G.

Anticoagulant agents
1. Vitamin K reductase inhibitors- WI
coumarin derivative warfarin (Coumadin) or
the indandione analog anisindione (Miradon).
substitutions at position 3 and 4 with the potential to form a cyclic hemiketal
therapeutic benefits are observed in 3 to 4 days.
CYP2C9 (which metabolizes warfarin)
Warfarin is used to treat deep vein thrombosis, pulmonary embolism, and clots due to
atrial arrhythmias and prosthetic cardiac valves.
Bleeding, skin necrosis, purple toe syndrome, and alopecia are observed; birth defects are
likely if taken during pregnancy.

2. Unfractionated and low-molecular-weight heparins.
Unfractionated heparins (UFHs) are mucopolysaccharide polymers (60 to 100 kDa;
extracted from mast cells of bovine lung tissue or porcine intestinal mucosa.
Low-molecular-weight (LMWHs, 2 to 10 kDa) are produced by careful fragmentation of
UFH and purification by gel filtration to produce agents such as: TED
o enoxaparin (Lovenox), tinzaparin (Innohep), and dalteparin (Fragmin).
o UFHs have high affinity for antithrombin III (AT-III) and catalyze the
inactivation of factor Xa and IIa by AT-III,
o LMWHs also bind to AT-III
Both UFHs and LMWHs IV and SC
LMWHs with longer half-life.
These agents are used for pulmonary emboli prophylaxis and to treat venous
thromboemboli until transitioned to warfarin.
Fondaparinux (Arixtra) is a synthetic pentasaccharide that inhibits factor Xa through
the action of AT-III.
Danaparoid (Orgaran) is a mixture of heparin sulfate, dermatan sulfate, and
chondroitin sulfate extracted from porcine mucosa and having a similar mechanism of
action as LMWHs.
Adverse effects related to heparin use are bleeding, heparin-induced thrombocytopenia
(HIT), alopecia, and osteoporosis.
Overdose treated protamine sulfate that neutralizes the polysaccharides via ionic
interaction.
3. Direct thrombin inhibitors BLAD
the catalytic or substrate recognition site of the protease without the need for AT-III.
Lepirudin (Refl udan) is a 65 amino acid recombinant derivative of hirudin, the
anticoagulant found in the saliva of the medicinal leech.
Bivalirudin (Angiomax) is a synthetic 20 amino acid derivative of hirudin.
Argatroban is also a parenterally administered, direct thrombin inhibitor, and all three of
these agents are used to treat HIT.
Dabigatran (Pradaxa) is the first orally active direct thrombin inhibitor and is used to
prevent stroke in patients with atrial fibrillation.
ADR: bleeding, but dabigatran is also associated with GI disturbances such as
esophageal reflux, gastric bleeding, and abdominal pain.
H. Antiplatelet agents ACD TCP TAE
1. Aspirin.
cyclooxygenase ,reduces the amount of thromboxane
Aspirin is used for the prophylaxis of myocardial infarctions and, in conjunction with
other agents, it decreases thrombosis aft er coronary stenting.
2. Dipyridamole (Persantine) and cilostazol (Pletaal)
stroke prophylaxis in cerebrovascular ischemia or after prosthetic valve replacement.
Cilostazol is also used for intermittent claudication.
3. Thienopyridines
Ticlopidine (Ticlid), clopidogrel (Plavix), and prasugrel (Effient;)
bioactivated by hepatic CYP enzymes before they are active.
bind to the P2Y12 receptors on
These drugs are used to decrease clot formation after angioplasty and stenting
procedures and are often combined with aspirin or GPIIb/IIIa inhibitors.
The following adverse effects are rare but can be serious: thrombocytopenia purpura,
aplastic anemia, neutropenia, cholestatic jaundice, fever, rash, and GI distress
4. Glycoprotein IIb/IIIa inhibitors
abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat).
decreased platelet aggregation during clot formation and reduced thrombus size.
Abciximab is the Fab fragment of a monoclonal antibody

I. Thrombolytic agents TASU
1. Tissue plasminogen activators (tPAs) are normally released by endothelial cells to activate
fibrin-bound plasminogen to plasmin. Plasmin then cleaves fibrin strands to cause the
disintegration of the clot.
Human tPA, alteplase (Activase)
Tenecteplase (Tnkase) is also a mutant of tPA designed to have enhanced fibrin
selectivity.
Their primary adverse effect is risk of bleeding, and this can be managed by the
administration of aminocaproic acid (Amicar).
2. Streptokinase (Streptase)
is a 47 kDa protein.
does not require the presence of fibrin to activate plasminogen
3. Urokinase (Abbokinase)
serine protease
Oral factor Xa inhibitor
Direct factor Xa inhibitor (rivaroxaban [Xarelto])
Oral direct thrombin inhibitor
Direct factor IIa (thrombin) inhibitor (dabigatran [Pradaxa])

Heparin
rapid-acting anticoagulant , administered parenterally.
Standard heparin (unfractionated heparin [UFH]) is a heterogeneous mixture of
glycosaminoglycans
Binds to antithrombin (AT)or heparin cofactor which accelerates the anticoagulant effect
of AT. irreversibly inactivates factor IIa (thrombin) and factor Xa
inhibits platelet function and increases vascular permeability

(IV) by continuous infusion, or subcutaneously (SC), IM cause hematoma
After IV administration, the anticoagulant effect of heparin is noted immediately.
Monitor activated partial thromboplastin time(APPT)
SE: osteoporosis, hypersensitivity, hyperkalemia


Low-Molecular-Weight Heparins TED, 2-10 kDA
dalteparin (Fragmin),
enoxaparin (Lovenox),
tinzaparin (Innohep).
inactivate factor Xa
the anti-Xa properties of LMWHs are more significant than their anti-IIa properties.
Hct, INR, renal function, and platelet count should be determined.

Advantages
Does not require aPTT monitoring for therapeutic effect
reduced binding affinity for plasma proteins and endothelial cells

UFH 60-100 kDA
renally compromised
pregnant women

Fondaparinux (Arixtra)
is a selective indirect factor Xa inhibitor
prevention of venous thrombosis associated with orthopedic surgery and abdominal
surgery,
for the treatment of DVT and pulmonary embolism.
inactivate factor Xa with no direct impact on factor IIa.
This agent has a long elimination half-life, OD SC at a fixed dose without the need for
routine coagulation monitoring.
Renal excretion!

Direct Thrombin Inhibitors BLAD
Argatroban, (liver)
lepirudin (Refludan), (renal)
bivalirudin (Angiomax) (renal)
dabigatran( pradaxa)

Alternative anticoagulants in patients with heparin-induced thrombocytopenia.

Continuous infusion and require aPTT monitoring for appropriate dosing adjustments.

Bivalirudin is also used in patients undergoing percutaneous coronary intervention.


Warfarin
oral anticoagulant with a delayed onset of effect
vitamin K antagonist
Vitamin K is essential for the conversion (carboxylation) of precursors to clotting factors
II, VII, IX, and X into inactive clotting factors and for the synthesis of protein C and
protein S.
It takes approximately 5 to 7 days to reach a steady state
Protein C and its cofactor protein S are also vitamin K dependent, and are depleted by
warfarin. Warfarin is rapidly and completely absorbed in the upper gastrointestinal (GI)
tract by passive diffusion, with nearly 100% bioavailability.
It is approximately 99% bound to serum albumin.
(Vd) for warfarin is 12.5% of body weight.
Monitor the prothrombin time (PT).
warfarin is metabolized by primarily by CYP1A2 and CYP3A4.
CYP2C9 (kidney) influences the rate of metabolism of warfarin and thus impacts dosing
requirements
ADR: hemorrhage, skin necrosis, purple toe
Chronic Alcohol ingestion induce metabolization , inc dose
Acute alcohol ingestion, inc bleeding

Tests Used to Monitor Antithrombotic Therapy
Before the initiation of antithrombotic therapy, obtain a baseline platelet count and
hematocrit (Hct),
PT and aPTT, the tests used to monitor warfarin and heparin, respectively.

Prothrombin Time/International Normalized Ratio
It reflects alterations in the extrinsic pathway
INR is the standard for monitoring warfarin therapy
prolonged by deficiencies of clotting factors II, V, VII, and X, low levels of fibrinogen
and very high levels of heparin.
The PT is measured by adding calcium and tissue thromboplastin
The ISI of the international reference thromboplastin is 1.0.
Regular intensity therapy INR goal is 2.5 (range, 2.03.0)
High-intensity therapy INR goal of 3.0 (range, 2.53.5).

Activated Partial Thromboplastin Time
The aPTT reflects alterations in the intrinsic pathway

used to monitor heparin therapy

adding a surface-activating agent (kaolin or micronized silica), a partial thromboplastin

reagent (phospholipid; platelet substitute), and calcium to the plasma sample.


Anti-Xa Activity
monitored in pts using LMWHs.
measured using a chromogenic assay


Reversal of Effect
DVT on heparin therapy, Bright red blood was evident on rectal examination, and a large
retroperitoneal mass was noted. How should the excessive heparin effect be reversed?
Heparin should be DC immediately, and treatment should include maintenance of fluid
volume and replacement of clotting factors with whole blood, fresh frozen plasma, or
clotting factor concentrates.
Use Protamine sulfate is infused slowly over 3 to 5 minutes

DVT
Homans' sign (pain behind the knee or calf on dorsiflexion of the foot)
Risk factor: obesity and immobilization
If hospitalized, IV UFH is selected for initial treatment for DVT, then warfarin( thrombolytic
therapy for 3-6 mos)
Monitor aPPT,
ADR: thrombocytopenia, hemorrhage

Nonpharmacologic Measures
use of elastic compression stockings
leg elevation
leg exercises
early postoperative ambulation
Intermittent pneumatic compression (IPC) of the leg muscles, using inflatable cuffs
applied to the calf and thigh
Pharmacologic Measures
low-dose heparin - aPTT monitoring is unnecessary. Bleeding complications are
minimized using this dosing regimen.
.
Pregnant
Other options are UFH and LMWHs
LMWHs in the prevention and treatment of DVT and PE during pregnancy
UFH extensively use in pregnancy


Arrythmias

Pathophysiology
Abnormal Impulse Formation
Abnormal Impulse Conduction
o Re-Entry
The impulse travels along one pathway
unidirectional antegrade (forward movement) block
The impulse propagates in a retrograde manner (i.e., moves backward)
through the previously blocked pathway.
o Block
left bundle branch blocks (LBBBs)
right bundle branch blocks (RBBBs) in the ventricles.

Classification of Arrhythmias
originating above the bundle of His are referred to as supraventricular arrhythmias.
o sinus bradycardia
o sinus tachycardia
o paroxysmal supraventricular tachycardia, atrial flutter
o atrial fibrillation (AF)
o Wolff-Parkinson-White (WPW) syndrome
o and premature atrial contractions (PACs).
o normal QRS complexes
Arrhythmias originating below the bundle of His are referred to as ventricular
arrhythmias
o premature ventricular contractions (PVCs),
o VT,
o ventricular fibrillation (VF).

Antiarrhythmic Drugs
Vaughn-Williams antiarrhythmic drug classes.
o Class I drugs, sodium channel blockers,
class IA is intermediate( Q, P, D)
IB is quick, (L, M, T)
IC is long ( M, F, P)
o Class II drugs are -adrenergic blockers (
o class III drugs are potassium channel blockers( B, S, A, I, D)
o class IV drugs are calcium channel blockers
Class IA and class III
o increase repolarization time, QTc interval, and the risk of TdP.
Class II and IV
o decrease the HR, decrease the force of ventricular contractility (may decrease
stroke volume), and prolong the PR interval
Class IB antiarrhythmics work only in ventricular tissue, cannot be used in AF or atrial
flutter.
Class IC should never be used after an MI or with heart failure (HF) or severe left
ventricular hypertrophy.
Others: adenosine, digoxin
Propafenone is a class IC agent with -blocking properties








Infectious disease

Disease Causative agent Info drugs
Dysentery shigella bloody diarrhea
Cholera Vibrio cholerae Rice watery stools
Travellers diarrhea e. coli doxycycline
Salmonella typhi non lactose fermenting ceftriaxone
Leptospirosis spirochete PEN G
Prohylaxis:Doxycycline
Syphilis Treponema
palladium
Benzathine PCN
cytomegalovirus Pneumonia in
immunocompromised,
retinitis
gancyclovir
Genital herpes HSV type 2 Also neonatal herpes acyclovir
Gingivostmatitis(
cold sores)
HSV type 1 Eye, encephalitis
Chicken pox
shingles
Varicella
zoster
Acyclovir, valacyclovir,
famciclovir, zoster
immune globulin
Pseudomonas colitis c. diff Superinfection vancomycin
endocartitis Strep. viridans From GIT,
nasopharynx, gingival

pneumonia legionella From Aircon
candidiasis Candida albicans nystatin
Infective
Endocarditis
Strepco viridans-
slowly develop
s. aureus
-rapid progessive

Fever, embolic
phenemona anemia

PCN + streptomycin
2 week therapy
RHD strepcoccus inflammation scarring
heart valves cause by

PEN G, PEN V, PRP
TB

M. hominis, M.
bovis
AACCCCERO 1
st
: RIPES
2
nd
: ethionamide,
capreomycin,
cycloserine(toxic), ASA,
kanamycin, amikacin,
cipro, ofloxacin, rifabutin,
clofazimine
amebiasis Entamoeba
hystolica
For amebic liver
abcess-
Single dose after 1 mon
Chloroquine+metronidazo
le

Emetine+ dihydroemetine

Coagulase test: differentiates S aerues to S. epidermidis, forms clot, coagulate fibrinogen
DTP; diphtheria toxoid pertussis, heat killed whole bacteria, tetanus
Coombs test: autoimmune hemolytic anemia
Neutrophils: bacteria
Basophils: fungi
Lymphocytes: virus
Eosinophils: parasites
Sulfisoxazole: kernictus
Sulfa drugs: SJS: erythema multiforme
Repiratory infection: caused by virus(mostly), symptomatic, involve airways, larynx throat
Ca: metal required in blood clotting
Encephalitis: not airborne, viremia
Viral infection: self limiting, immunization
Positive tuberculin test: hypersensitivity to TB bacillus and its products
TCN: stain teeth of 6 mos in utero to 8 y/o, interval with Mg, Ca containing products
Staphyloccal infection: different to treat because of drug resistance
PEN V: prophylaxis to rheumatic heart disease
Chloramphenicol: aplastic anemia: idiosyncratic, thrombocytopenia: dose related
RHD: inflammation scarring heart valves cause by strepcoccus

Cefaclor, cephalexin, cephradine, cefadroxil: all affected by food
Cefaclor: 2
nd
gen, otitis media
Cephalotin: 1
st
gen, given IM cause poorly absorbed
Cefoperazone: stability is less than 24 hours
Aminoglycoside:
ototoxic, nephrotoxic
inactive against anaerobic negative bacteria, fungi, virus
Post operative and intra abdominal infection, respi, skin, bone disease
All cephalosporin: ADR is
GI effects
Hematological
CNS
phlebitis
Extended PCN- anti pseudomonal, widest spectrum
Piracillin
Ticarcillin
Mezlocillin
Sulbenicillin
AminoPCN- wide spectrum
Amoxicillin, ampicillin, becampicillin
PCN caution with history of
Asthma- bronchoconstriction
high fever, uticaria- hypersensitivity with PCN
Dapsone+ rifampicin: combi therapy in leprosy
Sexually transmitted disease treatment
PCN, TCN
Erythromycin, spectinomycin
Cause of pneumonia:
Virus, bacteria, pneumococcus
Ascaris: all azole
Severe amoebic infection: metronidazole + diloxanide
Absorption reduce by food: TCN , metronidazole
Absorption increase by food: griseosulvin: fatty foods
Ketoconazole: well absorbed after oral admin
Bacampicillin and metampicillin are prodrugs of ampicillin
PCN: anaphylactic shock, cross sensitivity, superinfection
TCN + PCN: antagonism effect
Doxycycline: impaired by divalent Fe, Mg, Ca, Al
Cardiac arrhythmias: concomitant admin of astemizole, erythtomycin, ketoconazole
Pseudomona aeruginosa: dangerous to eye
Boils: staphylococcus
Idoxuridine: HSV of eyelids and conjunctiva
Corticosteroid increase susceptibility to infection
Pthalylsulfathiazole: indicated for decreasing intestinal micro flora
Penicilloyl polylysine: subs for skin test in PCN allergy, negative result doesnt rule out
hypersensitivity -but indicates no anaphylaxis reaction to occur
Doxyxycline: poorest choice in UTI
Spectinomycin(trobicin): alternative for gonnorhea in PCN allegy or PCN resistant
Spectrobid: identical ADR to ampicillin
Ticarcillin: smaller dose than carbenicillin, preffered in CHF, RF, HTN
INH: one of the most potent Anti-TB drugs
Rifampin: sweet orange urine
INH: peripheral neuropathy
PZA: uric acid
Ethambutol: optic neuritis, visual acuity
Streptomycin: 8
th
nerve damage
Chloramphenicol: typhoid fever
Gentamicin: effectivity increase in alkaline urine
TCN: fanconi like symdrome: out dated TCN ingestion
Aminoglycoside: cidal in gram - +, better in alkaline urine
Amphotericin: salting out with electrolyte addition
COPD: h. influenza. Klebsiella
PEN V: URI from swimming pool
Hepatitis: inc in SGOT, SGPT, bilirubin, jaundice
INH: keystone tx in pulmonary TB
Rifampin: second major drug use in TB

1. Isoniazid is a primary antitubercular agent that
(A) requires pyridoxine supplementation.
(B) may discolor the tears, saliva, urine, or feces orange-red.
(C) causes ocular complications that are reversible if the drug is discontinued.
(D) may be ototoxic and nephrotoxic.
(E) should never be used because of hepatotoxic potential.


2. All of the following factors may increase the risk of nephrotoxicity from gentamicin therapy
except which one?
(A) age >70 years
(B) prolonged courses of gentamicin therapy
(C) concurrent amphotericin B therapy
(D) trough gentamicin levels < 2 mg/mL (E) concurrent cisplatin therapy

3. In which of the following groups do all four drugs warrant careful monitoring for drug-related
seizures in high-risk patients?
(A) penicillin G, imipenem, amphotericin B, metronidazole
(B) penicillin G, chloramphenicol, tetracycline, vancomycin
(C) imipenem, tetracycline, vancomycin, sulfadiazine
(D) cycloserine, metronidazole, vancomycin, sulfadiazine
(E) metronidazole, imipenem, doxycycline, erythromycin

4. AC is a 34-year-old male admitted with a diagnosis of peritonitis. Cultures are positive for
Bacteroides fragilis, Enterococcus faecalis, and Staphylococcus aureus. Which of the following
would be the best initial therapy to recommend?
(A) telithromycin
(B) quinupristin/dalfopristin
(C) tigecycline
(D) trimethoprim/sulfamethoxazole
(E) kanamycin

5. TJ is a 45-year-old female presenting with an Enterobacter aerogenes bacteremia with a low-
grade fever (101.6F). Th e most appropriate management of her fever would be to
(A) give acetaminophen 1000 mg orally every 6 hrs.
(B) give aspirin 650 mg orally every 4 hrs.
(C) give alternating doses of aspirin and acetaminophen every 4 hrs.
(D) withhold antipyretics and use the fever curve to monitor her response to antibiotic
therapy.
(E) use tepid water baths to reduce the fever.

6. BC has an upper respiratory infection. Two years ago, she experienced an episode of
bronchospasm after penicillin therapy. Current cultures are positive for a strain of Streptococcus
pneumoniae that is sensitive to all of the following drugs. Which of these drugs would be the
best choice for this patient?
(A) amoxicillin/clavulanate (B) telithromycin (C) ampicillin (D) cefaclor (E) loracarbef

7. All of the following drugs are appropriate therapies for a lower urinary tract infection owing to
Pseudomonas aeruginosa except
(A) norfloxacin.
(B) trimethoprimsulfamethoxazole.
(C) ciprofloxacin.
(D) tobramycin.
(E) methenamine mandelate.

8. BT is a 43-year-old female seen by her primary-care physician for a mild staphylococcal
cellulitis on the arm. Which of the following regimens would be appropriate oral therapy?
(A) dicloxacillin 125 mg every 6 hrs
(B) vancomycin 250 mg every 6 hrs
(C) methicillin 500 mg every 6 hrs
(D) cefazolin 1 g every 8 hrs
(E) penicillin V 500 mg every 6 hrs

9. RC is a 33-year-old male with a history of HIV for 10 years who now presents with
Mycobacterium avium-intracellulare (MAI). Which of the following drugs has demonstrated in
vitro activity against MAI?
(A) daptomycin (B) clarithromycin (C) erythromycin base (D) cloxacillin (E) minocycline

10. All of the following statements regarding pentamidine isethionate are true except which one?
(A) It is indicated for treatment or prophylaxis of infection owing to Pneumocystis carinii.
(B) It may be administered intramuscularly, intravenously, or by inhalation.
(C) It has no clinically significant effect on serum glucose.
(D) It is effective in the treatment of leishmaniasis.

11. RE is a 23-year-old male with a history of severe asthma. An outbreak of H1N1 influenza
has just been reported in his community, and he is exhibiting initial symptoms of the infection.
Which agent would be the most useful to treat RE?
(A) cidofovir (B) famciclovir (C) oseltamivir (D) zanamivir (E) ribavirin

12. Dr. Jones requests your help in selecting a protease inhibitor as part of a regimen for a
treatment-naive male patient. Which of the following would you recommend?
(A) darunavir/ritonavir
(B) lopinavir/ritonavir
(C) nelfinavir
(D) saquinavir/ritonavir
(E) tipranavir/ritonavir

13. Drugs usually active against penicillinase-producing Staphylococcus aureus include which of
the following?
I. piperacillintazobactam
II. amoxicillinclavulanate
III. nafcillin

14. Antiviral agents that are active against cytomegalovirus (CMV) include which of the
following?
I. ganciclovir
II. foscarnet
III. acyclovir
A clofazimine B itraconazole C levofloxacin D neomycin
Levofloxacin15. It may be administered once per day for the treatment of urinary tract
infections.
clofazimine 16. It may cause pink to brownish skin pigmentation within a few weeks of initiation
of therapy.
Itraconaxole 17. Coadministration with astemizole or terfenadine may lead to life-threatening
cardiac dysrhythmias.


1. A patient with a long history of cardiovascular disease develops worsening ventricular
arrhythmias. Which of the following drugs is most likely to be the cause of the arrhythmia?
(A) Quinidine (B) Propanolol (C) Dobutamine (D) Methyldopa

2. A patient is admitted into the emergency room and manifests ventricular tachycardia following
an acute myocardial infarction (MI). This arrhythmia is life threatening and must be controlled
immediately. Which of the following drugs would be best to quickly control the condition?
(A) Dobutamine (B) Digitalis (C) Quinidine (D) Lidocaine (E) Atropine

3. A woman who is undergoing a endocrine work-up to diagnose the cause of a large multi-
nodular goiter develops atrial fibrillation. Which of the following would be best to treat this
arrhythmia?
(A) Verapamil (B) Propranolol (C) Digitalis (D) Bretylium (E) Tocainide

4. A 57-year-old man with atrial flutter is initially treated with quinidine to control the
arrhythmia. He is released from the hospital, and while his condition improves, sporadic
arrhythmias continue. Which of the following drugs might be used as an adjunct to quinidine in
the treatment of the atrial flutter?
(A) Digitalis (B) Lidocaine (C) Procainamide (D) Nifedipine (E) Propranolol


9. A 76-year-old man has suffered from atrial fibrillation for many years. This condition has
been under good control with amiodarone and diltiazem until recently, when he started
experiencing palpitations and came back to see you. You decide to start the patient on digoxin
therapy. How does this medication work?
(A) It decreases intracellular sodium and increases intracellular potassium
(B) It lowers intracellular calcium
(C) It decreases stroke volume and cardiac output
(D) It diminishes elimination of sodium and water
(E) It increases vagal activity and decreases sympathetic tone

10. A 47-year-old woman is admitted for treatment of acute myocardial ischemia. Her prior
medication included digoxin for atrial fibrillation. She also suffers from hypertension, for which
she is currently not taking anything. Before you discharge her home, you decide to add a
medication that works well for hypertension. While she is still on the floor she develops a
dangerous arrhythmia, which you are fortunately able to treat promptly. Which medication you
added likely increased the effects of digoxin that this patient was already taking?
(A) Valsartan (B) Hydrochlorothiazide (C) Hydralazine (D) Tadalafil (E) Lovastatin

1. A 27-year-old man presents with complaints of a painless ulcer on his penis. He admits to
having unprotected intercourse with a woman he met in a bar during a conference 2 weeks ago.
A scraping of the lesion, visualized by dark field microscopy, demonstrates spirochetes, and a
diagnosis of syphilis is made. Which of the following is the treatment of choice assuming the
patient has no known allergies?
(A) Benzathine penicillin G (B) Penicillin G (C) Penicillin V (D) Doxycycline (E) Bacitracin

2. A 19-year-old military recruit living in the army barracks develops a severe headache,
photophobia, and a stiff neck, prompting a visit to the emergency room. A lumbar puncture
reveals a diagnosis of bacterial meningitis. Which of the following cephalosporins is likely to be
given to this patient?
(A) Cefazolin (B) Cefuroxime axetil (C) Ceftriaxone (D) Cefoperazone (E) Cefepime

3. A 27-year-old intravenous drug abuser is admitted for fever and shortness of breath. Multiple
blood cultures drawn demonstrate S. aureus. The cultures further suggest resistance to
methicillin. The attending physician also orders a transesophageal echocardiogram that shows
tricuspid vegetations consistent with endocarditis. Which of the following is an appropriate
antibiotic?
(A) Aztreonam (B) Imipenem (C) Gentamicin (D) Vancomycin (E) Ceftriaxone

4. A 57-year-old chronic alcoholic develops hepatic encephalopathy. In an attempt to decrease
his ammonia levels, you decide to sterilize his intestines, knowing that the gastrointestinal flora
is responsible for the ammonia that his liver can no longer detoxify. Which antibiotic, given
orally, will accomplish this?
(A) Neomycin (B) Vancomycin (C) Erythromycin (D) Ciprofloxacin (E) Nitrofurantoin

5. A 12-year-old boy presents with a rash on the palms and the soles of his feet as well as fever
and headache. He was camping last week- end and admits to being bitten by a tick. His Weil-
Felix test result is positive, suggesting Rocky Mountain spotted fever. What antibiotic should be
given?
(A) Streptomycin (B) Bacitracin (C) Ciprofloxacin (D) Doxycycline (E) Erythromycin
Streptomycin can be used to treat plague and brucellosis.
Bacitracin is only used topically.
Ciprofloxacin can be used to treat anthrax

6. A 27-year-old African American woman is seen in the emergency room with complaints of
urinary frequency, urgency, and dysuria. A urinary analysis demonstrates bacteria and white
blood cells, and she is given trimethoprim/sulfamethoxazole. She now returns with sores and
blisters around her mouth and on the inside of her mouth. Given her history and findings, what
should you include in the differential of her current complaint?
(A) Glucose-6-phosphate dehydrogenase deficiency
(B) Steven-Johnson syndrome
(C) Red man syndrome
(D) Aplastic anemia
(E) Disseminated M. aviumintracellulare infection

7. A 43-year-old HIV-positive woman with a CD4+ count of 150 presents with shortness of
breath. An arterial blood gas determination indicates hypoxia, and a chest x-ray shows bilateral
interstitial infiltrates. A suspected diagnosis of Pneumocystis carinii pneumonia (PCP) is
confirmed with bronchoscopy and silver staining of bronchial washings. Which of the following
therapies should be started?
(A) Isoniazid (B) Clindamycin (C) Azithromycin (D) Miconazole (E)
Trimethoprim/sulfamethoxazole

8. A 35-year-old diabetic woman presents to the emergency room with signs and symptoms of
urinary tract infection, including fever, dysuria, and bacteriuria. Given that she is diabetic, she is
admitted for treatment with intravenous ciprofloxacin. What is the mechanism of this drug?
(A) Inhibition of the 30s ribosome
(B) Inhibition of the 50s ribosome
(C) Inhibition of bacterial cell wall synthesis
(D) Inhibition of RNA synthesis
(E) Inhibition of DNA gyrase

9. A 35-year-old Mexican-American man presents to his family physician because his mother
has been visiting from Mexico and was found to have tuberculosis (TB). The family physician
places a purified protein derivative (PPD), which has negative results, but recommends
prophylaxis against TB. Which of the following is indicated for TB prophylaxis in exposed adult
patients?
(A) Rifampin (B) Ethambutol (C) Isoniazid (D) Streptomycin (E) Pyrazinamide

10. A 19-year-old woman has been under the care of an allergist and immunologist since she
learned she had a deficiency of C59 (the membrane attack complex) of the complement
cascade. Her roommate at college recently developed meningitis due to Neisseria meningitides.
Upon learning this, her physician recommends that she begin taking what antibiotic for
prophylaxis?
(A) Ceftriaxone (B) Isoniazid (C) Rifampin (D) Dapsone (E) para-Aminosalicylic acid (PAS)

11. A 12-year-old girl has undergone a bone marrow transplant for the treatment of acute
lymphoblastic leukemia (ALL). Five days later, she develops fever, and blood cultures reveal
Candida albicans in her blood. Which of the following antifungals would be appropriate to use
immediately?
(A) Nystatin (B) Miconazole (C) Clotrimazole (D) Ketoconazole (E) Amphotericin

It is often toxic and causes fevers and chills on infusion, the shake and bake.
Nystatin is used as a swish and swallow treatment for oral candidiasis.
Miconazole and clotrimazole are topical antifungals.
Ketoconazole is good for mucocutaneous candidiasis.

12. A 23-year-old AIDS patient develops fever, neck pain, and photophobia. He is seen in the
emergency room, where a lumbar puncture is performed. The cerebrospinal fluid (CSF) reveals
Cryptococcus neoformans on India ink stain. Which of the following agents is preferred for the
treatment of cryptococcal meningitis?
(A) Tolnaftate (B) Fluconazole (C) Griseofulvin (D) Cycloserine (E) Flucytosine

13. A 23-year-old recent college graduate has plans to go to Africa to work for a year in the
Peace Corps before returning to start medical school. He visits his family physician for a
prescription for appropriate malarial prophylaxis. He brings a map from the Centers for Disease
Control (CDC) that shows that the area he will be in has a high incidence of chloroquine
resistance. Which antimalarial should he take?
(A) Primaquine (B) Doxycycline (C) Mefloquine (D) Pyrimethamine (E) Quinine

Mefloquine is the primary agent used for prophylaxis in chloroquine-resistant areas.
Primaquine is not used for prophylaxis before exposure.
Doxycycline is used with quinine for acute malarial attacks due to multiresistant strains.
Pyrimethamine is used for suppressive care and not even for acute attacks.

14. A 14-year-old boy returns from a Boy Scout backpack trip with foul-smelling watery
diarrhea. On further questioning, he admits to drinking water from a mountain brook without
first boiling it. Stool is sent for ova and parasites, confirming the diagnosis of Giardia lamblia
infection. Which of the following drugs is appropriate treatment?
(A) Metronidazole (B) Nifurtimox (C) Suramin (D) Mebendazole (E) Thiabendazole

15. A 42-year-old AIDS patient presents to the emergency room with mental status changes and
a headache. A computed tomography (CT) scan is ordered and demonstrates a ring enhancing
lesion. You decide to treat him empirically due to the possibility of Toxoplasmosis gondii
abscess. Which agent should be included in his treatment?
(A) Ivermectin (B) Praziquantel (C) Pyrimethamine (D) Niclosamide (E) Pyrantel pamoate

Toxoplasmosis is treated with a combination of pyrimethamine and sulfadiazine.
Ivermectin is used to treat filariasis,
praziquantel is used to treat schistosomiasis.
Niclosamide can be used to treat tapeworm infections,
pyrantel pamoate is used to treat many helminth infections.

16. A 23-year-old immunocompetent woman sees her family physician with painful bumps
on her labia and vulva. On examination, there are vesicles in the described region. You suspect
herpes simplex infection on clinical grounds and recommend which of the following?
(A) Amantadine (B) Valacyclovir (C) Vidarabin (D) Foscarnet (E) Rimantadine

17. A 23-year-old HIV-positive woman presents to the obstetrician. The patient admits to
missing her last two menstrual periods, and a urinary human chorionic gonadotropin (hCG)
indicates that she is indeed pregnant. Which agent is used to decrease the risk of transmission of
HIV to the unborn child?
(A) Idoxuridine (B) Didanosine (C) Saquinavir (D) Zidovudine (E) Interferon a

Zidovudine is the only agent approved to prevent fetal transmission of HIV as it crosses the
placenta.
Idoxuridine is used in the treatment of herpes simplex virus (HSV) keratitis.
Didanosine is used to treat HIV in children as young as 6 months.
Saquinavir is used to treat HIV and is a protease inhibitor.
Interferon a works best against single-stranded RNA viruses.

18. A 37-year-old woman presents with fever, malaise, and right upper quadrant pain. Blood
tests reveal that she has an increase in her liver enzymes. In addition, hepatitis serology indicates
that she has hepatitis B virus (HBV). Which of the following agents can be used in the
management of this virus?
(A) Lamivudine (B) Zidovudine (C) Ribavirin (D) Interferon a (E) Acyclovir




1. Calcium-channel blockers can have all of the following characteristics except
(A) they block the slow inward current carried by calcium during phase 2 of the cardiac action
potential.
(B) they dilate peripheral arterioles and reduce total peripheral resistance
(C) they constrict coronary arteries and arterioles and decrease oxygen delivery to the
myocardium.
(D) they are useful in treating vasospastic angina.
(E) adverse effects include bradycardia and edema.

2. The termination of heparin activity by protamine sulfate is the result of
(A) a chelating action.
(B) the inhibition of gastrointestinal absorption of heparin.
(C) the displacement of heparinplasma protein binding.
(D) an acidbase interaction.
(E) the prothrombin-like activity of protamine.

4. Digoxin may be useful in treating one of the following conditions:
(A) AV block
(B) torsades de pointes
(C) congestive heart failure
(D) ventricular tachycardia
(E) bradycardia

13. All of the following agents can be used to manage atrial fibrillation except
(A) verapamil. (B) lidocaine. (C) dronedarone. (D) propranolol. (E) quinidine.

14. Which of the following is a likely adverse event of heparin therapy?
(A) purple toe syndrome
(B) thrombocytopenia
(C) dry cough
(D) skin necrosis
(E) hypertension

15. A major use of dabigatran is in
(A) thrombocytopenia.
(B) stroke prophylaxis in atrial fibrillation.
(C) decreasing clotting after stent placement.
(D) breaking down clots that have formed during myocardial infarction.
(E) intermittent claudication

16.Alteplase is less likely to cause systemic bleeding than urokinase because
(A) it only activates thrombin that is associated with a clot.
(B) it has more specific effects on platelets.
(C) it is a recombinant protein.
(D) it only activates plasminogen associated with a clot.
(E) urokinase is extracted from hemolytic streptococcus that causes bleeding.

18. All of the following agents have actions on blood platelets to modify clot formation except
(A) eptifibatide. (B) dabigatran. (C) clopidogrel. (D) dipyridamole. (E) tirofiban.

19.Warfarin
I. increases hepatic vitamin K epoxide.
II. decreases reduced hepatic vitamin K.
III. decreases the absorption of dietary vitamin K.

25. Which of the following is required for heparins action on factor Xa?
I. Antithrombin III
II. Fibrinogen
III. Thrombin

2. Prophylaxis against venous throboembolic disease (VTED) may include
(A) nonpharmacological prophylaxis.
(B) pharmacological prophylaxis.
(C) nonpharmacological and pharmacological prophylaxis.
(D) neither nonpharmacological nor pharmacological prophylaxis.

3. Unfractionated heparin binds to antithrombin III and inactivates clotting factor(s)
(A) Xa (B) IXa (C) IIa (D) All of the above (E) None of the above

4. Initiation of UFH therapy for the patient described in question 1 would best be achieved with
(A) 5000 U loading dose followed by 1000 U/hr.
(B) 5000 U loading dose followed by 1800 U/hr.
(C) 8000 U loading dose followed by 1800 U/hr.
(D) 1000 U loading dose followed by 1000 U/hr.

5. When choosing an Food and Drug Administration (FDA)-approved LMWH to treat this
patient, you would administer
I. enoxaparin 1.0 mg/kg/dose subcutaneously every 12 hrs.
II. enoxaparin 1.5 mg/kg/dose subcutaneously every 24 hrs.
III. tinzaparin 175 IU/kg/dose subcutaneously every 24 hrs.

6. Which of the following tests are used to monitor heparin antithrombotic therapy?
I. international normalized ratio (INR)
II. activated partial thromboplatin time (aPTT)
III. heparin assay


7. A patient to be commenced on oral anticoagulant therapy for DVT would be treated with
I. oral anticoagulant therapy with warfarin for a goal INR of 2.0 to 3.0.
II. oral anticoagulant therapy with warfarin for a goal INR of 2.5 to 3.5.
III. oral anticoagulant therapy with aspirin for a goal INR of 2.0 to 3.0.

8. A patient on oral anticoagulant therapy is commenced on sulfamethoxazole-trimethoprim,
double-strength twice daily. One may expect to see the INR
I. increase.
II. decrease.
III. remain unchanged.

9. If a patient has an INR 20 and active bleeding that is clinically significant (i.e., hematuria),
the pharmacist should
I. hold the drug therapy.
II. administer vitamin K.
III. administer fresh frozen plasma.

10. Compared to unfractionated heparin (UFH), LMWHs have
I. preferential binding affinity to factor Xa relative to IIa (thrombin).
II. shorter half-lives.
III. dose-dependent renal clearance.

11. An 87-year-old woman who weighs 49 kg (108 lb) and is 66 inches tall has sustained a hip
fracture requiring open reduction with internal fixation (ORIF) surgery. She has a documented
serum creatine value recorded in the chart and in the laboratory results as 4.3 mg/dL. The
orthopedic surgeon asks you, the pharmacist, about the appropriate fondaparinux dosing for this
patient to prevent venous thromboembolism after the surgery. Which of the following are
contraindications to the use of fondaparinux in this patient?
I. Patient weighs < 50 kg.
II. Patient has severe renal impairment.
III. Patient is elderly.

1. Strong anticholinergic effects limit the antiarrhythmic use of
(A) quinidine (Various).
(B) procainamide (Various).
(C) mexiletine (Various).
(D) fl ecainide (Tambocor).
(E) disopyramide (Norpace).

2. A pronounced slowing of phase 0 of the myocardial action potential results in a prolongation
of either atrial depolarization, causing a prolonged P wave on the electrocardiogram
(EKG/ECG), or ventricular depolarization, causing a prolonged QRS complex characterized by
which class of antiarrhythmics?
(A) Class I (B) Class II (C) Class III (D) Class IV (E) Class V

3. Which of the following class III antiarrhythmics has been reported as carrying a risk for
causing torsades de pointes?
(A) lidocaine (Xylocaine)
(B) amiodarone (Cordarone)
(C) quinidine (Various)
(D) flecainide (Tambocor)
(E) diltiazem (Cardizem)

4. A patient receiving a class I antiarrhythmic agent complains of GI symptoms, including
nausea, vomiting, and occasional diarrhea after taking a dose. The patient is most likely
receiving
(A) lidocaine (Xylocaine).
(B) procainamide (Various).
(C) quinidine (Various).
(D) flecainide (Tambocor).
(E) propranolol (Inderal).

5. Class III antiarrhythmics have which of the following effects to the cardiac cells action
potential?
(A) Slow the rate of rise for phase 0 of depolarization.
(B) Delay the fast-channel conductance of sodium ions.
(C) Prolong phases 2 and 3 of repolarization.
(D) Inhibit the slow-channel conductance of calcium ions.
(E) Prolong the refractory period of the action potential.

6. Which of the following drugs is a class IV antiarrhythmic that is primarily indicated for the
treatment of supraventricular tachyarrhythmias?
(A) ibutilide (Corvert)
(B) mexiletine (Various)
(C) diltiazem (Cardizem)
(D) procainamide (Various)
(E) propranolol (Inderal)

7. Relatively new antiarrhythmic agent, which has not yet been formally added into the Vaughan
Williams classifi cation table but received a class IIa rating with a class B level of evidence to
decrease the need for hospitalization in patients with paroxysmal atrial fibrillation or after
conversion of persistent atrial fibrillation. Which of the following agents is best described by the
above statements?
(A) aliskiren (Tekturna)
(B) inamrinone (Various)
(C) dronedarone (Multaq)
(D) amiodarone (Cordarone)
(E) dofetilide (Tikosyn)

8. Which of the following drugs is a class III antiarrhythmic agent that is effective in the acute
management of atrial fibrillation or atrial flutter of recent onset?
(A) propranolol (Inderal)
(B) ibutilide (Corvert)
(C) metoprolol (Lopressor)
(D) disopyramide (Norpace)
(E) diltiazem (Cardizem)

9. All of the following problems represent concerns when patients are started on amiodarone
except
(A) extremely long t.
(B) need for multiple daily doses.
(C) development of hyperthyroidism or hypothyroidism.
(D) development of liver toxicity.
(E) interactions with numerous other drugs.

10. Based on the criteria used for recent national guidelines used within the cardiology arena,
which of the following recommendations would most likely result in the use of a selected
antiarrhythmic therapy for a patient with atrial fi brillation?
(A) Class I; level C
(B) Class I; level A
(C) Class IIa; level B
(D) Class III; level A
(E) Class IIb; level A