following is NOT one o f the functions o f sodium? A. involved in the nerve-impulse transmission B. plays key role in interstitial osmotic pressure C. has important role in acid-base balance D. is important in protein synthesis E. has influence over tissue hydration

62. The major extracellular anion is A. B. C. D. chloride phosphate sulfate acetate

63. Which o f the following does not help in controlling the pH o f blood? A. B. C. D. E. chloride phosphate acetate sulfate none.

58. Which o f the following cations participates in protein synthesis? A. B. C. D. E. sodium calcium Potassium magnesium ammonium

64. Parenteral antibiotic preparations can be given in the following routes o f administration except: A. B. C. D. E. IV injection Short-term infusion IM injection Intrathecal injection Subcutaneous injection

59. Which o f the following cations is involved in muscle contraction or excitability? A. B. C. D. E. sodium potassium calcium magnesium all o f the above

65. What are the conditions in which parenteral antibiotics are used? A. when high antibiotic blood level are required B. when physicochemical properties of the drug do not allow the other routes o f administration C. when the GIT is contraindicated D. when the infection is serious E. all o f the above

60. Which o f the following is NOT a common parenteral calcium preparation? A. B. C. D. calcium calcium calcium calcium chloride gluconate gluceptate acetate

61. Parenterally magnesium is given as A. magnesium chloride B. magnesium sulfate C. magnesium gluconate

66. Which o f the following affect the dosing frequencies o f parenteral antibiotic preparations except

B. C. D. E.

seriousness o f the infection the site o f infection the patients disease state all of the above

67. Which of the following is not correct about the safe antineoplastic handling guidelines? A. A horizontal laminar flow hood should be used during drug preparation with exhaust directed to the outside B. All syringes and IV tubing should have Luer-Lok fittings C. Special care should be taken when IV administration sets are primed D. Final dosage adjustment should be made into the vial, ampule, directly into an absorbing gauze pad E. Negative pressure technique should be used during withdrawl of medication from vials.

B. Negative pressure technique should be used C. The pressure inside and outside the vial should be made equal D. Pressure is o f little importance E. No need to take care o f pressure inside the bottle

70. Which o f the following are the proper procedure for disposal o f materials used in the preparation and administration of antineoplastic? A. Needles should not be clipped or recapped B. Preparations should be discarded in containers that are puncture-proof, leak-proof, and properly labeled C. Hazardous waste may be incinerated at high temperature D. Hazardous waste may be buried in an EPA-licensed hazardous waste dump or chemically deactivated. E. All o f the above

68. Which o f the following is NOT a correct way o f priming IV administration sets o f antineoplastic agents? A. IV tubing can be primed before adding the drug B. It is possible to prime the IV tubing while adding the drug C. The tubing can be primed with drugfree fluid before connecting it to the chemotherapy drug contained D. The tubing can be primed into sterile gauze in a sealable plastic bag E. None o f the above

71. Which is not TRUE about the personnel involved in the preparation and administration of antineoplastic agents A. Wear closed-front cuffed surgical gowns B. Use double layered latex surgeons gloves C. not wash the hands thoroughly after removal o f the gloves D. Should be monitored routinely E. Should receive special training

69. During the withdrawal o f antineoplastic agents from vials, A. Positive pressure technique should be used

72. Which of the following is not true about infusion phlebitis? A. It is a serious problem that occurs during the administration of parenteral antineoplatics.

B. It is characterized by pain, swelling, heat sensation and redness at the infusion site C. It is inflammation o f the arteries D. It is possible to eliminate or minimize the risk o f phlebitis by diluting and filtration of the drug E. None o f the above

73. Which o f the following are the measures that should be taken immediately if extravasation occurs A. Stopping the infusion. B. Injecting hydrocortisone or another anti-inflammatory agent directly into the affected area C. Applying a cold compress D. Finally, after doing all the above mentioned steps, it is possible to apply warm press to increase the blood flow. E. All o f the above

they need not be manufactured by the same standards to process IV preparations. B. According to USP the container design for the irrigating solutions and injections is different. C. Irrigating solutions for topical use should be packaged in pour bottles D. Irrigating solutions for topical use are intended for such purposes as irrigating the wounds, moistening dressing, and cleaning surgical instruments.

76. Which o f the following is not true about infusion o f an irrigating solution? A. Is commonly used for many surgical patients. B. Is used to perfuse tissues in order to maintain the integrity o f surgical filed during urological procedure. C. Help to produce a clear field o f view during urological procedure D. Can be made to have less risk o f infection by adding a suitable antibiotic preparation E. Is helpful in correcting electrolyte disturbances

74. Which o f the following is not true about the parenteral biotechnology products? A. Many o f them require reconstitution with sterile water or normal saline B. They could be only administered parenterally by direct IV injection or infusion C. They must not be shaken vigorously to avoid destroying the protein molecules D. They require special storage such as refrigeration or freezing E. None

77. In peritoneal dialysis,which o f the following is true? A. a hypotonic dialysate is infused directly into the peritoneal cavity B. a dialysate, which contains dextrose and electrolytes, removes harmful substances by chemically reacting with them C. after some period o f time, the solution is drained from the body D. addition o f drugs such as antibiotics is not advisable E. all o f the above

75. Which o f the following statements about irrigating solutions is not true? A. Since they are not intended for infusion into the venous system,

78. In hemodialysis

A. the irrigating solution is directly injected into the patients blood B. the patients blood is transfused through a dialyzing membrane C. the dialyzing membrane unit removes harmful substances from the patients vascular system D. after passing through the dialyzer, the blood reenters the body through an artery E. B and C

D. Compounding parenterals E. IV infusion

83. What types o f needles are used when only shallow penetration is required? A. B. C. D. regular-bevel needles intradermal-bevel needles short-bevel needles long-bevel needles

79. Hypodermic needles can be made using A. B. C. D. E. copper stainless-steel aluminum silver B and C

84. Short needle lengths o f about % inch to 5/8 inch are suitable for A. compounding parenteral preparations B. intradermal and subcutaneous injections C. intrathecal injections D. IV injections E. Intraspinal injections

80. Subcutaneous injections usually require a needle fo which gauge size? A. B. C. D. E. 24-gauge 12-gauge 20-gauge 15-gauge 18-gauge

85. Which of the following needle lengths are suitable for IV infusion? A. B. C. D. 1 Vi inch-long needles 3 Vi inch-long needles 2 inch-long needles 4 inch-long needles

81. Which o f the following is a suitable needle for intramuscular injection? A. B. C. D. E. a needle a needle a needle a needle a needle o f 24-gauge o f 20-gauge o f 17-gauge o f 13-gauge o f 27-gauge

86. What length o f the needles should be used for intracardiac injection? A. B. C. D. 2 inch-long needles 3 '/ 2 inch-long needles 1.25 inch-long needles 2.5 inch-long needles

87. Which o f the following is not a true statement about syringes? 82. Needles between 18 and 20 gauge are commonly used for A. IV injection B. Intraderma) injection C. Intrathecal injection A. They are devices used for withdrawing or instilling fluids. B. They have a small opening at one end to accommodate the head o f a needle

C. They cannot be used to inject fluids D. They are made o f either glass or plastic E. There are different sizes o f syringes

88. Syringes can have a maximum volume o f A. B. C. D. E. 40ml 50ml 60ml 70ml 80ml

A. it is suitable for drugs that do not irritate the veins B. it is a preferred injection site for administration o f isotonic solution C. the dorsal forearm surface is chosen for venipuncture D. commonly employed for long-term IV therapy E. commonly employed for short-term IV therapy 93. Which o f the following is suitable for central vein injection? A. B. C. D. E. subclavian vein splenic vein median cubital vein pulmonary vein all o f the above

89. Which o f the following syringe tips should be used when administering antineoplastic agents? A. B. C. D. E. catheter tips eccentric tips luer-slip tips luer-lok tips B and D

94. Which o f the following is not true about continuous-drip infusion? A. it is suitable for drugs with a narrow therapeutic index B. not useful for fluid and electrolyte replacement C. it is a slow, primary-line infusion o f an IV preparation D. careful control o f the flow rate is very important E. All o f the above

90. Which o f the following syringe tips is designed to minimize venous irritation? A. B. C. D. catheter tips eccentric tips luer-slip tips luer-lok tips

91. Which o f the following is not true about catheter tips? A. they are used for wound irrigation B. they are not intended for injections C. they can be used to administer enteral feedings D. they help reduce venous irritation E. all o f the above

95. Which o f the following are true about direct (bolus) injection A. it is used when a rapid delivery o f small volumes o f drugs is required B. an immediate effect is achieved by this technique C. this technique is suitable for drugs that cannot be diluted D. in this technique the therapeutic drug level is achieved quickly E. all o f the above

92. Which o f the following is not true about the peripheral vein injection?

96. Which o f the following is appropriate for the intermittent delivery of small amounts o f IV solutions or diluted medications? A. direct injection B. piggyback method C. continuous-drip infusion D. additive set infusion E. B and C

B. C. D. E.

syringe pumps mobile infusion pump implantable pumps none o f the above

100. Which o f the following pump types should be used if the medication is to administered in concentrated form? A. B. C. D. E. volumetric pumps syringe pumps mobile infusion pump patient-controlled pumps none o f the above

97. All the following are advantages o f intermittent infusion injection devices EXCEPT A. these devices permit intermittent delivery while eliminating the need for multiple venipuncture B. they allow for prolonged venous access with a continuous infusion C. they are suitable for patients who do not require, or would be jeopardized by, administration of large amounts o f IV fluids D. they permit greater patient ambulation E. they avoid the use of heparin solution

Which o f the following 101 . pumps is designed for ambulatory and home patients? A. B. C. D. E. volumetric pumps syringe pump mobile infusion pumps implantable pumps patient-controlled analgesic pumps

102. 98. In a situation when the use of gravity flow alone might lead to inaccurate dosing or risk patient safety, which IV infusion method should be used? continuous-drip infusion direct (bolus) injection additive set infusion intermittent infusion injection devices E. pumps and controllers A. B. C. D.

Implantable pumps are

A. used for intermittent infusion B. useful for administering concentrated medications C. allow for administration o f drugs on patient demand D. are surgically placed under the skin to provide a continuous release o f medication E. A and D

99. Which type o f pump is suitable for intermittent infusion of medications such as antibiotics as well as for continuous infusion o f IV fluids? . volumetric pumps Al

103. Which o f the following is true about the patient-controlled analgesic pumps? A. they are used to administer narcotics intermittently or on demand by the patient

B. the narcotics are administered by programming the pump within the patient-specific parameters C. there is need to involve the physician D. A and C E. A?B and C

D. Insoluble complex formation between calcium and tetracycline E. none

107. All o f the following statements about chemical incompatibility are true except A. some chemical incompatibilities are not visible B. oxidation and reduction o f drugs are examples o f chemical incompatibilities C. giving penicillin G after tetracycline is an example o f chemical incompatibility D. photolysis can lead to chemical incompatibility E. chemical incompatibility may result in therapeutic inactivity

104. Which o f the following is not a characteristic o f controllers? A. unlike pumps, they exert no pressure on the IV fluid B. they are more complex and generally more expensive than pumps C. they are able to achieve reasonable accuracy D. they cannot be used for arterial drug infusion or for infusion into small veins E. All o f the above

105.

Chemical incompatibilities

108. Which o f the following does not increase the probability o f incompatibility? A. wide variation in pH between two components B. increased storage temperature C. higher degree o f dilution o f the solutions D. longer time in solution E. none

A. occur when a drug combination produces a visible change in the appearance o f a solution B. reflect the chemical degradation o f one or more o f the admixed drugs, resulting in toxicity or therapeutic inactivity C. occurs when two or more drugs, IV fluids, or both are combined and the result is a response other than intended D. A and C E. none

109. Which o f the following help to prevent or minimize incompatibility A. mixing each drug thoroughly after it is added to the preparation B. administering solutions immediately after they are mixed/prepared C. keeping the number o f drugs combined to the minimum D. consulting compatibility reference E. all o f the above

106. Which o f the following is not a physical incompatibility? A. evolution o f carbon dioxide when sodium bicarbonate and hydrochloric acid are admixed B. visible color change C. formation o f precipitate

110. Which o f the following statements is not true about phlebitis? A. it is a major complication among the physical hazards o f parenteral drug therapy. B. It may result from vein injury or irritation C. It is possible to minimize or prevent phlebitis D. Heat sensitization and redness at the infusion site are the major symptoms E. All o f the above

114. Embolism is likely to happen with all o f the following except A. entry o f air into the IV tubing B. central catheter misplacement C. particulate matter that could be present in the parenteral product D. infusion pump failure E. none

115. Gasping syndrome can be caused by A. rubber vial closures that may interact with the enclosed drug B. air embolism that may result from entry o f air into the IV tubing C. some preservatives included in the drug preparation D. particulate matter that may be present in the parenteral product E. A and D

111. Which o f the following hazards o f parenteral drug therapy could be reduced by diluting the drug to be administered? A. B. C. D. E. extravasation pain irritation allergic reaction A and B

116. Which o f the following tests are done to control the quality of sterile products? I. sterility testing II. pryrogen testing III. larity testing A. B. C. D. E. I only II only I and II only II and III only I, II and III

112. to A. B. C. D. E.

Cold IV infusion could lead

phlebitis extravasation air embolism hypothermia allergic reactions

113. Neurotoxicity may be a serious complication in case o f A. B. C. D. E. IV administration Intrathecal administration Intracardiac administration Intrasynovial administration Intraarterial administration 117. All o f the following are true about the sterility testing except A. sterility testing ensures that the process used to sterilize the product was successful B. the official USP standard for testing sterility requires a 10-test samples to be taken for batches o f 20-200 units

c . the official USP standard for testing

sterility requires a minimum o f 5test samples to be taken for batches less than 20 units D. the membrane sterilization method is often used to conduct sterility testing E. none

121 . Which o f the following documentations are required by various agencies and organizations A. training procedures B. laminar flow hood certification C. production records D. Quality control results E. All o f the above

118. In vitro limulus lysate testing refers to A. sterility testing B. pyrogen test C. clarity test D. acidity test E. bioavailability test

119. The single most important aspect o f an effective quality assurance program is A. training o f pharmacists and technicians B. monitoring the manufacturing process C. quality control check D. documentation E. all 120. Which o f the following is/are correct about process simulation testing? I. it duplicates the sterile product production using an appropriate growth media in place o f drug II. it is used to evaluate aseptic techniques III. used to test the sterility o f the product prepared A. B. C. D. E. I only is correct Ill only I and II are correct II and III are correct I,II and III are correct

Answers Sterile Products

1. Answer: D. Soft gelatin capsules. Explanation: Sterile products are pharmaceutical dosage forms that are sterile. They include parenteral preparations, irrigating solutions, and ophthalmic solutions.

2. Answer: B. Refer to the procedures used during preparation that maintain the sterility o f pharmaceutical dosage forms. Explanation: Aseptic techniques are those methods and procedures that will make sure that the pharmaceutical dosage form prepared is sterile.

3. Answer: E. All o f the above Explanation: Because they bypass the protective barrier o f the body, parenteral preparations should be sterile. But absolute sterility, where there are no any living microorganisms is not practical. So always a maximum limit is given to the presence o f microorganisms in the parenteral preparations.

4. Answer: D. A,B&C Explanation: Pyrogens are metabolic products of live or dead microorganisms that cause fever upon injection into the body.

5. Answer: C. only isotonic solutions should be injected into the body. Explanation: It is always desirable and advantageous if solutions to be injected are isotonic. But incase this is not possible, hypertonic solutions could also be injected to the body through large vein so that there would be rapid dilution and phlebitis could be avoided.

6. Answer: C. 0.9% NaCl solution. Explanation: Isotonic solutions are those which exert the same osmotic pressure as blood. O f the above 0.9% NaCl solution is isotonic with blood.

7. Answer: C. cause hemolysis. Explanation: Hypotonic solutions are those having osmotic pressure lower than the blood. These solutions if injected into the body cause cells to expand, and this can lead to hemolysis and pain. So they should not be administered before proper adjustment is made. 8. Answer: A. they have greater osmotic pressure than the blood. Explanation: Hypertonic solutions are those which exert greater osmotic pressure than the blood. These solutions are administered through a large vein, either the subclavian or internal jugular vein to avoid phlebitis and ensure rapid dilution.

9. Answer: B. important for the manufacturing o f sterile drug products Explanation: Clean rooms are areas specially constructed and maintained to reduce the probability o f environmental contamination o f sterile products during the manufacturing process.

10.Answer: D. Airflow with uniform velocity along vertical lines. Explanation: In clean rooms the airflow should move with a uniform velocity along parallel lines. The velocity of the airflow is 90 feet per minute.

11 .Answer: B. 0.3mm or larger with an efficiency o f 99.97%. Explanation: HEPA filters are used to cleanse the air entering the rooms. They remove all airborne particles, which are 0.3mm or larger, with an efficiency o f 99.97%.

12.Answer: A. Federal class 10,000. Explanation: HEPA filtered rooms are generally classified as federal class 10,000, which means that they contain no more than 10,000 particles o f 0.5mm or larger per cubic foot o f air.

13. room.

Answer: A. the air pressure inside the clean room should be greater than out side the clean

Explanation: Positive-pressure flow is used to prevent air from flowing into the clean room. The air pressure inside the clean rooms is greater than the pressure outside the room. This ensures that the airflow would be outward when a door to the clean room is opened. ~

14.Answer: E. all the above. Explanation: In order to avoid any place or space that might allow the development o f infectious microorganisms, the walls and floors o f a clean room must have all the above mentioned characteristics.

15. Answer: A. they create an aseptic environment for the preparation o f sterile products. Explanation: Laminar flow hoods are clean-room work benches specially designed to create aseptic environment for the preparation o f sterile products. A class 100 environment exists inside a certified horizontal or vertical laminar airflow hood. Laminar flow hoods are used in the manufacture o f sterile products if the manufacturing plants do not have clean rooms. They can also be used in conjunction with clean rooms. The HEPA filters used in laminar flow hoods are o f higher efficiency air filters than that o f clean rooms.

16. Answer: D. Allows for the re-circulation o f purified air filtered by HEPA. Explanation: Horizontal laminar flow does not allow for the re-circulation o f the filtered air. All the air filtered by the HEPA goes to the exhaust after use.

17. Answer: E. All o f the above. Explanation: In vertical laminar airflow hoods, the airflow is vertical, flowing down on the workspace. This airflow pattern protects the operator against potential hazards from the products being prepared. Moreover, a portion o f the HEPA-filtered air circulated a second time through the HEPA filter. Just like the horizontal hoods, the vertical flow laminar hoods use a high efficiency air filter.

18. Answer: C. DOP smoke test Explanation: The dioctyl phthalate (DOP) test ensures that no particle larger than 0.3mm passes through the HEPA filter. Particle counter is used to determine the particle count. In addition, an anemometer is used to determine airflow velocity.

19. Answer: E. all o f the above Explanation: All the above mentioned methods can be used to achieve sterilization.

Explanation: Moist heat sterilization is the most commonl) used and reliable method o f sterilization. Here the microorganisms are destroyed by cellular protein coagulation and is commonly achieved by using the autoclave.

21.Answer: B. 121 0C, 15 minutes. Explanation: Autoclave is the instrument most commonly used to achieve moist heat sterilization. Here the objects to be sterilized are exposed to saturai ed steam under pressure at a minimum temperature o f 121 C for at least 15 minutes. Because he temperature required is not as high as that o f dry heat sterilization, moist heat sterilization causes less product and equipment damage

22.Answer: C. gas sterilization. _Explanation: Chemical or gas sterilization is used to sterilize surfaces and porous materials (e.g., surgical dressings) that other sterilization methods may damage.

23.Answer: C. ethylene oxide. Explanation:

Ethylene oxide is the-gas most commonly used to achieve chemical sterilization.

24.Answer: B. mechanical sterilization. Explanation: Mechanical sterilization or filtration remoj/es but does not destroy microorganisms and clarifies solutions by eliminating particulate mattei . For solutions rendered unstable by thermal, chemical, or radiation sterilization, filtration is prefe rred method.

25. Answer: C. a mesh of millions o f microcapilarry pores o f varying size filter solutions by a process o f physical sieving Explanation:

Membrane filters are 1-200 mm thick films which can be made from cellulose esters,
microfilaments, polycarbonate, synthetic polymers, silver or stainless steel. The microcapillary pores should be identical size. Because pores make up 70-80% o f the surface, screen filters have a higher flow rate than depth filters.

26.Answer: C. ensures complete microbial removal. Explanation:

Screen filters could be particulate filters, microbial filters, or final filters. The functions of particulate filters include all of the above except that it cannot ensure the complete microbial removal. This is the function o f the microbial filters.

27. Answer: D. inability to maintain sterility until the time o f use. Explanation: Ampoules are the oldest type of parenteral product containers. They are made of glass and are opened by breaking the glass at a score line on the neck. This can lead to dislodging o f some glass particles, and thus the product must be filtered before it is administered. Ampoules are intended for single use only but it is able to maintain sterility until it is opened.

28.Answer: E. Vials avoid the risk o f contamination from multiple withdrawals. Explanation: Vials are glass or plastic containers closed with a rubber stopper and sealed with an aluminum crimp. With vials, there is always risk o f microbial contamination as a result o f multiple withdrawal. The rubber stopper can also become cored, causing a small bit o f rubber to enter the solution.

29.Answer: D. A and B.

Explanation: Sterile water for injection or sterile sodium chloride for injection are the most commonly used drug diluents.

30.Answer: D. double chamber vials. Explanation: A double chamber vial eliminates the need to enter the vial twice, thereby reducing the risk of microbial contamination. In this system, the top chamber, containing sterile water for injection, is separated from the unreconstituted drug by rubber closure. To dislodge the inner closure and mix the contents o f the compartment, external pressure is applied to the outer rubber closure.

3] .Answer: B. ADD-vantage. Explanation: In ADD-vantage system the vial containing the drug is screwed into the top o f an ADD-vantage IV bag, and the rubber diaphragm is dislodged from the vial, allowing the IV solution to dissolve the drug. It allows for a ready-to-mix sterile IV product designed for intermittent administration o f potent drugs that do not have long-term stability in solution.

32.Answer: A. emergency cases Explanation:

Drugs administered in an emergency (eg. Atropine, epinephrine) are available for immediate injection when packaged in prefilled syringe.

33. Answer: C. prefilled cartridge

*

Explanation: Prefilled cartridges are ready-to-use parenteral packages that offer improved accuracy and sterility. They consist o f a plastic cartridge holder and a prefilled medication cartridge with a needle attached. The medication (eg narcotics) is premixed and premeasured.

34. Answer: D. less than 100ml Explanation: Infusion solutions are divided into two categories: small-volume parenterals, those having a volume less than 100ml; and large-volume parenterals, those having a volume o f 100ml or greater.

35.Answer: E. A and B Explanation: Glass and plastic polymers are the materials which are used to package parenteral products.

36.Answer: E. Less interaction with the parenteral preparation

Explanation: Compared to plastics, glass less frequently interacts with the preparation it contains.

37.Answer: B. subcutaneous Explanation: Insulin is administered subcutaneously. Subcutaneous administration refers to injection into the subcutaneous tissue beneath the skin layers, usually o f the abdomen, arm, or thigh.

38.Answer: A. 5ml Explanation: Intramuscular administration means injection into a muscle mass. The mid-deltoid area and gluteus medius are common injection sites. No more than 5ml o f a solution should be injected by this route.

39.Answer: B. IV

Explanation: IV administration is the most important and most common parenteral administration route.

40. Answer: C. it allows an immediate therapeutic effect by delivering the drug directly into the circulation. Explanation: Since the drug is directly delivered into the circulation, IV administration allows an immediate therapeutic effect by. But it cannot be used for delayed absorption, or to deliver drugs directly to the heart. IV administration is also not suitable for skin tests.

41.Answer: C. intradermal Explanation: Intradermal administration involves injection into the most superficial skin layer. Because this route can deliver only a limited drug volume, its use generally is restricted to skin tests and certain vaccines.

42. Answer: D. it is suitable for drugs intended for prolonged or delayed absorption

Explanation: Drugs intended for prolonged or delayed absorption are administered intramuscularly.

43.Answer: E. Intraspinal Explanation: Intraspinal refers to the injection into the spinal column. Local anesthetics are frequently administered via this route during surgical procedures. Injection into the spinal fluid is called intrathecal. It is used sometimes for antibiotics and cancer therapy.

44.Answer: C. intra-articular Explanation: Intra-articular refers to injection into a joint space. Corticosteroids use this route for the treatment o f arthritis. Intrasynovial is injection into the joint fluid.

45.Answer: A. epidural Explanation: Epidural administration refers to the injection o f medications, usually local anesthetics and/or narcotics near or outside the dura mater of the central nervous system. It is used frequently during childbirth.

46. Answer: A. these preparations consist o f only one sterile drug product added to an IV fluid Explanation: IV admixtures consist o f one or more sterile drug products added to an IV fluid.

47.Answer: E. all o f the above Explanation: Fluids used in the preparation and administration o f parenteral products include sterile water and sodium chloride, dextrose, and Ringers solutions.

48.

Answer: E. All o f the above

Explanation: IV fluids have multiple applications. They can be used as vehicles in IV admixture, as basis for correcting body fluid disturbances, provide a caloric source in parenteral nutrition, and in adjusting electrolyte imbalance.

49.Answer: B. 5% Explanation: Generally a solution o f dextrose 5% in water (d5w) is used as a vehicle in IV admixture. D5W may also serve as a hydrating solution. In higher concentrations (eg. 10% solution in water), dextrose provides a source o f carbohydrate in parenteral nutrition solution.

50.Answer: C. diabetes mellitus Explanation:

Dextrose solution should be used cautiously in patients with diabetes mellitus, since it can
increase the already higher than normal glucose level o f diabetic patients.

51.Answer: C. acid-sensitive. Explanation: Because the pH o f D5W ranges from 3.5-6.5, instability may result if it is combined with an acidsensitive drug.

52.Answer: D. 15% Explanation: Dextrose concentrations greater than 5% are hypertonic and hence should not be given through normal route.It should be given through a central vein.

53.Answer: D. 0.45%

Explanation: Because the 0.9% sodium chloride solution is isotonic with blood, it is called normal saline solution. A solution of 0.45% sodium chloride solution is called termed as half-normal saline. A solution o f 0.225% sodium chloride is termed quarter-normal saline.

54. Answer: C. multiple reconstitution o f various medications. Explanation:

Bacteriostatic sodium chloride, which is a 0.9% solution is intended solely for multiple reconstitution. It contains an agent that inhibits bacterial growth, which allows its use in multipledose preparations.

55. Answer: D. the absence o f sodium lactate from Ringers solution is the only difference between lactated Ringers solution and Ringers solution. Explanation: Ringers injection differs from lactated Ringers solution in that it does not contain sodium lactate and has slightly different concentrations o f sodium chloride and calcium chloride.

56.Answer: C. sodium Explanation: Sodium is the chief extracellular cation, and potassium is the chief intracellular cation in the body.

57.Answer: D. is important in protein synthesis. Explanation: Sodium has very important part in interstitial osmotic pressure, acid-base balance, tissue hydration, nerve-impulse transmission and muscle contraction.

58.Answer: C. Potassium Explanation: Potassium plays an important role in protein synthesis. The other important functions o f potassium include carbohydrate metabolism, muscle contraction (especially cardiac muscle), neuromuscular excitability.

59.

Answer: E. All o f the above

Explanation: All the four cations are involved in muscle contraction or excitability.

60.Answer: D. calcium acetate

Explanation: The common parenteral calcium preparations include calcium chloride, calcium gluconate, calcium gluceptate.

61 .Answer: B. magnesium sulfate Explanation: Magnesium is given parenterally as magnesium sulfate.

62.Answer: A. chloride Explanation: Chloride is the major extracellular anion and phosphate is the major intracellular anion. 63.Answer: D. sulfate. Explanation: Chloride and acetate help to control the pH o f blood and phosphate can act as a buffer to prevent marked changes in acid-base balance. 64. Answer: E. Subcutaneous injection

Explanation: Parenteral antibiotic preparations may be given intermittently by direct IV injection, short-term infusion, IM injection or intrathecal injection but not by subcutaneous injection.

65. Answer: E. all o f the above. Explanation: Parenteral antibiotic preparations are available as sterile unreconstituted powders, which must be reconstituted with sterile water, normal saline, or d5w, or as a sterile, ready to use liquid parenterals. They are used to treat infections that are serious and require high antibiotic blood levels or when the GIT route is contraindicated, such as in ileus.

66.Answer: E. all o f the above Explanation: Dosing frequencies o f parenteral antibiotics vary from once daily to as often as 2 hours, depending on the kinetics o f the drug, seriousness o f the disease, the site o f infection, and the patients diseases state or organ status (eg. Renal disease).

67.Answer: A. A horizontal laminar flow hood should be used during drug preparation with exhaust directed to the outside. Explanation: ~

All pharmacy and nursing personnel should receive special training in the safe antineoplastic handling guidelines. According to these guidelines the laminar flow hood used during preparation should be o f the vertical type, with the exhaust directed to the outside.

68.Answer: B. It is possible to prime the IV tubing while adding the drug Explanation: IV tubing should never be primed while adding the drug.

69.Answer: B. Negative pressure technique should be used Explanation: Negative pressure technique should be used during withdrawal o f medication from vials. This will prevent pressure from building up inside the vial and causing the drug to spray around the needle.

70. Answer: E. All o f the above. Explanation: All o f the above are the proper methods to dispose the antineoplastic materials.

71 .Answer: C. Should not wash the hands thoroughly after removal o f the gloves. Explanation: After the removal o f gloves (even if they are double layered latex surgeons gloves), the personnel should wash hands thoroughly.

72.Answer: C. It is inflammation o f the arteries Explanation: Infusion phlebitis is the inflammation o f the veins, not arteries.

73.

Answer: E. All o f the above

Explanation: Extravasation is one o f the serious problems that occur during the administration o f antineoplastic agents. It is the infiltration o f a drug into subcutaneous tissue surrounding the vein and is especially harmful when antineoplatics with vesicant properties are administered. The measures that should be taken if extravasation occurs include all o f the above plus injecting an antidote if available.

74.Answer: B. They could be only administered parenterally by direct IV injection or infusion Explanation:

Biotechnology products may be administered by direct IV injection or infusion, or by IM or subcutaneous injection.

75. Answer: A. Since they are not intended for infusion into the venous system, they need not be manufactured by the same standards to process IV preparations. Explanation: Although irrigating solutions are not intended for infusion into the venous system, they are prepared by the same standard procedures used for IV preparations. 76.Answer: E. Is helpful in correcting electrolyte disturbances Explanation: Irrigating solutions are not used in correcting electrolyte disturbances.

77.

Answer: C. after some period o f time, the solution is drained from the body

Explanation: In peritoneal dialysis, a hypertonic solution is infused directly into the peritoneal cavity via a surgically implanted catheter. The dialysate, which contains dextrose and electrolytes, removes harmful substances by osmosis and diffusion. After a specified period o f time, the solution is drained out o f the body. Antibiotics and heparin may be added to the dialysate.

78.Answer: E. B and C. Explanation: In hemodialysis, irrigating solution is not directly injected to the patients blood. Instead, the patients blood is transfused through a dialyzing membrane unit that removes harmful substances from the patients vascular system. After passing through the dialyzer, the blood reenters the body through a vein.

79.

Answer: E. B and C

Explanation: Hypodermic needles are stainless or aluminum devices that penetrate the skin for the purpose of administering or transferring a parenteral product.

80.Answer: A. 24-gauge Explanation: Needle gauge is the outside diameter o f the needle shaft; the larger the number, the smaller the diameter. Subcutaneous injections require a 24-gauge or 25-gauge needle 81 .Answer: B. a needle o f 20-gauge Explanation:

IM injections require a needle with a gauge between 19 and 22.

82. Answer: D. Compounding parenterals Explanation: For compounding parenterals, needles o f 18-22 gauge are the most suitable ones.

83.Answer: C. short-bevel needles Explanation: Bevels are slanting edges cut into needles tips to facilitate injection through tissue or rubber vial closure. Regular-bevel needles are the most commonly used type and are suitable for subcutaneous and IM injections and hypodermoclysis. Short-bevel needles are suitable for shallow penetration as in IV injection. Intradermal-bevel needles are designed for intradermal injections and have the most beveled edges.

84.Answer: B. intradermal and subcutaneous injections Explanation: Needle lengths range from 'A inch to inch. Choice o f needle length depends on the desired penetration. Intradermal and subcutaneous injections necessitate short needle strength, usually % inch to 5/8 inch.

85.Answer: C. 2 inch-long needles. Explanation: Iv infusion requires needles that range in length from 1 'A inches to 2 !4 inches.

86.

Answer: B. 3 V2 inch-long needles

Explanation: Intracardiac injection requires a n eed le length o f 3 Vi in ch es

87. Answer: C. They cannot be used to inject fluids. Explanation: Syringes are devices for injecting, withdrawing, or instilling fluids. They consist o f a glass or plastic barrel with a tight-fitting plunger at one end; a small opening at the other end accommodates the head o f a needle.

88.Answer: C. 60ml

Explanation: Syringe volumes range from 0.3-60ml. Insulin syringes have unit gradation (lOOunits/ml) rather than volume gradation.

89. Answer: D. luer-lok tips Explanation: Luer-lok tips are threaded to ensure that the needles fits tightly in the syringe. Antineoplatic agents should be administered with syringes o f this type.

90.Answer: B. eccentric tips Explanation: Eccentric tips, which are set off center, allow the needle to remain parallel to the injection site and minimize venous irritation.

91 .Answer: D. they help reduce venous irritation. Explanation: Catheter tips are useful for wound irrigation and administration o f enteral feedings. They are not intended for injections and they do not minimize venous irritation.

92.Answer: D. commonly employed for long-term IV therapy Explanation: Peripheral vein injection is used in patients who require only short term IV therapy.

93.Answer: A. subclavian vein. Explanation: For central vein injection, large veins in the thoracic cavity, such as the subclavian vein, are used.

94.Answer: B. not useful for fluid and electrolyte replacement Explanation: Continuous-drip infusion is a slow, primary-line infusion o f an IV preparation and is useful to maintain a therapeutic drug level or provide fluid and electrolyte replacement. Drugs with a narrow therapeutic index such as aminophyline, heparin, and pressor agents (epinephrine, norepinephrine, phenylepnrine) typically are administered by this method. In this method, the flow rate must be controlled strictly.

95.Answer: B. not useful for fluid and electrolyte replacement Explanation:

Continuous-drip infusion is a slow, primary-line infusion of an IV preparation and is useful to maintain a therapeutic drug level or provide fluid and electrolyte replacement. Drugs with a narrow therapeutic index such as aminophyline, heparin, and pressor agents (epinephrine, norepinephrine, phenylepnrine) typically are administered by this method. In this method, the flow rate must be controlled strictly.

96.Answer: D. additive set infusion. Explanation: Additive set infusion which makes use o f a volume-control device is appropriate for intermittent delivery o f small amounts o f IV solutions or diluted medications. Here the fluid chamber is attached to an independent fluid supply or placed directly under the established primary IV line.

97.

Answer: E. they avoid the use o f heparin solution

Explanation: When the intermittent infusion injection devices (also called scalp vein, heparin-lock, or butterfly infusion set) are used, dilute heparin solution orN SS are added to prevent clotting in the cannula.

98.Answer: E. pumps and controllers Explanation: Pumps and controllers are electronic devices used to administer parenteral infusions when the use o f gravity flow alone might lead to inaccurate dosing or risk patient safety. They can be used to administer parenteral nutrition, chemotherapy, cardiac medication, blood products.

99.Answer: A. volumetric pumps Explanation: The volumetric pumps are used for intermittent infusion o f medications such as antibiotics. They are also used for continuous infusion o f IV fluids, parenteral nutrition, anticoagulants, and anti asthma medications.

100.

Answer: B. syringe pumps

Explanation: Syringe pumps are used to administer intermittent or continuous infusions o f medications (eg. Antibiotics, opiates) in concentrated form.

101.

Answer: C. mobile infusion pumps.

Explanation: Mobile infusion pumps are small infusion devices designed for ambulatory and home patients and used for administering chemotherapy and opiate medication.

102. Answer: D. are surgically placed under the skin to provide a continuous release o f medication Explanation: Implantable pumps are devices surgically placed under the skin to provide a continuous release of medication, typically an opiate. The reservoir in the pump is refilled by injecting the medication through a latex diaphragm in the pump.

103.

Answer: E.A,B&C

Explanation: Patient-controlled analgesic pumps are used to administer narcotics intermittently or on demand by the patient within the patient-specific parameters, which are ordered by the physician and programmed into the pump

104.

Answer: B. They are more complex and generally more expensive than pumps.

Explanation: Controllers, unlike pumps, exert no pumping pressure upon the IV fluid. Rather, they rely on gravity and control the infusion by counting drops electronically, or they infuse the fluid mechanically and electronically. In comparison to pumps, they are less complex and generally less expensive. They are able to achieve reasonable accuracy. They are very useful for uncomplicated infusion therapy but cannot be used for arterial drug infusion or for infusion into small veins. 105. Answer: B. reflects the chemical degradation o f one or more o f the admixed drugs, resulting in toxicity or therapeutic inactivity. Explanation: When two or more drugs must be administered through a single IV line or given in a single solution, an undesirable reaction ( due to incompatibility) that could be catastrophic may occur. A physical incompatibility occurs when a drug combination produces a visible change in the appearance o f a solution. A chemical incompatibility reflects the chemical degradation o f one or more o f the admixed drugs, resulting in toxicity or therapeutic inactivity. And a therapeutic incompatibility occurs when two or more drugs, IV fluids, or both are combined and the result is a response other than intended.

106. Answer: A. evolution o f carbon dioxide when sodium bicarbonate and hydrochloric acid are admixed Explanation: Evolution o f carbon dioxide when sodium bicarbonate and hydrochloric acid are admixed is a chemical incompatibility.

107. Answer: C. Giving penicillin G after tetracycline is an example o f chemical incompatibility

Explanation: The reduced bactericidal activity of penicillin G when given after tetracycline is an example of therapeutic incompatibility. Because tetracycline is a bacteriostatic agent, it slows bacterial growth; penicillin, on the other hand, is most effective against rapidly proliferating bacteria. 108. Answer: C. higher degree o f dilution of the solutions.

Explanation: Incompatibility is more likely to occur when the components o f an IV solution differ significantly in pH, as with acids and bases that may react and yield salt, which can form insoluble precipitate. High storage temperature speeds drug degradation and thus, incompatibility. Generally, the more dilute the drugs are in a solution, the less chance of interaction and incompatibility. The longer the time the drugs are in solution, the higher the probability o f interaction and incompatibility.

109.

Answer: E. all of the above

Explanation: In order to minimize or prevent incompatibilities; each drug should be mixed thoroughly after it is added to the preparation, solutions should be administered promptly after they are mixed or prepared to minimize the time available for a potential reaction to occur, the number o f drugs mixed together in IV solution be kept to the minimum, and if a prescription calls for unfamiliar drugs or IV fluid, compatibility references should be consulted.

110. Answer: A. it is a major complication among the physical hazards o f parenteral drug therapy. Explanation: Phlebitis, which is a minor complication, may result from vein injury or irritation. Phlebitis can be minimized or prevented through proper IV insertion technique, dilution or irritating drugs, and a decreased infusion rate.

111.

Answer: B. pain

Explanation: Pain from infusion is most common with peripheral IV administration o f a highly concentrated preparation. Switching to central vein infusion and/or diluting the drug might alleviate the problem.

112.

Answer: D. hypothermia.

Explanation: Hypothermia, possibly resulting in shock and cardiac arrest, might stem from administration o f a cold IV solution. This problem can be prevented by allowing parenteral products to reach room temperature.

113.

Answer: B. Intrathecal administration

Explanation: Neurotoxicity may be a serious problem in case of intrathecal or intraspinal administration o f drugs containing preservatives. Preservative free drugs should be used in those circumstances.

114.

Answer: D. infusion pump failure

Explanation: Air embolism could be caused by the entry o f air into the IV tubing. Central catheter misplacement may lead to air embolism. To ensure that the catheter has passed into the subclavian vein and advanced to the level o f the vena cava, the placement should always be verified radiologically. Particulate that may be present in the parenteral products may also lead to embolism.

115.

Answer: C. some preservatives included in the drug preparation

Explanation; Preservative toxicity can be a serious complication, especially in children. For example, premature infants receiving parenteral products containing benzyl alcohol can develop a fatal acidotic toxic syndrome, which is referred to as the gasping syndrome.

116.

Answer: E. I, II and III.

Explanation: In the quality control and quality assurance o f sterile products, various types o f tests are used to ensure that all sterile products are free o f microbial contamination (sterility test), pyrogens (pyrogen testing), and particulate m atter (clarity testing). 117. Answer: C. the official USP standard for testing sterility requires a minimum o f 5-test sample to be taken for batches less than 20 units Explanation: The official USP standard for testing sterility require a minimum o f two test samples to be taken for batches less than 20 units.

118.

Answer: B. pyrogen test

Explanation: Pyrogen testing for sterility products can be accomplished by means o f qualitative fever response testing in rabbits or by in vitro limulus testing. People handling sterile products can attempt to avoid problems with pyrogens by purchasing pyrogen free water and sodium chloride for injection from reputable manufacturers and by using proper handling and storage conditions.

119.

A nsw er: A . training o f pharm acists and tech n ician s

Explanation: Practical quality assurance programs for noncommercial sterile products include training, monitoring o f manufacturing process, quality control check and documentation. Training o f pharmacists and technicians in proper aseptic techniques and practices is the single most important aspect o f effective quality assurance program. Training should impart a thorough understanding o f departmental policies and procedures.

120.

Answer: C. I and II are correct

Explanation: Process validation o f sterile product manufacturing includes a written procedure to follow as well as evaluation o f aseptic technique through process simulation. Process simulation testing duplicates sterile product production except that an appropriate media is used in place o f the drug product. After preparation and incubation o f the final product, no growth indicates proper aseptic techniques were followed.

121.

Answer: E. All o f the above

Explanation: Documentation o f training procedures, quality control results, laminar hood certification, and production records are required by various agencies and organizations.

Thromboembolic Diseases

Success doesn't "happen". It is organized, preempted, captured, by consecrated common sense. F. E. Willard

1. Which o f the following may be causes for venous thromboembolic disease (VTED)? A. B. C. D. E. Vascular injury venous stasis hypercoagulable state decreased protein C all o f the above

A. UFH is cleared by rapid phase( cellular) elimination B. when administered in fixed doses the anticoagulant response to UFH varies in the same patient C. heparin binds only to antithrombin D. B & C E. A & C

2. Which one of the following is not a patient specific risk factor of thromboembolic disease? A. B. C. D. E. varicose veins high-dose estrogen therapy immobility malignancy Lupus anticoagulant

6. For all thrombotic indications other than suspected or proved pulmonary embolism, the indication for heparin therapy is A. B. C. D. E. 70 units/kg 100 units/kg 80 units/kg 90 units/kg none o f the above

3. All o f the following are pharmacological prevention methods of VTED, except A. taking unfractionated heparin (UFH) B. oral anticoagulant therapy C. low-molecular-weight heparin( LMWH) D. graduated compression stockings E. synthetic pentasaccharide

7. In proven VTED, the treatment includes A. B. C. D. E. 5000 units unfractionated heparin IV is used a rebolus o f 80 units/kg IV heparin is given there is a maintenance infusion of 18 units/kg/hr warfarin therapy is started on day 1 all o f the above

4. Unfractionated heparin is indicated for A. for acute treatment o f VTED B. prevention o f recurrence o f VTED C. prevention o f acute MI in patients with peripheral arterial disease D. prevention o f stroke E. all o f the above

8. The anticoagulant effects o f UFH are usually monitored by a A. B. C. D. E. aPTT PT/TNR CBC platelet count none o f the above

9. Which one o f the following statements is false? 5. Which one o f the following statements is false? A. aPTT ratio is measured by dividing the mean o f the normal

B.

C. D. E.

laboratory aPTT by the observed aPTT for many aPTT reagents, a therapeutic effect is achieved with an aPTT ratio o f 1.5-2.5 it is inappropriate to use the same aPTT ratio for all reagents A&C

13.Dose response to warfarin is influenced by which o f the following? A. difference in metabolic clearance B. inaccuracies in prothrombin time testing C. increased intake o f green leafy vegetables D. alcohol consumption E. all o f the above

10.Pulmonary embolism requires UFH therapy with a dose o f A. B. C. D. E. 70 units/kg 15 units/kg/hr 25 units/kg/hr A&B None o f the above

14.Warfarin reaches maximal blood concentration in healthy volunteers in A. B. C. D. E. 90 min 5-10 min 20 min 60 min none o f he above

11 .Warfarin is proven effective in which of the following cases A. primary and secondary prevention o f VTED B. prevention o f systemic arterial embolism in patients with medicinal prosthetic heart C. prevention o f acute MI in patients with peripheral arterial disease D. prevention o f stroke in patients with acute MI. E. all o f the above

15. All o f the following drugs potentiate anticoagulant effect o f warfarin except A. B. C. D. E. erythromycin ketoconazole griseofulvm omeprazole isoniazid

16. All of the following inhibit anticoagulant effect o f warfarin except A. B. C. D. E. rifampicin carbamazepire cimetidine penicillin barbiturates

12. The mechanism o f action o f oral anticoagulants(warfarin) is A. it interferes with cyclic inter conversion o f vitamin K and its 2,3-epoxide B. it catalyzes the inactivation of Ha C. it results in production of hemostatically defective clotting factors D. A & B E. A & C

17. One o f the following does not poetntiate warfarin effects A. low vitamin K intake B. liver disease C. thyrotoxicosis D. chronic use o f alcohol

E. acute use o f alcohol

18. Which o f the following statements is/are true about warfarin? A. it is a coumarin compound B. it is available in an injectable form C. the initial dose can be flexible D. A & C only E. all o f the above

A. treatment o f venous thrombosis B. treatment of pulmonary embolism C. prevention of systemic embolism D. valvular heart disease E. thrombosis and antiphospholipid syndrome

23.Once the desired therapeutic INR has been achieved for 2 consecutive days, follow up INR monitoring in the weeks 7 14 should be done at a frequency of: A. two or 3 times per week B. once a week C. once every 2 weeks D. once every 4 weeks E. none o f the above

19.The dose o f warfarin is computed on the basis o f A. B. C. D. E. PT INR CBC A&B A&C

20.PT is sensitive to changes o f which of the following vitamin K dependent coagulation factors A. B. C. D. E. II VII X II,VII,x None o f the above

24.Low molecular weight heparin have been proven safe and efficacious for the prevention and treatment of A. venous thromboembolism B. treatment of pulmonary embolism C. prevention of systemic embolism D. valvular heart diseases E. arterial fibrillation

21 .The problem o f variability in responsiveness o f PT reagents is overcome by introduction o f a standardised test known as A. B. C. D. E. ISI INR calcium aPTT none o f the above

25. Which one o f the following statements is true? A. LMWHs are approximately on third the size o f heparin B. LMWHs are fragments o f heparin C. LMWHs are homogenous in size with a molecular weight o f 4000 D. A and B E. all o f the above

22.The therapeutic INR goal and range for oral anticoagulant therapy is the same for all o f the following indications except

26. Warfarin therapy may be given for a period o f 12 months to lifetime for all the following indications except A. B. C. D. E. cancer anticardiolipin antibody anti thrombin deficiency idiopathic VTE recurrent event thrombophilia

D. Omit the next dose E. A, B and C

30.The LMWII with the lowest average MW, and the highest bioavailability and longest half life is with A. B. C. D. E. dalteparin enoxaparin tinzaparin A and B None o f the above

27. When there is a clinical situation with INR > 9.0 but no clinically significant bleeding, the guideline for reversal o f warfarin effects are A. omit the next .dose or two of warfarin B. omit next dose o f warfarin, and give vitamin K1 ( 1.0-2.5 mg orally) C. give vitamin K1 (2-4 mg orally) D. give vitamin K1 (3-5 mg orally) E. none of the above

31 .For unstable angina and non-ST segment elevated myocardial infarction, which LMWH is not applicable A. B. C. D. E. dalteparin enoxaparin tinzaparin A&B None o f the above

28.In a clinical situation when the INR> 5.0 but <9.0 with an increased risk of bleeding the guideline for reversal o f warfarin effects is A. omit the next dose o f warfarin and monitor INR B. omit the next dose o f warfarin and give vitamin K1 ( 1.0-2.5 mg orally) C. give vitamin K1 (2-4 mg orally) D. give vitamin K1 (3-5 mg orally) E. none o f the above

32. Which LMWH is recommended for extended hip prophylaxis and knee replacement surgery A. B. C. D. E. dalteparin enoxaparin tinzaparin A&C None o f the above

33. Which one o f the following is not a correct dose for hip-replacement surgery prophylaxis? A. 5000 IU dalteparin daily for 5 10 days B. 30 mg enoxaparin every 12 hours for 7-10 days C. 2500 IU tinzaparin daily for 5 10 days D. A and B E. all o f the above

29.I f the INR > 20.0 and there is serious bleeding the guideline for reversal is A. give vitamin K1 ( 1 0 mg by slow IV infusion) B. give fresh frozen plasma transfusion C. give prothrombin complex concentrate

ANSW ERS

Thromboembolic Diseases
1. Answer: E. all o f the above Explanation: Venous thromboembolic disease (VTED) occurs when one or m ore o f the elements o f Virchows triad are present, resulting in deep venous thrombosis (DVT) and/or pulmonary embolism. They are vascular injury, venous stasis and hyper coagulable state (i.e. decreased protein C, protein S or antithrombin).

2. Answer: D. malignancy Explanation: The risk factors for thromboembolic disease could be patient specific which include age ( older than 40 years o f age., obesity , varicose veins, immobility, pregnancy, high dose estrogen therapy, previous venous thromboembolism, deficiency o f antithrombin or protein C or protein S, activated protein C resistance, antiphospholipid antibody, lupus anticoagulant and risk factors associated with medical illness and surgical procedures include trauma or surgery( especially involving the pelvis , hip and lower limbs); malignancy ( especially pelvic, abdominal and metastatic, and major medical illness( especially heart failure or recent myocardial infarction, paralysis o f the lower limbs, inflammatory bowel disease, sepsis, kidney disease, polycythemia, paraproteinemia, Behcets syndrome and homocysteinemia). So choices A, B,C and E are patient specific risk factors while malignancy is a risk factor associated with medical illness.

3. Answer: D. Graduated compression stockings Explanation: In the pharmacological prevention, VTED can be prevented by counteracting increased blood coagulability with unfractionated heparin( UFH), oral anticoagulant therapy, low molecular weight heparin(LMWH) or synthetic pentasaccharide. But in the non-pharmacologic prevention, VTED can be prevented by reducing venous stasis with external pneumatic compression or graduated compression stockings.

4. Answer: A. For acute treatment o f VTED Explanation: Patients with proven VTED should receive concomitant unfractionated heparin for acute treatment and warfarin therapy acutely, followed by warfarin therapy for continued prevention of recurrence o f VTED, unless contraindications are present ( e.g. pregnancy) B, C & D are indications o f warfarin.

5. Answer: C. Heparin binds only to antithrombin

Explanation: Heparin binds to a number o f plasma proteins other than antithrombin that compete with antithrombin heparin binding, UFH is cleared by rapid phase( cellular) elimination followed by a more gradual( renal) clearance. When administered in fixed doses, the anticoagulant response to UFH varies among patients and within the same patient( i.e. inter and intra-patient variability). This variability is caused by difference in patients5 plasma concentrations o f heparin neutralizing proteins and rates o f heparin clearance.

6. Answer: A. 70 units/kg Explanation: UFHs therapeutic effect is hastened by administration of a loading dose, which may be empirically selected( e.g. 5000 units bolus given IV) or individualized by the patients dosing weight. The weight based approach has resulted in the use o f loading doses varying from 70-100 units/kg. In some instances, the indication for which heparin therapy is being initiated is considered, with 70 units/kg being used for all thrombotic indications other than suspected or proven pulmonary embolism, for which up to 100 units/kg may be used.

7. Answer: E. all o f the above Explanation: In suspected VTED first obtain a base line aPTT(activated partial thromboplastin time., PT/INR(prothrombin time/international normalized ratio), CBC(complete blood count) then check for contraindications to heparin therapy. After that give 5000 units UFH intravenous push then order imaging study. In proven VTED, if therapy is indicated, rebolus with 80 units/kg IV and start maintenance infusion o f 18 units/kg/hr. Check aPTT at 6 hours, and- adjust to maintain a range corresponding to a therapeutic heparin level. Check platelet count daily and start warfarin therapy on day 1; adjust subsequent daily dosing based on PT/INR. Stop UFH after 4-5 days o f over lap ( UFH with warfarin), when INR is > 2 for 2 consecutive days. Anticoagulate with warfarin for 3-6 months (patient/disease state specific).

8. Answer: A. aPTT Explanation: The anticoagulant effect o f UFH are usually monitored by the aPTT(activated partial thromboplastin time. The aPTT should be monitored 6 hours after commencing heparin therapy.

9. Answer: A. aPTT ratio is measured by dividing the mean of the normal laboratory aPTT by the observed aPTT Explanation: The aPTT ratio used to determine therapeutic effect is measured by dividing the observed aPTT by the mean o f the normal laboratory control aPTT. For many aPTT reagents, therapeutic effect is achieved with an aPTT ratio o f 1.5-2.5. However, because aPTT reagents may vary in their sensitivity, it is inappropriate to use the same aPTT ratio( i.e. 1.5-2.5) for all reagents. The therapeutic range for each aPTT reagent should be calibrated to be equivalent to a heparin level of

0.2-0.4 U/ml by whole blood( protamine titration) or to an antifactor Xa level( i.e. plasma heparin level) o f approximately 0.3-0.7 U/ml.

10.Answer: C. 25 units/kg/hr Explanation: In the weight based dosing nomogram the UFH therapy varies between 15 and 25 units/kg/hr. Lower doses are used initially for most thrombotic indications other than pulmonary embolism, which requires a more aggressive therapy i.e. up to 25 units/kg/hr(which is up to 100 units/kg) based on the consideration that the clearance o f heparin may be increased, thus necessitating an increased dose.

11 .Answer: E. all o f the above Explanation: Warfarin is proven effective in the primary and secondary prevention o f VTED, prevention o f systemic arterial embolism in patients with tissue and mechanical prosthetic heart valves or arterial fibrillation, prevention o f acute Ml in patients with peripheral arterial disease and prevention o f stroke, recurrent infarction, and death in patients with acute ML Warfarin may also be used in patients with valvular heart disease to prevent systemic arterial embolism, although its effectiveness has never been demonstrated by a randomized clinical trial.

12.Answer: E. A& C Explanation: * Oral anticoagulants (e.g. warfarin) are vitamin K antagonists, producing their anticoagulant effect by interfering with the cyclic inter conversion o f vitamin K and its 2,3-epoxide( vitamin K epoxide. Inhibition o f this process leads to the depletion o f vitamin KH2 and results in the production o f hemostatically defective, vitamin K-dependent coagulant proteins or clotting factors.

13. Answer: E. all o f the above

Explanation: Dose response to warfarin is influenced by pharmacokinetic factors( i.e. difference in absorption and metabolic clearance, pharmacodynamic factors( i.e. difference in the hemostatic response to given concentrations to warfarin), technical factors {e.g. inaccuracies in prothrombin time(PT) and international normalized ratio( INR) testing and reporting} and patient specific factors { e.g. diet (increased intake o f green, leafy vegetables)}, poor compliance( missed dose, self medication, alcohol consumption), poor communication between patient and physician( undisclosed use o f drugs that may interact with warfarin).

14.Answer: A. 90 min Explanation:

Warfarin is rapidly absorbed from gastro intestinal tract and reaches maximal blood concentration in healthy volunteers in 90 minutes.

15.Answer: C. griseofulvm Explanation: Erythromycin, ketoconazole, omeprazole and isoniazid potentiate anticoagulant effect,but griseofulvin inhibits anticoagulant effect.

16.Answer: C. cimetidine Explanation: Drugs that can potentiate anticoagulant effect include phenylbutazone, metronidazole, sulfinpyrazone, trimethoprim-sulfamethoxazole, disulfiram, amiodarone, anabolic steroids, clofibrate, thyroxine, cimetidine, fluconazole, piroxicam, tamoxifen, quinidine, large doses o f vitamin E and phenytoin. But cholestyramine, barbiturates, rifampin, girseofulvin, carbamazepine and penicillin inhibit anticoagulant effect o f warfarin.

17.

Answer: D. chronic use o f alcohol

Explanation: Factors that may potentiate the anticoagulant effect o f warfarin include low vitamin K intake, reduced vitamin K absorption, liver disease, hyper metabolic states (e.g. thyrotoxicosis) and acute use o f alcohol. But high vitamin K intake and chronic use o f alcohol inhibits the anticoagulant effect o f warfarin.

18. Answer: E. all o f the above Explanation: Warfarin a coumarin compound, is the most widely used oral anticoagulant in North America. Although it is primarily administered orally, an injectable preparation is also available. The initial dose o f warfarin therapy can be flexible depending on the patient specific parameters.

19.Answer: D. A & B Explanation: When warfarin therapy is started , PT and INR should be performed daily until a stable daily dose is reached( the dose that maintains PT & INR with in the therapeutic ranges and does not cause bleeding). This means the dose o f warfarin is computed on the basis o f prothrombin time and INRs.

20. Answer: D.I1,VI1, X Explanation:

The PT is responsive to depression o f three o f the four vitamin K dependent procoagulant clotting factors i.e. prothrombin or factors II, VII and X.

21.Answer: B. INR Explanation: PT is performed by adding a mixture o f thromboplastin and calcium to citrated plasma and measuring the time( in seconds) it takes for the blood to clot. However, values vary among laboratories according to the type o f thromboplastin and the instrument used to measure PT. The problem o f variability in responsiveness o f PT reagents has been overcome by the introduction of a standardized test known as the INR. INR is equal to the observed PT ratio{( i.e. patient PT/mean laboratory control PT)IS1}, where ISI( international sensitivity index) is a measure o f the responsiveness o f a given thromboplastin to reduction o f vitamin K-dependent coagulation factors. The lower the.ISI, the more responsive the reagent and the closer the derived INR will be to the observed PT ratio.

22.Answer: E. thrombosis and antiphospholipid syndrome Explanation: For indications mentioned in choices A, B and C and D, the INR goal and range o f INR are 2.5 and 2.0-3.0 respectively. But in case o f indications mentioned in choice E , the INR goal is 3.0 while its range is 2.5-3.5. Indications like tissue heart valves, anterior myocardial infraction ( to prevent systemic embolism), valvular heart disease, arterial fibrillation and bileaflet mechanical valve in the aortic position( with normal sinus rhythm) have an INR goal o f 2.5.

23.Answer: C. Once every 2 weeks Explanation: Once the desired therapeutic INR has been achieved for 2 consecutive days, (e.g. for concomitant heparin plus warfarin overlap therapy), follow up INR monitoring can be performed according to the following protocol. Week 1: monitor INR 2 or 3 times _ Week 2: monitor INR 2 times Week 3-6: monitor INR once a week Week 4-14: monitor INR once every 2 weeks Week 15- end of therapy: monitor INR once every 4 weeks (if INR dose responsiveness remains stable; if dose adjustment is necessary; a more frequent monitoring scheme is reemployed until stable dose responsiveness is achieved).

24.Answer: A. venous thromboembolism Explanation: Each o f the LMWHs have been evaluated in a large number o f randomized clinical trial and have been proven to be safe and efficacious for the prevention and treatment o f venous thrombo embolism and to date, different LMWHs have been evaluated for their role in prevention of venous thrombosis, treatment o f VTED, and management o f unstable angina pectoris/non- Q wave MI. ~~~

25.Answer: D. A and B Explanation: LMWHs are fragments o f standard commercial grade heparin produced by either chemical or enzymatic depolymerization. LMWHs are approximately one third the size o f heparin. Like heparin .which has a mean molecular weight o f 15000 daltons( range 3000-30,000 daltons), LMWHs arc heterogeneous in size with a mean molecular weight o f 4,000-5,000 daltons( range 1,000-10,000 daltons).

26.Answer: D. Idiopathic VTE Explanation: The duration o f warfarin therapy is 3-6 months for first event with reversible or time-limited risk factor, > 6 months for idiopathic VTE( first event) and it could also be 12 months to life time in indications like cancer( until resolved), anticardiolipin antibody, antithrombin deficiency and recurrent event, idiopathic or with thrombophilia.

27.Answer: D. Give vitamin Ki (3-5 mg orally) Explanation: In a clinical situation when INR > therapeutic level but <5.0 with no clinically significant bleeding, rapid reversal not indicated for reasons o f surgical intervention,the guideline says that when INR is significantly above therapeutic range, lower the dose or omit the next dose; resume warfarin therapy at a lower dose when the INR approaches desired range; but when INR is minimally above therapeutic range, dose reduction may not be necessary. When the INR > 9.0 with no clinically significant bleeding, give vitamin Kj (3-5 mg orally; closely monitor INR, repeat dose o f vitamin Ki if INR not substantially reduced by 24-48 hours.

28.

Answer: B. omit the next dose o f warfarin and give vitamin Ki ( 1.0-2.5 mg orally)

Explanation: When INR > 5.0 but < 9.0, no significant bleeding, the guidelines for reversal o f warfarin effects is to omit the next dose or two o f warfarin; monitor INR more frequently; resume warfarin therapy at a lower dose when the INR is in therapeutic range. But if there is a risk o f bleeding omit the next dose o f warfarin; give vitamin K* ( 1.0-2.5 mg orally). I f more rapid reversal is needed before urgent surgery or dental extraction, give vitamin Ki ( 2-4 mg orally); give an additional dose o f vitamin K] (1-2 mg orally) if the INR remains high at 24 hours.

29. Answer: E. A, B and C Explanation: When the INR > 20.0 with serious bleeding, major warfarin over dose requiring very rapid reversal o f anticoagulant effect, the guideline is to give vitamin K) ( 10 mg by slow IV infusion) with fresh frozen plasma transfusion o f prothrombin complex concentrate, depending on urgency, vitamin Ki injections may be needed every 12 hours. ~

And when there is life threatening bleeding( serious warfarin overdose); give prothrombin complex concentrate with vitamin Kj ( 10 mg by slow IV infusion); repeat if necessary depending on INR.

30. Answer: B. Enoxaparin Explanation: Dalteparin has an average MW, bioavailability and half life o f 6000 daltons, 87% and 3-5 hours respectively. While tinazaparin has a MW o f 6500 daltons, 87 % bioavailability and half life of 3-9 hours. But enoxaparin has a MW o f 4500,a bioavailability o f 92 % and half life o f 4-5 hours.

31.Answer: C. Tinzaparin Explanation: For unstable angina and non-ST segment elevated myocardial infarction, dalteparin is given 120 IU/ kg every 12 hours for 5-8 days plus aspirin indefinitely or enoxaparin is given 1 mg/kg every 12 hours for 2-8 days plus aspirin indefinitely but tinzaparin is not applicable.

32.Answer: B. Enoxaparin Explanation: Enoxaparin is given 40 mg daily for 3 weeks for extended hip prophylaxis and 30 mg every 12 hours for 7-10 days for knee replacement surgery. But both dalteparin and tinzaparin are not recommended.

33.Answer: C. 2500 IU tinzaparin daily for 5-10 days Explanation: For hip-replacement surgery prophylaxis 5000 IU dalteparin is given daily for 5-10 days and 30 mg enoxaparin every 12 hours or 40 mg daily for 7-10 days but tinzaparin is not recommended.

34.Answer: A. Dalteparin Explanation: For treatment o f DVT with or without PE, 1mg/kg o f enoxaparin is given every 12 hours as a bridge to warfarin until stable INR is achieved(for out patient treatment only) or 1.5 mg/kg enoxaparin every 24 hours as a bridge to warfarin( For inpatient only) until stable INR. Tinzaparin can also be given at 175 lU/kg every 24 hours as a bridge to warfarin( out patient) and treatment is permitted until stable INR. But dalteparin is not applicable in this clinical setup.

35.

Answer: E. all o f the above

Explanation:

Synthetic pentasaccharides(fondaparinux)is indicated for thromboprophylaxis against DVT/PE after total hip replacement surgery, total knee-replacement surgery and after hip-fracture repair surgery.

36.Answer: A. Fondaparinux is administered intramuscularly Explanation: Fondaparinux must not be administered intramuscularly. It is administered, subcutaneously after which the drug is completely bioavailable, with steady state peak plasma levels achieved approximately 3 hours after administration o f the dose and the elimination half life is 17-21 hours, enabling once-daily dosing. The drug should not be used in patients with body weight less than 50 kg, as the incidence o f major bleeding was found to double in this patient population during clinical trials. The initial dose should be started 6-8 hours after surgery when hemostasis is established.

37. Answer: E. all o f the above Explanation: A usual dose o f 2.5 mg subcutaneously once daily for 5-9 days is recommended to prevent venous thromboembolism in patients undergoing total hip-replacement, hip fracture surgery or knee replacement surgery.

38.Answer: C. Protamine is an effective antidote Explanation: Fondaparinux is contraindicated in hypersensitivity, active bleeding, severe renal impairment bacterial endocarditis thrombocytopenia associated with fondaparinux and in patients weighing less than 50 kg. And precautions should be taken in procedures that enhance bleeding, renal impairment, heparin-induced thrombocytopenia, neuraxial anesthesia and indwelling epidural catheter use, pregnancy/breast feeding and elderly patients. The anticoagulant antagonist protamine is ineffective as an antidote against fondaparinux.