TEST BANK for Pharmacology for Health Professionals, 5th Ed by Bryant, B Knights, Darroch & Rowland

Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 1: Drugs and Medicines Test Bank MULTIPLE CHOICE 1. The definition of pharmacology is: A. The study of the formulation of drugs B. The study of farming techniques C. The study of drugs including their source, nature, actions and effects in living systems D. The study of pharmacy (the preparation and development of drugs) ANS: C Pharmacology is the study of how substances, such as drugs, affect human physiology and pathology.

2. Useful drugs have the following important attributes: A. Affinity, toxicity and specificity B. Potency, selectivity and specificity C. Potency, toxicity and efficacy A. D Toxicity, efficacy and formulation ANS: B A useful drug will exhibit therapeutic effects at lower concentrations and have a narrow range of actions on particular receptors. These attributes decrease the incidence of adverse effects.

3. Potency refers to: A. A drug’s ability to produce an effect B. The narrowness of a drug’s range of actions C. The amount of drug required to produce an effect D. A drug’s ability to produce adverse reactions ANS: C If a dose of one drug exhibits a greater effect compared with the same dose of a similar drug, this indicates that the drug has high potency.

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4. In Greek civilisations medical care was characterised by: A. A The introduction of hospitals and hospices B. The belief that diseases result from natural causes C. The belief that diseases could be cured with specific remedies D. Deliberate clinical testing of drugs for their action ANS: B This idea was advanced by Hippocrates in the 5th century BC. By studying natural laws, one can make a diagnosis of an illness.

5. A drug from both human and animal sources is: A. Papaver somniferum (morphine) B. Iodine C. Insulin D. Eucalyptus oil ANS: C Insulin is derived from human pancreatic cells, recombinant techniques and from animals such as cows (bovine insulin).

6. The approved (generic) name of a drug is: A. A name that is protected by copyright B. A precise description of the drug’s chemical composition and molecular structure C. The name used to market the drug D. The official drug name assigned by the manufacturer and approved by the local regulatory authority ANS: D It is a shorter name, derived from the chemical name and listed in official compendiums.

7. A pharmacologically active compound derived from non-plant material is: A. Mineralocorticoid B. Glycoside C. Alkaloid D. Phenol ANS: A Mineralocorticoids are synthesised in the adrenal cortex of the mammalian kidney.

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8. Drugs are classified by all of the following methods, EXCEPT: A. Clinical use B. Chemical formula C. Manufacturer D. Mechanism of action ANS: C Drugs are not classified according to their manufacturer or the manufacturing process.

9. Over-the-counter drugs are available: A. In general stores and supermarkets B. From a pharmacy assistant C. With a prescription D. In pharmacies, supermarkets and general stores ANS: D OTC drugs are available from all three sources and do not require a prescription.

10. An information source that provides data about specific drugs relevant to a particular country is: A. Pharmacopoeia B. Compendium C. Encyclopaedia D. Formulary ANS: A Pharmacopoeias are specific to a country, for example, the British Pharmacopoeia.

Encyclopaedias and compendiums contain information about drugs available worldwide.

Formularies contain information about pharmaceutical processes.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 2: Legal, Clinical and Ethical Foundations of Pharmacotherapy Test Bank MULTIPLE CHOICE 1. The most highly valued evidence in 'evidence-based medicine' (EBM) involves the use of: A. Results from animal studies B. Results from randomised controlled clinical trials C. Results from case series D. Results from anecdotal evidence ANS: B Meta-analyses systematically review all relevant results from randomised controlled clinical trials (RCCT) and are considered to be the ‘gold standard’ of evidence.

2. The role of the Therapeutic Goods Administration (TGA) in Australia is to: A. Register all drugs that are imported into Australia B. Subsidise drugs considered essential to optimum health care C. Instigate clinical trials of drugs D. Register drugs according to quality, safety, efficacy and cost effectiveness ANS: D Any drug for which a clinical claim is made must be registered by the TGA. 3. One of the descriptions of the quality use of medicines (QUM) is the use of: A. Subsidised medicines only B. Medicines safely and effectively C. Alternative and prescription medicines concurrently D. Medicines that have undergone randomised clinical trials only ANS: B The quality use of medicines (QUM) involves rationalising government policies and ensuring that medicines are used safely and effectively.

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4. Which of the following health professionals may prescribe certain types of drugs, check dosages and administer s2 or s3 drugs?

A. Pharmacist B. Nurse C. Occupational therapist D. Doctor or pharmasist ANS: D In this example, a doctor or pharmasist may prescribe drugs.

5. With regard to prescribing drugs: A. Prescriptions in hospitals are usually written on a prescription form B. Prescriptions must include the right patient, drug, dose, route and time of administration C. Telephone orders are made by the pharmacist to the nurse D. Standing orders are verbal orders from a doctor to nursing staff ANS: B Answer B is the only correct statement.

6. Pharmaceutics is the science of: A. Drug activity B. Drug counselling C. Drug formulation D. Drug synthesis ANS: C Pharmaceutics, as a science, involves the formulation of specific drug preparations for clinical use.

7. An example of a preparation for parenteral administration is: A. Enteric-coated tablets B. Intravenous infusions C. Transdermal patch D. Sustained-release preparations ANS: B Parenteral administration refers to the administration of drugs by injection.

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8. The best definition of adherence is: A. The patient reports adverse effects of the drug B. The pharmacist complies with the doctor’s orders C. The doctor follows the patient’s requests D. The patient follows all aspects of the treatment plan ANS: D For patients to be ‘compliant’ with therapy, they must follow all therapeutic advice given to them.

9.

Concerning drug regulations in Australia: A. State and territory laws control the use of therapeutic goods B. Medical devices are not subject to regulation C. Non-medicinal drugs (alcohol, tobacco) are not subject to regulation D. State and territory laws control the use of 'poisons'

ANS: D In general, state and territory laws control the use of 'poisons' and commonwealth legislation controls the use of therapeutic goods.

10. In Australia, drugs and poisons are regulated by placing them in: A. Jurisdictions B. Classifications C. Regulations D. Schedules ANS: D SUSMP schedule drugs according to a uniform regulatory scheme.

11. In Australia, drugs are classified into a specific Schedule by: A. Therapeutic Goods Administration (TGA) B. National Drugs and Poisons Schedule Committee C. National Health and Medical Research Council D. United Nations Convention on Narcotic Drugs ANS: A The TGA makes the final decision on registering the drug for therapeutic use in Australia and decides which Schedule it should be classified into.

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12. Which Schedules include drugs used medically?

A. Schedules 2, 3, 8 and 9 B. Schedules 2, 3, 4 and 8 C. Schedules 5, 6, 7 and 9 D. Schedules 2, 3, 4 and 9 ANS: B Schedules 2 (pharmacy medicines), 3 (pharmacist-only), 4 (Prescription-only) and 8 (controlled drugs) include drugs used medically.

13. Which factor is NOT of major importance in the decision to place a drug into a particular Schedule?

A. Potential toxicity B. Manufacturing process C. Potential clinical activity D. Abuse potential ANS: B Drug scheduling is not based on the manufacturer process. Classification depends on formulation, action, toxicity and potential for abuse.

14. Which ethical principle involves giving all persons equal access to health and health care?

A. Autonomy B. Non-maleficence C. Beneficence D. Justice ANS: D Justice affords all people, despite socioeconomic status, the right to equal healthcare benefits.

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15. The ethical principle of beneficence involves: A. The right to refuse treatment B. The right to have sufficient information to make informed decisions C. Doing good as part of duty of care D. Doing no harm as part of duty of care ANS: C Beneficence underpins the duty of care owed to patients and clients by health professionals to meet required standards of care delivery.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 3: Over-The-Counter Drugs and Complementary Therapies Test Bank MULTIPLE CHOICE 1. In reference to over-the-counter drugs: A. They have a high incidence of severe adverse reactions B. They can only be purchased in a pharmacy C. They provide relief from minor symptoms in a small percentage of the population D. They are used by people to self-treat minor illnesses ANS: D Over-the-counter drugs are able to be purchased without a prescription as it is assumed that, with the doses advised, they are safe enough for the general public to undertake self-medication.

2. Schedule 2 drugs are those drugs that are: A. Available for purchase in a supermarket B. Prescription-only C. Sunscreens and medicated shampoos D. Purchased in a pharmacy where professional advice is available with their supply ANS: D Schedule 2 drugs are classed as pharmacy-only and can be bought without a prescription where advice from a pharmacist is available.

3. Which drug would not be considered for use as an over-the-counter medicine?

A. Antihistamines B. Aspirin C. Decongestants D. Antidepressants ANS: D Antidepressants require a prescription. With use at therapeutic doses, there is a potential for adverse effects.

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4. Complementary medicine is defined as: A. Scientifically unfounded and lacking supporting evidence B. Scientifically validated in some instances and may integrate alongside mainstream healthcare practice C. Practices that include iridology, aromatherapy and macrobiotics D. Medicine that is unregulated by the TGA ANS: B Complementary medicine includes vitamins and herbal remedies that are regulated by the TGA. 5. A characteristic of Traditional Chinese Medicine (TCM) is: A. An emphasis on health promotion, stabilisation and energy balance B. Illness may be caused by astral dysfunction C. Treatment concentrates on alleviating the symptoms D. Teachings are inherited through oral tradition ANS: A There is a long, written history of Chinese medicine. A holistic approach is taken and includes exercise, diet and balancing of energy levels in order to maintain good health.

6. Products used in complementary and alternative medicines do not usually include: A. Vitamins B. Herbal medicines C. Minerals D. Synthetic drugs ANS: D Complementary and alternative medicines include ingredients such as herbs, vitamins, minerals and nutritional supplements.

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7. Regarding the regulation of CAM therapies: A. Most products are registered by the TGA B. Most products undergo rigorous testing, regulation and monitoring by the TGA C. Products of low risk are allowed to be self-assessed by the provider D. Products of high risk are banned from use ANS: C Depending on the ingredients and the claims made, the TGA may monitor the therapy.

The level of control depends on the risk level of the therapy.

8. What is considered by regulatory authorities to be the MAIN problem with CAM therapies?

A. Lethal effects B. Inadequate levels of scientific evidence C. High cost D. Inadequate labelling ANS: B The main issue related to CAM therapy use is the lack data on safety and efficacy.

9. The definition of herbal medicine is: A. Treatment with volatile oils and their aromas B. Treatment with part-per-million dilutions of the substance that produces symptoms C. Treatment using preparations of plant material D. Treatment of the patient in the home environment ANS: C Parts of plants and their extracts are used in herbal medicines for the treatment of illness.

10. Which treatment is considered to be an alternative pharmacological therapy?

A. Exercise B. Counselling C. Homeopathy D. Acupuncture ANS: C Minute amounts of plant drugs are used in homeopathy. The other examples presented are non-drug-based therapies.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 4: Molecular Drug Targets and Pharmacodynamics Test Bank MULTIPLE CHOICE 1. The term that best describes the strength of interaction between a drug and its molecular target is: A. Specificity B. Selectivity C. Affinity D. Potency ANS: C Affinity describes the strength of interaction between drugs and their molecular targets.

2. Which of the following statements is the correct meaning of the term 'maximal drug efficacy’: A. Maximal drug efficacy is the maximum response a drug can produce B. Maximal drug efficacy is when several drugs have the same potency and the same efficacy C. Maximal drug efficacy measures the attraction between the drug and its target D. Maximal drug efficacy refers to increasing the drug dose until the receptors are saturated ANS: A Maximal drug efficacy is the maximum response a drug can produce. Clinical effectiveness depends on this level of efficacy rather than the potency.

3. The synthesis of cyclic adenosine monophosphate (cAMP) by membrane-bound adenylate cyclase is under the control of: A. Type 1: Transmitter-gated channels B. Type 2: G-protein-coupled receptors C. Type 3: Catalytic (kinase-linked) receptors D. Nuclear receptors ANS: B Cyclic adenosine monophosphate (cAMP) is synthesised by membrane-bound adenylate cyclase under the control of a number of GPCRs. The cAMP secondary messenger is linked to the action of β-adrenoceptors and many other receptors.

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4. A secondary messenger capable of diffusing through the cytoplasm that causes the release of calcium from intracellular storage sites is: A. Cyclic adenosine monophosphate (cAMP) B. Diacylglycerol (DAG) C. Protein kinase C D. Inositol triphosphate (IP3) ANS: D Inositol triphosphate (IP3) diffuses through the cytoplasm and causes the release of calcium from storage sites. The increased intracellular calcium then regulates the activity of other enzymes, producing a response such as increased contractility. These particular secondary messengers are important for producing the effects mediated by α-adrenoceptors and muscarinic receptors.

5. A term that refers more specifically to a decrease in the response of the receptor–secondary messenger system is: A. Tachyphylaxis B. Desensitisation C. Downregulation D. Upregulation ANS: B Desensitisation refers more specifically to a decrease in the response of the receptor–secondary messenger system and is a common feature of many receptors.

6. A mechanism/s associated with receptor desensitisation is/are: A. Uncoupling of the receptor from its secondary messenger system B. Altered binding of the drug to the receptor C. Decrease in the number of receptors D. All of the above ANS: D Mechanisms underlying receptor desensitisation are complex. They include (1) an uncoupling of the receptor from its secondary messenger system, (2) altered binding of the drug to the receptor and (3) a decrease in the number of receptors.

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7. The increased responsiveness to stimuli when a drug that blocks receptors is abruptly withdrawn after chronic use is likely to be due to: A. Tachyphylaxis B. Desensitisation C. Downregulation D. Upregulation ANS: D Upregulation of receptors often occurs after chronic use of drugs that block receptors. If the drug is abruptly withdrawn, the person may experience increased responsiveness to stimuli (e.g. rebound hypertension).

8. The statement that best describes a partial agonist is: A. Partial agonists produce the same maximal response as the endogenous ligand B. Partial agonists produce less than the maximal response even when all the receptors are occupied C. Partial agonists are always less potent than full agonists D. Partial agonists bind to the receptor and block the action of the endogenous ligand without producing any effects of their own ANS: B Partial agonists produce less than the maximal effect even when all receptors are occupied.

9. A term that represents the drug potency and can be used to compare drugs acting on the same target is: A. EC50 B. Emax C. IC50 D. Km ANS: A The EC50 is the concentration at which the drug produces 50% of its maximal response.

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10. Antagonists that block the response to an agonist at some point within the cascade of intracellular events are best termed: A. Non-competitive antagonists B. Inverse antagonists C. Competitive (reversible) antagonists D. Competitive (irreversible) antagonists ANS: A Non-competitive antagonists block the response to an agonist at some point within the cascade of intracellular events.

11. The following property confers drug selectivity for a molecular target: A. Chemical structure B. Molecular size C. Electrical charge D. All of the above ANS: D Selectivity of a drug for any molecular target depends on its chemical structure, molecular size and electrical charge.

12. Diminished responsiveness after repeated exposure to the same concentration of a drug that stimulates the receptor is referred to as: A. Tachyphylaxis B. Desensitisation C. Downregulation D. Upregulation ANS: A Tachyphylaxis is seen when an individual's initial response to the drug cannot be reproduced, even with larger doses of the drug. Glyceryl trinitrate transdermal patches require an intermittent dose schedule for this reason.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 5: Drug Absorption, Distribution, Metabolism and Excretion Test Bank MULTIPLE CHOICE 1. Absorption is greatest for which of the following orally administered dosage forms: A. Enteric-coated tablets B. Suspensions C. Tablets D. Capsules ANS: B For oral drugs absorption is greatest for liquids, elixirs and syrups > suspension solutions > powders > capsules > tablets > coated tablets > enteric-coated tablets.

2. Absorption is slowest for which of the following orally administered dosage forms: A. Enteric-coated tablets B. Syrups C. Tablets D. Powders ANS: A Enteric coating slows the speed of disintegration of the drug into solution form. It prevents dilution of the drug before it reaches the intestine.

3. The passive transfer of a drug from a region of higher concentration to a region of lower concentration is influenced by: A. The surface area of the membrane exposed to the drug B. The concentration gradient of the drug C. The lipid–water partition coefficient of the drug D. All of the above ANS: D Passive diffusion is influenced by the surface area of the membrane exposed to the drug, the concentration gradient of the drug and the lipid–water partition coefficient (i.e. log P value) of the drug.

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4. The sodium–potassium pump is an example of which of the following transport mechanisms: A. Passive diffusion B. Passive carrier-mediated transport C. Diffusion through aqueous channels (pores) D. Active carrier-mediated transport ANS: D The sodium–potassium pump is an example of an active transport mechanism.

5. The statement that best describes the action of ABC transporters is: A. ABC transporters rely on the hydrolysis of ATP to provide energy to pump substrates across membranes B. ABC transporters are independent of ATP hydrolysis C. ABC transporter action relies on the concentration gradient of the drug D. ABC transporters have no selectivity with regard to the substances they either efflux or influx ANS: A ABC (ATP Binding Cassette) transporters are primarily transporters that rely on the hydrolysis of ATP to provide the energy to pump substrates across membranes. A well-known group of transporters in the ABC family is the P-glycoprotein (P-gp) efflux transporters. P-gp transporters have some selectivity with regard to the drug they are able to carry.

6. The following statement relating to the pKa of a drug is FALSE: A. Drugs with lower pKa values are stronger acids B. Aspirin (pKa 2.98) is more water soluble in an acid environment C. Aspirin (pKa 2.98) is more lipid soluble in an acid environment D. Aspirin (pKa 2.98) is more ionised in a basic environment ANS: B Chemically, aspirin is a 'stronger' acid because of its low pKa. Aspirin will be un-ionised (uncharged) in an acidic environment and therefore more lipid-soluble (less water-soluble) as a result.

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7. Enteric coatings on drugs are used to: A. Prevent decomposition of chemically sensitive drugs by gastric secretions B. Prevent dilution of the drug before it reaches the intestine C. Delay the release of the drug D. All of the above ANS: D Enteric coatings are used to: (1) prevent the decomposition of chemically sensitive drugs by gastric secretions, e.g. erythromycin is unstable in an acidic pH; (2) prevent the dilution of the drug before it reaches the intestine; (3) prevent nausea and vomiting induced by the drug’s effect in the stomach; and (4) provide a delayed release of the drug.

8. The following routes DO NOT completely bypass the liver and escape first-pass metabolism: A. Sublingual administration B. Parenteral administration C. Rectal drug administration D. Ophthalmic drug administration ANS: C Approximately 50% of the drug that is absorbed from rectal administration escapes first-pass metabolism as it bypasses the liver.

9. Intra-articular parenteral drug delivery refers to: A. Delivery of the drug into the bone marrow B. Delivery of the drug into the synovial cavity of the joint C. Administration of the drug into the peritoneal cavity D. Administration of the drug to the pleura ANS: B Intra-articular refers to drug delivery into the synovial cavity of a joint to relieve joint pain and reduce inflammation. Intra-osseous refers to the delivery of a drug into the bone marrow, intraperitoneal refers to the administration of the drug into the peritoneal cavity and intrapleural refers to the administration of the drug into the lung pleura.

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10. The following statement relating to intrathecal administration is FALSE: A. Intrathecal administration bypasses the blood–brain barrier B. Intrathecal administration is when the drug is injected directly into the spinal subarachnoid space C. Intrathecal administration is used when rapid central nervous system effects of drugs are desired D. Intrathecal administration is permitted using drugs reconstituted with diluents containing preservatives ANS: D Preservatives are neurotoxic and should not be administered via the intrathecal route.

Practitioners must ensure that diluents (solvents) used for the reconstitution of drugs intended for intrathecal use are free of preservatives.

11. Suspensions cannot be administered by: a. intravenous (IV) route b. intramuscular (IM) route c. intrathecal route.

A. a only B. a and b C. a and c D. a, b and c ANS: C To avoid harm, it is important that particulate matter is not administered via the intravenous or intrathecal routes. Suspensions can be administered via the intramuscular route and can be used to slow the rate of diffusion from the site of administration and sustain the action of the drug.

12. Given the volume of distribution (V), the drug likely to distribute more extensively throughout the body is: A. Digoxin (V = 6 L/kg) B. Warfarin (V = 8 L) C. Frusemide (V = 12 L) D. Theophylline (V = 0.5 L/kg) ANS: A Volume of distribution is an abstract term and is not a real volume. For example, if a drug is tightly bound to plasma proteins, most of it will remain within the circulatory system Copyright © 2019 Elsevier Australia

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and it will have a volume of distribution similar to that of the blood volume (e.g. warfarin). If, however, it is distributed out of the circulatory system and binds to tissue protein, less remains in the blood and the drug will appear to be distributed in a larger volume. Volume of distribution can be expressed as volume per weight. Given a 70-kg person, digoxin will have an estimated volume of distribution of 420 L and theophylline will have an estimated volume of distribution of 35 L. 13. An example of a conjugation reaction is: A. Oxidation B. Hydroylsis C. Glucuronidation D. Reduction ANS: C Glucuronidation is an example of a phase II conjugation reaction.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 6: Pharmacogenetics and Individualised Drug Therapy

Test Bank MULTIPLE CHOICE 1. The study of variations in DNA sequence as related to drug response is best defined as: A. Pharmacognosy B. Pharmacogenomics C. Pharmacogenetics D. Genetic polymorphism ANS: C Pharmacogenomics is defined as ‘the study of variations in DNA and RNA characteristics as related to drug response’, whereas pharmacogenetics is defined as ‘the study of variations in DNA sequence as related to drug response’.

2. Allelle is best described as: A. Difference in a DNA sequence compared with a reference DNA sequence B. Alternate sequences of the same gene C. Arising from substitution of one nucleotide for another D. All of the above ANS: B Alleles are alternate sequences of the same gene, one on each chromosome inherited from each parent.

3. A nucleotide substitution that does not change the amino acid codon is best termed: A. Synonymous single nucleotide polymorphism (SNP) B. Nonsynonymous single nucleotide polymorphism (SNP) C. Genetic polymorphism D. None of the above ANS: A Synonymous SNPs do not change the amino acid but may alter a functional activity such as transcript stability.

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4. A single nucleotide polymorphism (SNP) resulting in a codon change from AAA to AAG is an example of a: A. Missense mutation B. Nonsense mutation C. Silent mutation D. Nonsynonymous SNP ANS: C The altered codon AAG still results in the coding of lysine as the amino acid and therefore is an example of a synonymous SNP, sometimes termed a silent mutation.

5. True/False. Phenotype may be predicted from the genotype for a trait due to a single gene and trait (phenotype) is likely to predict the genotype.

A. True B. False ANS: B Trait (phenotype) may not predict the genotype because the trait may be influenced by non-genetic factors.

6. Genetic polymorphism refers to a change in DNA sequence that occurs at an allele frequency of: A. <1% B. 1% C. 5% D. 10% ANS: B Genetic polymorphism refers to a change in DNA sequence that occurs at an allele frequency of 1%.

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7. Potential consequences of polymorphic drug-metabolising enzymes include: A. Increased plasma drug concentrations and duration of action B. Decreased plasma drug concentrations and therapeutic failure C. Adverse drug reactions/toxicity D. All of the above ANS: D Consequences of polymorphic drug-metabolising enzymes include increased plasma drug concentrations and duration of action, decreased plasma drug concentrations and therapeutic failure, adverse drug reactions/toxicity, failure to activate a prodrug, drug metabolism via alternative pathways and exacerbation of drug interactions.

8. Phenotype refers to: A. Variations in the DNA sequence B. Variations in DNA and RNA characteristics as related to drug response C. The clinical manifestations of genetic polymorphisms D. All of the above ANS: C If change occurs in a single gene it gives rise to a monogenetic trait that is evident from the phenotype. The phenotype refers to the clinical manifestation.

9. Variant TPMT resulting in reduced TPMT activity is associated with: A. Reduced efficacy of opioid analgesics B. Increased warfarin efficacy C. Higher incidence of 6-mercaptopurine toxicity D. Reduced tamoxifen outcomes ANS: C Patients who do not carry wild-type TPMT alleles have extremely low TPMT activity and almost always develop neutropenia when taking 6-mercaptopurine. TPMT metabolises the cytotoxic immunosuppressant drugs azathioprine (the prodrug of 6-mercaptopurine) and 6-mercaptopurine. Normally, 6-mercaptopurine is ‘detoxified’ by TPMT and reduced TPMT activity is associated with a high frequency of myleosuppression.

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10. True/False. Genetic polymorphisms that affect drug action are only associated with alterations in drug metabolism.

A. True B. False ANS: B Polymorphisms are also present in drug molecular targets including receptors, enzymes and transporters.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 7: Pharmacokinetics and Dosing Regimens Test Bank MULTIPLE CHOICE 1. The area under the plasma concentration versus time curve (AUC) can be used to calculate: A. Rate of metabolism B. Clearance after IV administration C. Half-life D. Rate of absorption ANS: B The AUC is proportional to the amount of drug in the plasma compartment at a particular point in time. This assumes that some of the drug is lost to metabolism and excretion.

2. If the area under the curve of an oral dose is one-quarter that for an IV dose, what can one assume the bioavailability of the oral dose is: A. 0.25%, B. 250%, C. 2.5 %, D. 25%, ANS: D Please refer to Chapter 7.

3. The half-life of a drug could be potentially decreased in which situation: A. Enzyme induction B. Renal failure C. Liver failure D. Cardiovascular disease ANS: A Inducing liver enzymes leads to increased metabolism of drugs and hence a decreased amount of drug in the system over time.

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4. Hepatic clearance of a drug mainly occurs as a result of: A. Blood flow B. Glomerular filtration C. Enzymatic capacity D. Water solubility ANS: C Hepatic clearance is the result of drug-metabolising liver enzymes.

5. If a client has renal impairment due to disease, in order to maintain plasma drug concentrations in the therapeutic range, you might have to consider: A. Ceasing therapy B. Reducing the frequency of dosing C. Increasing the frequency of dosing D. Reducing the dose and frequency of administration ANS: D If a client has renal impairment, and hence decreased excretory functions, there could be a potential build-up of toxic metabolites. It would therefore be necessary to decrease the amount of drug and the frequency of administration.

6. Systemic clearance may be expressed as: A. L/h B. mL/h C. g/L D. Weight/volume ANS: A Systemic clearance, the amount of drug removed from the system per unit time, is measured as litres per hour (L/h) or millilitres per minute (mL/min) and is related to blood flow rate.

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7. If a drug has a half-life of 4 hours: A. The drug will exhibit its maximum effect after 4 hours B. The plasma concentration of the drug will fall to 50% of the peak plasma concentration in the 4 hours C. The initial dose of drug administered will be eliminated in 4 hours D. Steady state will be reached in 4 hours ANS: B Half-life is defined as the time it takes for the concentration of the drug to decrease by half.

8. When a drug-metabolising enzyme is saturated and at its maximum capacity: A. The plasma concentration of the drug rapidly decreases to the sub-therapeutic range B. The rate of metabolism increases further with increasing dose C. The rate of metabolism decreases D. The plasma concentration of the drug increases and may reach the toxic range ANS: D In the case of an enzyme reaching its maximum capacity, the rate of metabolism cannot increase further with increasing doses. Any change in the dose could lead to a large increase in the plasma drug concentration. This could potentially lead to the drug reaching toxic levels. This situation is referred to as saturable metabolism.

9. In general, the number of half-lives it takes for a drug to reach steady-state concentration is: A. 10 B. 2–4 C. 3–5 D. 1 ANS: C Please refer to Chapter 7.

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10. The type of drug that could potentially have a large volume of distribution is: A. A drug that is tightly bound to plasma proteins B. A drug that binds to tissue proteins C. A water soluble drug D. A drug with high molecular weight ANS: B A drug that is distributed out of the circulatory system and into the tissues will appear to be distributed in a larger volume.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 8: Adverse Drug Reactions and Drug Interactions Test Bank MULTIPLE CHOICE 1. Thalidomide was withdrawn from the market due to the adverse drug reaction (ADR): A. Liver damage B. Congenital malformations C. Anaphylaxis D. Blood dyscrasias ANS: B Thalidomide was withdrawn from the market due to a notable ADR of congenital malformations when taken during pregnancy.

2. Adverse drug reactions characterised by an exaggerated effect of a known drug effect are classified as: A. Type A B. Type B C. Type D D. Type F ANS: A Type A (augmented, dose-related) ADRs are characterised by predictability from the known pharmacology of the drug—often an exaggeration of effect.

3. Teratogenesis associated with thalidomide use during pregnancy is BEST classified as which of the following adverse drug reactions: A. Type A B. Type B C. Type C D. Type D ANS: D Type D (delayed, time-related) ADRs are characterised by the appearance of delayed effects and are generally considered unacceptable.

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4. The appearance of tardive dyskinesia in persons treated long-term with neuroleptic drugs for schizophrenia is classified as which of the following adverse drug reactions: A. Type A B. Type B C. Type C D. Type D ANS: C Type C (chronic, dose-related and time-related) ADRs are characterised by occurrence as a consequence of long-term use.

5. Haemolytic anaemia due to sulfonamide antibiotic use in patients with glucose-6-phosphate dehydrogenase deficiency is classified as which of the following ADRs: A. Type A B. Type B C. Type C D. Type D ANS: B Type B (bizarre, non-dose related) adverse drug reactions are unpredictable and uncommon reactions associated with high morbidity and high mortality.

6. Symptoms associated with opiate withdrawal syndrome are best classified as: A. Type A B. Type C C. Type D D. Type E ANS: D Type E (end of use, withdrawal) ADRs are related to withdrawal of a drug.

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7. Unexpected drug failure is BEST classified as which of the following adverse drug reaction types: A. Type C B. Type D C. Type E D. Type F ANS: D Type F (failure, unexpected failure of therapy) ADRs are increasingly common and are often caused by drug interactions.

8. Anaphylaxis associated with penicillin is classed as which type of allergic drug reaction: A. Type I hypersensitivity B. Type II antibody-dependent cytotoxic C. Type II complex-mediated D. Type IV cell-mediated delayed hypersensitivity ANS: A Penicillins are associated with an immediate Type I hypersensitivity. This allergic reaction manifests as urticaria, anaphylaxis, angio-oedema and bronchospasm.

9. Serum sickness associated with anticonvulsants, antibiotics, hydrazine and diuretics is classified as: A. Type I hypersensitivity B. Type II antibody-dependent cytotoxicity C. Type III complex-mediated reaction D. Type IV cell-mediated delayed hypersensitivity ANS: C Serum sickness is a Type III complex-mediated reaction.

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10. Bleeding associated with co-administration of aspirin with warfarin is an example of: A. Pharmacodynamic drug interaction B. Pharmacokinetic drug interaction C. Antagonism D. All of the above ANS: A The co-administration of aspirin with warfarin is a 'direct' pharmacodynamic interaction because the drugs have an additive effect of anticoagulation at a common target. Warfarin is an anticoagulant that inhibits vitamin K-mediated synthesis of clotting factors and aspirin decreases platelet aggregation. Co-administration increases the risk of bleeding.

11. Myopathy associated with co-administration of azole antifungals with statins is an example of: A. Pharmacodynamic drug interaction B. Pharmacokinetic drug interaction C. Antagonism D. All of the above ANS: B Azole antifungals inhibit CYP3A4 liver isoenzymes decreasing the clearance of some statins. The accumulation of the drug increases the risk of statin-induced myopathy. This is an example of a pharmacokinetic drug interaction because the plasma concentration of the drug is altered by the interaction.

12. A drug more likely to inhibit the CYP2D6 isoenzyme is: A. Itraconazole B. Amiodarone C. Verapamil D. Paroxetine ANS: D Paroxetine inhibits the CYP2D6 isoenzyme.

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13. An effect that grapefruit juice would have on cyclosporin, an immunosuppressant associated with dose-related nephrotoxicity, is: A. Decrease the immune suppressing action of cyclosporin B. Reduce the risk of nephrotoxicity C. Increase the risk of nephrotoxicity D. Decrease the plasma level of cyclosporin ANS: C Chemicals present in grapefruit juice inhibit the activity of CYP3A4 present in the liver and small bowel. The enzyme present in the small bowel appears to contribute significantly to the first-pass metabolism of numerous CYP3A4 substrates. Thus, the bioavailability of a number of drugs, such as cyclosporin, increases significantly when they are taken with grapefruit juice, resulting in increased potential for toxicity.

14. An effect that St John’s wort would have on verapamil, a calcium channel blocker is: A. Increase the plasma level of verapamil B. Inhibit the hepatic metabolism of verapamil C. Decrease the renal clearance of verapamil D. Decrease the plasma level of verapamil ANS: D St John’s wort contains chemicals called hyperforins, which mimic the effects of rifampicin as an inducer of CYP enzymes. Consumption for 2 weeks significantly induces the activity of both hepatic and intestinal CYP3AD. The clearances of many drugs including verapamil have been shown to increase as a result with a risk of therapeutic failure.

15. Serotonin toxicity (headaches, changes in mental status, tremors, autonomic instability, GI upset, myalgia and motor restlessness) associated with co-administration of St John’s wort with serotonin-reuptake inhibitors (sertraline, paroxetine, fluoxetine) is more likely due to: A. Pharmacodynamic interaction B. Pharmacokinetic interaction C. Antagonism D. All of the above ANS: A These symptoms may be explained by inhibition of serotonin reuptake in the brain by St John’s wort. When used with other serotonergic agents it may precipitate symptoms consistent with serotonin excess.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 9: Overview of the Autonomic and Somatic Nervous Systems: Drugs Affecting Cholinergic Transmission

Test Bank MULTIPLE CHOICE 1. The autonomic nervous system (ANS) is organised into parasympathetic and sympathetic subdivisions. The third subdivision is: A. Central nervous system (CNS) B. Peripheral nervous system (PNS) C. Enteric nervous system D. Vagal network ANS: C The ANS is organised into three subdivisions: parasympathetic nervous system, the sympathetic nervous system and the enteric nervous system.

2. Agonism of M2 receptors results in: A. Decreased gastrointestinal motility B. Decreased force of atrial contraction C. Bronchodilation D. Mydriasis ANS: B Stimulation of the cholinergic M2 receptors causes a parasympathetic response resulting in decreased atrial contraction in the heart.

3. M2 receptor stimulation (agonism) does NOT directly affect the: A. SA node B. AV node C. Atrial force of contraction D. Coronary smooth muscle ANS: D M2 cholinergic receptors do not innervate coronary smooth muscle.

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4. Non-selectively blocking the action of acetylcholine (ACh) in the parasympathetic nervous system is likely to result in which of the following adverse effect/s: A. Bronchoconstriction B. Excessive bronchial secretions C. Xerostomia D. Diarrhoea ANS: C Muscarinic antagonism is likely to result in xerostomia (dry mouth).

5. A cholinergic drug more likely to worsen urinary incontinence is: A. Muscarinic agonist B. Muscarinic antagonist C. M1 receptor agonist D. M2 receptor partial agonist ANS: A Stimulation of M3 receptors causes contraction of the detrusor muscle and relaxes the bladder sphincters.

6. The action potential of a neuron is propagated by the: A. Outward movement of sodium and inward movement of potassium B. Outward movement of both sodium and potassium C. Inward movement of sodium and outward movement of potassium D. None of the above ANS: C Movement of sodium into the neuron and the movement of potassium out of the neuron occur principally via voltage-gated sodium and potassium channels.

7. The duration of action of acetylcholine (ACh) action is: A. 1–2 milliseconds B. 1–2 seconds C. 1–2 minutes D. 1–2 hours ANS: A The action of ACh is brief (1–2 milliseconds). After acetylcholine has exerted its effect Copyright © 2019 Elsevier Australia

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on the postsynaptic receptors the excess amount is inactivated rapidly by the enzyme acetylcholinesterase.

8. Bethanechol, an agent used systemically for urinary retention, is an example of a: A. Sympathomimetic B. Parasympatholytic C. Parasympathomimetic D. All of the above ANS: C Muscarinic receptor agonists are also referred to as parasympathomimetics, e.g. bethanechol.

9. Adverse reaction/s NOT associated with bethanechol is/are: A. Bradycardia B. Nausea and vomiting C. Sweating D. Constipation ANS: D Bethanechol is a muscarinic receptor agonist. Stimulation of muscarinic receptors increases gastric motility, gastric tone and promotes defaecation.

10. Quaternary amine cholinergic receptor agonists, such as bethanechol, are: A. More likely to cross the blood–brain barrier B. Associated with more CNS-related adverse effects C. Associated with drug-induced delirium D. Less likely to cross the blood–brain barrier ANS: D Quaternary amines are charged and therefore are unable to cross the blood–brain barrier.

As a result, these agents have reduced central nervous system (CNS) effects when compared to uncharged cholinergic receptor agonists or antagonists.

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11. A class of drug used to treat the tremor associated with both Parkinson’s disease and antipsychotic drug use is: A. Pilocarpine B. Parasympatholytics C. Inhibitors of acetylcholinesterase D. All of the above ANS: B Muscarinic receptor antagonists that cross the blood–brain barrier and reduce cholinergic transmission centrally are used to treat the extrapyramidal effects (tremor, involuntary movements and rigidity) associated with Parkinson’s disease and antipsychotic drug use.

12. An adverse effect NOT usually associated with atropine-like drugs is: A. Tachycardia B. Bronchoconstriction C. Constipation D. Urinary retention ANS: B Atropine-like drugs relax the smooth muscle of the bronchial tract but are less effective than sympathomimetics (such as salbutamol) as a bronchodilator.

13. The likely clinical indication for oxybutynin is: A. Bronchodilator B. Parkinson’s disease C. Urinary antispasmodic D. Mydriatic ANS: C Oxybutynin is a muscarinic antagonist used clinically as an antispasmodic for urge incontinence.

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9-5

14. Acetylcholine interacts with which of the following receptors on the motor end-plate at the neuromuscular junction: A. M1-receptors B. NN-receptors C. NM-receptors D. M3-receptors ANS: C Acetylcholine receptors are classed as either nicotinic (NN or NM) or muscarinic (M1, M2, M3). Acetylcholine interacts with NM-receptors on the motor end-plate at the neuromuscular junction.

15. The nerve impulse transmitted via acetylcholine at the neuromuscular junction (NMJ) is rapidly terminated (within 1 ms) by: A. Phosphodiesterase (PDE) B. Acetylcholinesterase (AChE) C. Monoamine oxidase (MAO) D. Tyrosine kinase ANS: B Acetylcholinesterase (AChE) inactivates acetylcholine (ACh).

16. Which of the following competitively blocks the action of acetylcholine (ACh) at postsynaptic and presynaptic nicotinic receptors: A. Suxamethonium B. Depolarising neuromuscular blockers C. Non-depolarising neuromuscular blockers D. None of the above ANS: C Non-depolarising drugs competitively block the action of acetylcholine at postsynaptic and presynaptic nicotinic receptors, blocking the normal feedback loop that increases ACh release under conditions of enhanced stimulation.

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17. An example of a depolarising neuromuscular blocker is: A. Pancuronium B. Suxamethonium C. Atracurium D. Vecuronium ANS: B Suxamethonium is a depolarising neuromuscular blocker. The remaining drugs are examples of non-depolarising (antagonists) neuromuscular blockers.

18. Which of the following statements relating to the non-depolarising neuromuscular drug, pancuronium, is FALSE: A. Pancuronium is highly water soluble B. Pancuronium is less effective when used with neostigmine C. Pancuronium is associated with life-threatening anaphylactoid reactions D. Pancuronium readily crosses the blood–brain barrier ANS: D Non-depolarising agents are quaternary ammonium compounds; they are poorly absorbed and do not readily cross the blood–brain barrier or placenta.

19. A drug that potentiates the effect of a non-depolarising neuromuscular blocker is: A. Anticholinesterase agents B. Carbamazepine C. High-dose corticosteroids D. Aminoglycoside antibiotics ANS: D Potentiation of the effect of a non-depolarising neuromuscular blocker can occur with inhalation anaesthetics, suxamethonium, antibiotics such as aminoglycosides, diazepam, calcium channel blockers, lithium, propranolol and magnesium salts.

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20. Which of the following statements relating to suxamethonium is FALSE: A. Suxamethonium has a rapid onset of action B. Suxamethonium has a short half-life (approximately 2–4 minutes) C. Suxamethonium requires neostigmine to reverse its effects D. Suxamethonium precipitates malignant hyperthermia ANS: C There is generally no need to reverse the effect of suxamethonium with drugs as it has a short half-life (approximately 2–4 minutes). Using an acetylcholinesterase inhibitor (such as neostigmine) will merely potentiate the effect of the depolarising neuromuscular blocker.

21. An anticholinesterase agent indicated for the management of Alzheimer’s disease is: A. Donepezil B. Neostigmine C. Pyridostigmine D. Ecothiopate ANS: A Donepezil, galantamine and rivastigmine are approved for the treatment of Alzheimer’s disease but not other types of dementia.

22. Which of the following drugs is/are likely to antagonise the effects of AChE inhibitors: A. Antihistamines B. Oxybutynin C. Tricyclic antidepressants D. All of the above ANS: D Classes of drugs that may antagonise the effects of AChE inhibitors include drugs for urinary incontinence (oxybutynin), antihistamines and some antipsychotics and antidepressants (especially tricyclic antidepressants).

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9-8

23. All of the following are adverse effects associated with the anticholinesterase, donepezil, EXCEPT: A. Diarrhoea B. Tachycardia C. Tremor D. Urinary incontinence ANS: B Infrequently, bradycardia occurs. These drugs should be used with caution in patients taking drugs that already cause bradycardia and hypotension.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 10: Overview of the Sympathetic Nervous System and Drugs Affecting Noradrenergic Transmission Test Bank MULTIPLE CHOICE 1. Adrenaline acts on: A. α1 adrenoreceptors to produce vasoconstriction B. β1 receptors to increase heart rate and contraction C. β2 receptors to dilate bronchial smooth muscle and relax the uterus D. All of the above ANS: D Adrenaline acts on α1 adrenoreceptors to increase IP3 and DAG and calcium levels, subsequently producing vasoconstriction. Stimulation of β1 receptors increases cAMP, PKA and calcium levels, which increase heart rate and contraction, while stimulation of β2 receptors increases cAMP but produces bronchodilation in bronchial smooth muscle and relaxation in the uterine tract.

2. Dobutamine, used to treat heart failure, acts to: A. Block β1 adrenoreceptors B. Decrease stroke volume C. Stimulate β1 adrenoreceptors D. Decrease O2 consumption in the heart ANS: C Dobutamine is a β1 adrenoceptor agonist. It increases cAMP and activates PKA, which phosphorylates calcium channels resulting in increased calcium entry to cardiac cells resulting in increased cardiac contraction.

3. A woman with hypertension requires a drug that decreases both cardiac output and peripheral vascular resistance. The most appropriate drug is: A. Atenolol B. Carvedilol C. Prazosin D. None of the above ANS: B Copyright © 2019 Elsevier Australia

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Carvedilol is a non-selective β-adrenergic-receptor antagonist and a selective α1-adrenergic antagonist. Heart rate and cardiac output are reduced by β1-adrenergic-receptor blockade while blockade of α1-adrenergic receptors causes vasodilation and decreases peripheral vascular resistance.

4. Adrenaline has the potential to interact with: A. MAO inhibitors B. Non-selective β-blockers C. Digoxin D. All of the above ANS: D MAO inhibitors potentiate the effect of adrenaline and may cause dysrhythmias. With non-selective β-blockers, α1-adrenergic-mediated vasoconstriction predominates, resulting in severe hypertension. Digoxin sensitises the myocardium to the effects of digoxin, increasing the risk of dysrhythmias.

5. A patient with urinary urgency and frequency is found to have benign enlargement of the prostate. The most appropriate therapy is: A. Atenolol B. Prazosin C. Dobutamine D. Digoxin ANS: B Prazosin is a selective α1-adrenergic blocker that relaxes smooth muscle in the bladder outflow tract and can relieve urinary obstruction caused by prostatic hyperplasia.

6. A selective β1-adrenergic receptor blocker is: A. Pindolol B. Atenolol C. Dobutamine D. None of the above ANS: B Atenolol is a selective β-blocker. Pindolol is a non-selective β1- and β2-adrenoreceptor blocker while dobutamine is a β1-adrenoreceptor agonist.

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7. Ephedrine (sulfate) is an adrenergic agonist that is: A. Non-selective, having both direct and indirect actions B. Selective for at α1 adrenoreceptors C. Selective for at β1 adrenoreceptors D. None of the above ANS: A Ephidrine acts directly at α and β adrenoreceptors and indirectly by increasing release of noradrenaline.

8. Common adverse effects associated with the use of prazosin include: A. Postural hypotension B. Headaches C. Nasal congestion D. All of the above ANS: D Please refer to Chapter 10.

9. Adrenergic drug/s considered safe to use in pregnancy is/are: A. Adrenaline B. Atenolol C. Sotalol D. All of the above ANS: A Adrenaline is classified as Pregnancy Safety Category A and therefore considered safe for use in pregnancy. Atenolol and sotalol are classified as Pregnancy Safety Category C and are not considered safe.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 11: Central Nervous System Overview and Anaesthetics Test Bank MULTIPLE CHOICE 1. Lesions or damage to the cerebellum lead to: A. Alterations in temperature regulation B. Weight loss C. Ataxia D. Loss of smell ANS: C The cerebellum is an error-detector for all movements, and a lesion or damage to it leads to ataxia (postural instability).

2. Drugs that disturb the cerebellum lead to: A. Dizziness and loss of equilibrium B. Weight loss C. Ataxia D. Loss of smell ANS: A Drugs that disturb the cerebellum or vestibular branch of the eighth cranial nerve—such as alcohol and some drugs used in mental disorders—cause dizziness and loss of equilibrium.

3. A diffuse system of nuclei that permits communication between the spinal cord, thalamus and cerebral cortex is: A. Cerebellum B. Thalamus C. Reticular activating system D. Extrapyramidal system ANS: C The reticular activating system (RAS) is a diffuse system of nuclei in the reticular formation of the brainstem that permits communication between the spinal cord, thalamus and cerebral cortex.

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4. Drug/s believed to suppress the limbic system, preventing it from activating the reticular formation and thus causing drowsiness and sleep, is/are: A. Amphetamines B. Benzodiazepines C. Lysergic acid diethylamide D. Antipsychotic agents ANS: B Drugs that affect the limbic system include benzodiazepines and opioids. The benzodiazepines are believed to suppress the limbic system, preventing it from activating the reticular formation and thus causing drowsiness and sleep, especially in patients with anxiety.

5. A series of indirect CNS motor pathways that are outside the main motor pathways that traverse the pyramids in the thalamus is the: A. RAS B. Cerebellum C. Extrapyramidal system D. Basal ganglia ANS: C The extrapyramidal system is a series of indirect CNS motor pathways that are outside the main motor pathways that traverse the pyramids in the thalamus. The system consists of many pathways or tracts that coordinate posture and movements of muscles in the limbs, head and eyes.

6. A series of paired nuclei in each cerebral hemisphere that coordinate gross automatic muscle movements and regulate muscle tone is named the: A. Limbic system B. Extrapyramidal system C. Reticular activating system D. Basal ganglia ANS: D The basal ganglia are a series of paired nuclei in each cerebral hemisphere that coordinate gross automatic muscle movements and regulate muscle tone. The main components are the corpus striatum (made up of the caudate nucleus and putamen) and the globus pallidus. The substantia nigra and the red nuclei of the mid-brain are sometimes included as components of the basal ganglia. They are connected with the cerebral cortex, Copyright © 2019 Elsevier Australia

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thalamus and hypothalamus, and regulate the tone and characteristics of all voluntary movements.

7. Damage to the basal ganglia can lead to: A. Loss of memory B. Drowsiness and sleep C. Increased muscle tone, rigidity and tremors D. Depression ANS: C Damage to the basal ganglia, commonly seen in Parkinson's disease, can lead to increased muscle tone, rigidity and tremors.

8. An ion found in high concentration within the neuronal cell is: A. Sodium B. Chloride C. Potassium D. All of the above ANS: C In the resting state, sodium and chloride are found in large amounts outside the cell, while potassium is in high concentrations within the cell.

9. Reserpine and methyldopa produce cerebral depression by depleting which CNS neurotransmitter/s: A. Acetylcholine (ACh) alone B. Noradrenaline (NA) and serotonin (5-HT) C. Dopamine (DA) and acetylcholine (ACh) D. Histamine and dopamine (DA) ANS: B Drugs such as reserpine and methyldopa that deplete noradrenaline and serotonin levels in the brain have a cerebral depressing effect.

10. An example of an excitatory amino acid (EAA) in the CNS is: A. Glycine B. GABA C. Glutamate Copyright © 2019 Elsevier Australia

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D. All of the above ANS: C Glutamate, aspartate, cysteic acid and homocysteic acid are excitatory amino acids.

11. Methylxanthines, such as caffeine and theophylline, antagonise the action of: A. Acetylcholine B. Dopamine C. Adenosine D. GABA ANS: C Refer to Table 14-1, p. 277. Methylxanthines inhibit the action of adenosine on the g-protein-coupled receptors (GPCR) A1 and A2.

12. Morphine exerts an agonist action at: A. Muscarinic receptors B. β2- receptors C. HT3- receptors D. µ-opioid receptors ANS: D Morphine is an agonist at µ-opioid receptors.

13. Metoclopramide stimulates gastric motility by: A. Antagonism of 5-HT4 receptors B. Stimulation of 5-HT4 receptors C. Antagonism of muscarinic receptors D. Stimulation of 5-HT3 receptors ANS: B Metoclopramide, in addition to blocking central DA receptors, blocks the reuptake of serotonin, which stimulates 5-HT4 receptors. Stimulation of these receptors indirectly stimulates gastric motility by enhancing cholinergic transmission in the GIT. 14. Stimulation of the g-protein-coupled receptor (GPCR) GABAB causes which of the following effects on secondary messenger systems: A. Increases cAMP levels Copyright © 2019 Elsevier Australia

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B. Decreases cAMP levels C. Increases IP3 levels D. Decreases DAG levels ANS: B Stimulation of the g-protein-coupled receptor (GPCR) GABAB decreases cAMP levels.

15. The stage consistent with surgical anaesthesia is: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 ANS: C Stages 1 and 2 constitute induction of anaesthesia. It is now recognised that stage 2 (excitation) can be dangerous, so the current practice is to induce general anaesthesia rapidly with an intravenously administered anaesthetic, then maintain the stage of surgical anesthesia (stage 3) by inhalation of an anaesthetic gas.

16. The potency of anaesthetic effect is strongly correlated with: A. Water solubility of the compound B. Lipid solubility of the compound C. Volatility of the compound D. None of the above ANS: B The potency of anaesthetic effects is strongly correlated with the lipid solubility of the compound. Highly lipid-soluble general anaesthetics (GAs) are very potent.

17. The proposed molecular and receptor targets of general anaesthetics (GAs) are: a. GABAA b. two-pore-domain potassium channels c. NMDA receptors A. a only B. a and b C. a, b and c D. c only ANS: C Copyright © 2019 Elsevier Australia

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At a molecular and receptor level, there appear to be three main targets to which GAs bind and they include: GABAA receptors at synapses and extrasynaptic receptors (anaesthetic binding potentiates the depressant actions of GABA via opening of chloride channels); two-pore-domain potassium channels (opening of K+ channels mediates the effects of some volatile GAs); and NMDA receptors, which mediate slow components of synaptic transmission (inhibited by most inhalation GAs).

18. Which of the following statements relating to the pharmacokinetic aspects of general anaesthetics (GAs) is INCORRECT: A. High lipid solubility delays recovery B. High lipid solubility enhances anaesthetic potency C. High blood–gas partition coefficient implies a longer time for equilibration of gas to tissues D. High blood flow to fatty tissues slows equilibration of drugs into them ANS: D High lipid solubility enhances anaesthetic potency. High lipid solubility delays recovery, as the agent forms a depot in fat tissues in the body and may take hours to be cleared from the body, leading to a ‘hangover’ effect. High blood–gas partition coefficient (solubility of the agent in blood) implies a longer time for equilibration of gas to tissues, as higher levels have to be reached. Low blood and tissue solubility speeds equilibration of the agent from the lungs to the blood and tissues and, hence, shortens onset time and recovery time. Alveolar ventilation is the most important factor in equilibration of a gaseous agent into the blood, especially for agents having high blood solubility. Low blood flow to fatty tissues slows equilibration of drugs into them.

19. The optimal anaesthetic agent has: A. High blood and tissue solubility with relatively high potency B. Low blood and tissue solubility with relatively low potency C. Low blood and tissue solubility with relatively high potency D. High blood and tissue solubility with relatively low potency ANS: C Optimal anaesthetic agents have low blood and tissue solubility with high potency.

Sevoflurane is a good example compared to nitrous oxide, which is weak but rapid, and ether, which is potent but slow.

20. Neostigmine, flumazenil and naloxone are included in the anaesthetist’s drug trolley for use as: A. Premedication Copyright © 2019 Elsevier Australia

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B. Induction agents C. Reversal drugs D. Muscle relaxants ANS: C Neostigmine, flumazenil and naloxone are reversal drugs.

21. Thiopentone and propofol are included in the anaesthetist’s drug trolley for use as: A. Premedication B. Induction agents C. Reversal drugs D. Muscle relaxants ANS: B Thiopentone and propofol are induction agents.

22. Metoclopramide, ondansetron and prochlorperazine are included in the anaesthetist’s drug trolley for use as: A. Premedication B. Analgesics C. Antiemetics D. Vasoconstrictors ANS: C Metoclopramide, ondansetron and prochlorperazine are antiemetic agents.

23. Clonidine and dexmedetomidine are included in the anaesthetist’s drug trolley for use as: A. Stabilising agents B. Analgesics C. Antiasthma drugs D. Vasoconstrictors ANS: A Clonidine and dexmedetomidine are used as stabilising agents.

24. Malignant hyperthermia is associated with the use of: a. halothane b. suxamethonium Copyright © 2019 Elsevier Australia

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c. benzodiazepines A. a alone B. a and b C. a and c D. a, b and c ANS: B Malignant hyperthermia (or hyperpyrexia) is a rare but potentially fatal condition occurring in susceptible patients with an inherited abnormality in muscle sarcoplasmic reticulum. It appears to be precipitated by the combination of depolarising neuromuscular blocking agents (suxamethonium) with a halogenated GA agent. Triggers include all volatile GAs, xanthines (including caffeine), phenothiazines and possibly sympathomimetics.

25. The properties of desflurane are best described as: A. Medium speed of induction, extensively metabolised and excreted via kidneys B. Fast speed of induction, minimal metabolism and excreted via lungs C. Fast speed of induction, extensively metabolised and excreted via kidneys D. Slow speed of induction, minimal metabolism and excreted via lungs ANS: B Desflurane is a volatile liquid anaesthetic agent exhibiting fast speed of induction, minimal metabolism and is excreted via lungs.

26. Which of the following inhalation anaesthetics is relatively more potent: A. Halothane, MAC (%) 0.8 B. Enflurane, MAC (%) 1.4 C. Sevoflurane, MAC (%) 2.1 D. Desflurane, MAc (%) 6.7 ANS: A The most potent anaesthetics, such as halothane, are those with low minimal alveolar concentration (MAC) values. These rapidly reach a concentration in the blood and brain sufficient to cause anaesthesia.

27. The pharmacokinetic profile of midazolam given IV is best described as: A. Slow onset of action and short elimination half-life B. Rapid onset of action and short elimination half-life C. Slow onset of action and long elimination half-life Copyright © 2019 Elsevier Australia

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D. Rapid onset of action and long elimination half-life ANS: B Intravenous administration of midazolam has a rapid onset of action (2–4 minutes) and a short elimination half-life (1–2 hours). It is metabolised in the liver and excreted by the kidneys.

28. Local anaesthetics produce their effect through: A. Inhibition of GABA receptors B. Inhibition of K+ channels C. Inhibition of voltage-dependent sodium channels D. Inhibition of ligand-gated sodium channels ANS: C Local anaesthetics enter the cell by diffusion through membranes, bind to a modulatory site in the voltage-dependent sodium channel, block the sodium channel and interfere with the transient opening of these channels, preventing the transient influx of sodium.

Hence, threshold potential is not reached, the cell membrane is not depolarised, the development of the action potential and its propagation are prevented and the nerve is blocked.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 12: Analgesics Test Bank MULTIPLE CHOICE 1. Sharp, transient fast pain signals are transmitted to the spinal cord by: A. A-delta fibres B. C-fibres C. Nociceptors D. Thalamus and cerebral cortex ANS: A Nociceptors detect pain but the A-delta fibres transmit sharp, transient fast pain signals to the spinal cord. This is in comparison to C-fibres that mediate burning, aching, slow, visceral pain.

2. An inflammatory mediator that lowers the threshold of nociceptors to other mediators is: A. Noradrenaline B. 5-HT C. Prostaglandins D. Glutamate ANS: C Arachadonic acid is a compound produced from damaged cell membranes that is metabolised by the cyclo-oxygenase enzyme system to tissue hormones called prostaglandins (PGs). These PGs lower the threshold of nociceptors to other mediators.

3. Compared to chronic pain, acute pain is best described as: A. Dull and aching B. Generally sharp, localised and may radiate C. Associated with absent physiological responses D. Persistent and diffuse in character ANS: B Acute pain is usually sudden and is generally sharp and localised. It may radiate.

Physiological responses may include various autonomic effects (pallor, sweating, tremor and tachycardia).

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12-2

4. Pain due to a stimulus that does not usually cause pain, e.g. pressure from clothing, is referred to as: A. Psychogenic pain B. Nociceptive pain C. Allodynia D. Paraesthesia ANS: C Allodynia refers to pain due to a stimulus that does not usually cause pain.

5. Pain occurring between doses of regular analgesics in patients with severe chronic pain is referred to as: A. Psychogenic pain B. Breakthrough pain C. Neuropathic pain D. Nociceptive pain ANS: B When pain occurs between doses of regular analgesics in patients with severe chronic pain, this is referred to as ‘breakthrough pain’. It is usually managed with extra doses of short-acting oral or transmucosal opioids.

6. The gradual decrease in the effectiveness of a drug given repeatedly over a period of time is best defined as: A. Tolerance B. Dependence C. Upregulation D. Antagonism ANS: A Drug tolerance is defined as the gradual decrease in the effectiveness of a drug given repeatedly over a period of time. If tolerance develops, higher doses are required to achieve the same effect.

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7. Tolerance develops to all of the following opioid effects, EXCEPT: A. Analgesia B. Sedation C. Nausea and vomiting D. Constipation ANS: D Tolerance develops to the analgesic effects and to the sedation, nausea and vomiting that opioids cause. Unfortunately, tolerance does not develop to the accompanying constipation.

8. Doses of morphine are titrated carefully depending on clinical response and adverse effects. The depth of respiratory depression can be correlated with the: A. Degree of constipation B. Extent of nausea and vomiting C. Depth of sedation D. Analgesic effect ANS: C The depth of respiratory depression correlates with the depth of sedation caused by opioid analgesics.

9. Which of the following statements relating to the use of analgesics in pregnancy is CORRECT: A. Morphine is a weaker analgesic than pethidine when used during labour B. Morphine has been associated with greater neonatal respiratory depression than pethidine C. Morphine has a faster onset of action than pethidine when used during labour D. Only pethidine crosses the placenta to enter fetal circulation ANS: B Morphine is a potent analgesic when used during labour, but has been associated with greater neonatal respiratory depression than pethidine and has a slower onset of action.

Both drugs cross the placenta to enter fetal circulation.

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10. NSAIDs should be avoided in late pregnancy due to the adverse effect: A. Increased risk of clotting B. Prolongation of gestation and labour C. Delayed closure of the ductus arteriosus D. Decreased maternal respiratory system function ANS: B NSAIDs should be avoided late in pregnancy because of an increased risk of bleeding (especially aspirin), adverse effects on the fetal respiratory system and prolongation of gestation and labour. NSAIDs may also cause the premature closure of the ductus arteriosus.

11. A major concern with the excessive use of opioids during pregnancy, particularly in an addicted woman, is: A. Delivery of an underweight baby at birth B. Fetal distress syndrome in utero C. Fatal withdrawal effects after birth D. All of the above ANS: D The use of opioids during pregnancy, particularly in an addicted woman, may lead to physical dependence in the fetus, causing severe withdrawal reactions in the neonate after birth. Pregnant women dependent on an opioid and/or enrolled in methadone maintenance programs may present with fetal distress syndrome in utero and often deliver an underweight baby at birth. Such infants are usually lethargic, with difficulty breathing, high-pitched cry and poor feeding and sleeping patterns. The infant will require small doses of morphine to prevent potentially fatal opiate withdrawal effects.

12. An example of an opioid receptor antagonist is: A. Buprenorphine B. Bodeine C. Naloxone D. Methadone ANS: C Naloxone is an opioid antagonist used to treat opiate-induced respiratory depression.

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13. The analgesic of choice for mild-to-moderate pain during pregnancy is: A. Ibuprofen B. Diclofenac C. Indomethacin D. Paracetamol ANS: D Paracetemol or codeine is the analgesic of choice for mild-to-moderate pain during pregnancy. Ibuprofen, indomethacin and diclofenac are NSAIDs. 14. Aspirin use in children should be avoided because of its association with: A. Reye’s syndrome B. Lack of efficacy C. Increased risk of respiratory depression D. Increased risk of seizures ANS: A Aspirin should not be used in children because of its association with Reye’s syndrome.

15. NSAIDs—especially those with long half-lives such as naproxen and piroxicam—are considered relatively dangerous in the elderly because of the adverse effects within: A. The gastrointestinal tract B. The renal system C. The cardiovascular system D. All of the above ANS: D NSAIDs should be used with caution in the elderly because of their adverse gastrointestinal effects (dyspepsia, gastric ulceration/bleeding); renal effects (reduced renal perfusion pressure); and cardiovascular effects (increased risk of myocardial infarction and heart failure).

16. An example of a full mu-opioid receptor agonist is: A. Naltrexone B. Morphine C. Buprenorphine D. Naloxone ANS: B Morphine is an example of a MOR agonist.

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17. An example of a mu-opioid receptor partial agonist is: A. Naltrexone B. Morphine C. Buprenorphine D. Naloxone ANS: C Buprenorphine is a partial agonist of mu-opioid receptors, having a less than maximal effect at these receptors.

18. The activation of the G-protein-coupled transmembrane opioid receptors results in which of the following secondary messenger effects?

A. Activation of adenylate cyclase, increase in cAMP levels, increased neuronal excitability and inhibition of excitatory pain transmitter release B. Inhibition of adenylate cyclase, reduction in cAMP levels, reduced neuronal excitability and inhibition of excitatory pain transmitter release C. Inhibition of adenylate cyclase, increase in cAMP levels, reduced neuronal excitability and inhibition of excitatory pain transmitter release D. Activation of adenylate cyclase, reduction in cAMP levels, reduced neuronal excitability and inhibition of excitatory pain transmitter release ANS: B Opioid receptors are G-protein-coupled transmembrane receptors, activation of which inhibits adenylate cyclase and reduces cAMP levels. Hyperpolarisation of presynaptic neurons leads to reduced neuronal excitability and inhibition of release of excitatory (pain) transmitters.

19. Adding buprenorphine to the regimen of a patient taking regular doses of morphine may result in: A. Increased analgesic effects of morphine B. Serotonin syndrome C. Withdrawal symptoms D. Inhibition of morphine metabolism ANS: C Partial agonists given with an opioid agonist may reduce the analgesic effects of the full agonist or precipitate withdrawal symptoms.

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20. An agents that is an opioid compound with virtually no analgesic effects and used as a cough suppressant is: A. Methadone B. Codeine C. Hydromorphone D. Pholcodeine ANS: D Pholcodeine is structurally similar to the opium derivative paraverine. This agent has virtually no analgesic effects, but retains many morphine-like effects, including suppression of cough and respiration. The agent causes mild sedation, nausea and vomiting, dependence and constipation.

21. Which of the following opioid analgesics are more likely to cause serotonin syndrome when taken with other serotonergic agents: A. Codeine and fentanyl B. Tramadol and pethidine C. Hydromorphone and fentanyl D. Dextropropoxyphene and morphine ANS: B Tramadol appears to bind to the mu (µ)-opioid receptors and also inhibits the reuptake of noradrenaline and serotonin (5-HT). Pethidine inhibits the action of MAO, an enzyme involved in the breakdown of 5-HT. Taking either of these agents concurrently with serotonergic drugs increases the likelihood of serotonin toxicity or serotonin syndrome.

22. The metabolite of pethidine (norpethidine) that is produced in the liver can accumulate and cause the adverse effect: A. Hepatotoxicity B. Nephrotoxicity C. Neurotoxicity D. Constipation ANS: C Norpethidine is neurotoxic. As a metabolite, it can accumulate and so pethidine is recommended for short-term use in acute pain.

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23. The serum half-life of naloxone is: A. 0.5–1 hour B. 1–2 hours C. 2–4 hours D. 4–8 hours ANS: A The serum half-life of naloxone is approximately 0.5–1 hour, whereas that of morphine is 1.5–2 hours. The difference in half-life means that frequent doses of naloxone may be required to prevent the person slipping back into the overdose state.

24. Aspirin and the NSAIDs peripherally inhibit the synthesis and release of prostaglandins (PGs) by inhibiting: A. 5-Lipoxygenase B. Cyclo-oxygenase C. Phospholipase A2 D. Phosphodiesterase ANS: B Aspirin and the NSAIDs peripherally inhibit the synthesis and release of prostaglandins (PGs) by inhibiting the cyclo-oxygenase (COX) enzymes. This COX inhibition accounts for most of the therapeutic effects and adverse effects of the NSAIDs and salicylates.

25. Ingestion of 20 or more paracetamol tablets (10 g) can cause the adverse effect: A. Neurotoxicity B. Hypertension C. Hepatotoxicity D. Gastrointestinal tract disorders ANS: C Overdoses of paracetamol can cause potentially fatal liver damage, kidney damage and hypoglycaemia due to the build-up of toxic metabolites.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 13: Antianxiety, Sedative and Hypnotic Drugs Test Bank MULTIPLE CHOICE 1. Agents likely to induce insomnia or sleep disturbances are: A. Opioids (e.g. morphine) B. Antihistamines (e.g. chlorpheniramine) C. Xanthines (e.g. caffeine) D. Phenothiazines (e.g. chlorpromazine) ANS: C Methylxanthines such as theophylline and caffeine are associated with inducing insomnia.

2. Agents likely to induce sedation or CNS depression are: A. Corticosteroids B. Nicotine C. Levothyroxine D. Opioids ANS: D Opioid analgesics cause dose-dependent sedation. Other agents that induce sedation or CNS depression include alcohol, sedating antihistamines, antipsychotics, tricyclic antidepressants, clonidine, methyldopa, cannabis and other CNS depressants.

3. The mechanism of action of diazepam and other benzodiazpines is: A. Facilitating the action of GABA on GABAA receptors, thereby enhancing chloride influx into the neuronal cell B. Inhibiting the action of GABA on GABAA receptors, thereby inhibiting chloride influx into the neuronal cell C. Facilitating the action of GABA on GABAA receptors, thereby inhibiting chloride influx into the neuronal cell D. Facilitating the action of GABA on GABAB receptors, thereby enhancing chloride influx into the neuronal cell ANS: A Copyright © 2019 Elsevier Australia

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Benzodiazepines facilitate the action of GABA on GABAA receptors, thereby enhancing chloride influx into the neuronal cell causing hyperpolarisation and decreased excitability of the neuron.

4. An agent that acts as an antagonist at the benzodiazepine binding site on the GABAA receptor is: A. Naloxone B. Flumazenil C. Flunitrazepam D. Fluphenthixol ANS: B Flumazenil is an antagonist at the benzodiazepine binding site on the GABAA receptor. It decreases the binding of GABA so the chloride channel remains closed. Flumazenil is used to treat benzodiazepine overdoses.

5. An example of a longer acting benzodiazepine that is commonly used as an antianxiety agent is: A. Temazepam B. Midazolam C. Diazepam D. Clonazepam ANS: C Diazepam is an example of a longer acting (long half-life) benzodiazepine commonly used for anxiety, agitation and sedation.

6. An example of a benzodiazepine used to treat epilepsy is: A. Clonazepam B. Flunitrazepam C. Temazepam D. All of the above ANS: A Clonazepam, midazolam and clobazam are used as anticonvulsants. Parenteral diazepam is indicated for intractable, repetitive seizures, such as status epilepticus. Oral diazepam may be used for short-term adjunctive therapy (1–2 weeks) with other antiepileptics for the treatment of convulsions.

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7. A benzodiazepine used for anticipatory nausea and vomiting associated with chemotherapy is: A. Clonazepam B. Temazepam C. Alprazolam D. Lorazepam ANS: D Lorazepam produces anterograde amnesic effects and, as a result, is an important adjunct medication used to prevent anticipatory nausea and vomiting associated with chemotherapy.

8. Benzodiazepines are contraindicated or should be avoided in certain conditions: A. Respiratory depression B. Severe hepatic impairment C. Concomitant alcohol use D. All of the above ANS: D Using benzodiazepines together with alcohol or other CNS depressants enhances the CNS-depressant effects of benzodiazepines, leading to excessive sedation and respiratory depression. Additionally, benzodiazepines are contraindicated in people with respiratory depression, sleep apnoea, severe hepatic impairment or myasthenia gravis.

9. Bizarre CNS effects such as hallucinations, amnesia and sleep-walking have been reported with the use of: A. Zopiclone B. Zolpidem C. Diazepam D. Lorazepam ANS: B Zolpidem, a non-benzodiazepine, has been reported to cause bizarre CNS effects such as hallucinations, amnesia, sleep-walking and inappropriate behaviours, particularly when taken with other psychoactive drugs including alcohol.

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10. Zolpidem is approved for use as: A. A sedative agent B. An anticonvulsant C. A muscle-relaxant D. An antianxiety agent ANS: A Zolpidem, a non-benzodiazepine, is used for short-term treatment of insomnia. It has some sedative properties similar to those of benzodiazepines but lacks the anticonvulsant, muscle-relaxant and antianxiety properties associated with the benzodiazepines.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 14: Antiepileptic Drugs Test Bank MULTIPLE CHOICE 1. Which of the following antiepileptic drugs acts by enhancing GABA inhibition: A. Phenytoin B. Gabapentin C. Ethosuximide D. Diazepam ANS: D Diazepam, a benzodiazepine, acts by enhancing GABA inhibition. Other agents that inhibit GABA are barbiturates and newer agents, vigabatrin, tiagabine and topiramate.

2. Which of the following antiepileptic drugs acts by inhibiting sodium channel function: A. Phenytoin B. Gabapentin C. Ethosuximide D. Diazepam ANS: A Phenytoin, carbamazepine, sodium valproate and lamotrigine act by inhibiting sodium channel function.

3. Drugs that may cause seizures by lowering the seizure threshold are: A. Antihistamines B. Serotonergic drugs C. Quinolone antibiotics and other antimicrobials D. All of the above ANS: D A wide range of drugs reduce the seizure threshold including common drugs such as antihistamines, tricyclic antidepressants, some antibiotics, vaccines, neuroleptic agents, narcotic analgesics, bronchodilators. Additionally, social drugs such as alcohol, caffeine, cocaine and cannabis may cause seizures.

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4. Ethosuximide is most likely used to treat which of the following seizure disorders: A. Generalised tonic–clonic seizures B. Absence seizures C. Simple or complex partial seizures D. Myoclonic ANS: B Ethosuximide is used in the management of absence seizures.

5. Which of the following statements relating to antiepileptic drug use in pregnancy is FALSE: A. All antiepileptic drugs are considered safe to use in pregnancy B. Fetal abnormalities are 2–3 times more likely in babies whose mothers took antiepileptics during pregnancy C. Increasing the intake of folic acid before conception and for the first 3 months of pregnancy may decrease the risk of spina bifida in the fetus D. Seizure control is of the highest priority during pregnancy ANS: A No antiepileptic drug is completely safe to use in pregnancy. Many antiepileptics are potentially teratogenic or can affect cognitive development of the child.

6. Vigabatrin reduces seizure activity by: A. Blocking voltage gated sodium channels B. Reducing the activity of glutamate C. Irreversibly inhibiting GABA transaminase D. Reducing GABA activity ANS: C Vigabatrin enhances GABA-mediated inhibition. This agent is an irreversible inhibitor of GABA transaminase, the enzyme that inactivates GABA, thereby allowing a build-up of the neurotransmitter in synapses.

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7. Which of the antiepileptics that inhibit sodium channel functioning displays non-linear pharmacokinetic parameters: A. Carbamazepine B. Phenytoin C. Lamotrigine D. Sodium valproate ANS: B With most drugs, as the dose is increased the plasma drug concentration increases in a linear, arithmetic (direct) relationship. However, because of saturable metabolism, the non-linear pharmacokinetics of phenytoin means that the dose–plasma concentration relationship is not linear. A small rise in dose may cause an unexpectedly large rise in plasma drug levels.

8. Gingival hyperplasia is associated with which of the following antiepileptic drugs: A. Carbamazepine B. Levetiracetam C. Ethosuximide D. Phenytoin ANS: D Idiosyncratic reactions associated with phenytoin use include hirsutism, gingival hyperplasia with bleeding, sensitive gum tissue or overgrowth of gum tissue, acne and facial coarsening.

9. Which of the following antiepileptic drugs causes autoinduction of metabolism: A. Phenytoin B. Sodium valproate C. Carbamazepine D. Lamotrigine ANS: C Carbamazepine causes autoinduction of metabolism. It induces higher levels of the enzymes that metabolise it and it may take a month to reach a stable, therapeutic serum level.

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10. Which of the following agents is associated with a high risk of severe, potentially life-threatening skin reactions (toxic epidermal necrolysis) when administered at high dosage or when drug interactions prolong its half-life: A. Phenytoin B. Sodium valproate C. Gabapentin D. Lamotrigine ANS: D Early clinical experience with lamotrigine has shown that there is a high risk of severe life-threatening skin reactions, including toxic epidermal necrolysis, in particular with high dosage or when drug interactions prolong the half-life. Any rashes or skin reactions should be carefully evaluated and recommended doses not exceeded.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 15: Psychotropic Agents Test Bank MULTIPLE CHOICE 1. The neurotransmitter depleted in Parkinson’s disease is: A. Serotonin (5-HT) B. Dopamine C. Acetylcholine D. Glutamate ANS: B Dopamine is the transmitter that is depleted in Parkinson’s disease.

2. Which of the following is a neurotransmitter in its own right and a precursor for noradrenaline: A. Serotonin (5-HT) B. Acetylcholine C. Tryptophan D. Dopamine ANS: D Dopamine is a neurotransmitter in its own right and a precursor for noradrenaline synthesis.

3. Tardive dyskinesia, a severe adverse effect of chronic treatment with antipsychotic agents, is thought to be due to effects on which receptor/s: A. D1 B. D2 C. D4 D. All of the above ANS: B There are various types of dopamine receptors in the brain, especially in the basal ganglia and limbic areas. D1 and D2 receptors are the primary receptor types influenced by the antipsychotic agents. Although both receptor types are involved with movement disorders in the basal ganglia, tardive dyskinesia, a severe adverse effect of chronic treatment with antipsychotic agents, is thought to be due to supersensitivity of D2 receptors.

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4. An atypical antipsychotic agent, clozapine, is less likely to cause extrapyramidal effects because: A. It has higher affinity for D2 receptors B. It does not cross the blood–brain barrier C. It has low affinity for D2 receptors but high affinity for D4 receptors D. It has no effect on dopamine receptors in the brain ANS: C Newer antipsychotic agents with low affinity for D2 receptors but high affinity for D4 receptors, such as clozapine, are less likely to cause extrapyramidal effects.

5. Usually, serotonin (5-HT) causes: a. an increase in neuronal discharge rate b. excitatory functions c. a decrease in neuronal discharge rate d. inhibitory functions A. a and b B. a and d C. c and a D. c and d ANS: D In most cells, 5-HT usually causes a decrease in discharge rate and hence is inhibitory.

There are many types of 5-HT receptors, with more than eight types found in brain regions. 5-HT2 receptors mediate excitation rather than inhibition.

6. Antagonistic activity on histamine receptors caused by many antipsychotics and antidepressants may result in: A. Weight gain B. Antiemetic effect C. Sedation D. All of the above ANS: D Histamine is thought to be involved in altering food and water intake, and in thermoregulation, autonomic activity and hormone release. Its effects are mediated by histamine H1, H2 and H3 receptors. As many of the psychotropic agents (antipsychotics and antidepressants) have antagonistic activity on histamine receptors, there are frequently adverse effects such as sedation, weight gain and antiemetic action.

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7. A disease characterised by reduced cholinergic function is: A. Depression B. Schizophrenia C. Alzheimer’s disease D. Parkinson’s disease ANS: C Huntington’s chorea and Alzheimer’s disease are characterised by cholinergic dysfunction.

8. Akathisia is manifest as: A. Shuffle in walk, arm or leg stiffness B. Abnormal motor restlessness and agitation C. Tremor D. Late-developing involuntary repetitive hyperkinetic movements ANS: B Akathisia is an abnormal motor restlessness and agitation.

9. An example of an atypical antipsychotic is: A. Chlorpromazine B. Risperidone C. Haloperidol D. Flupenthixol ANS: B Risperidone, amisulpride, aripiprazole, clozapine, olanzapine, paliperidone, quetiapine and ziprasidone are examples of atypical antipsychotics.

10. Extrapyramidal side effects are most likely with the atypical antipsychotic drug: A. Clozapine B. Aripiprazole C. Risperidone D. Amisulpride ANS: D Amisulpride has a higher reported incidence of extrapyramidal side effects compared to Copyright © 2019 Elsevier Australia

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other atypical antispychotics. Extrapyramidal side effects include akathisia, dystonia, parkinsonism and tardive dyskinesia.

11. Orthostatic hypotension induced by antipsychotic agents is most likely due to the antagonism of : A. M3 receptors B. 5-HT1 receptors C. α1 adrenoreceptors D. β2 receptors ANS: C Inhibition of α1 adrenoreceptors results in arterial vasodilation with a resultant drop in blood pressure.

12. Negative symptoms, known as hypo-behaviours, associated with schizophrenia are: A. Hallucinations B. Flat mood C. Hostility D. Delusions ANS: B Schizophrenia is manifest by disordered emotion, speech and thought. Negative symptoms or hypo-behaviours include flat affect, lack of motivation and diminished speech patterns. Positive symptoms or hyper-behaviours include hallucinations, delusions and hostility.

13. Which of the following antipsychotic agents are less likely to cause extrapyramidal effects: A. Chlorpromazine B. Haloperidol C. Flupenthixol D. Olanzapine ANS: D Second-generation agents, such as clozapine, olanzapine and risperidone, have different profiles of action compared to typical antipsychotics and are less likely to induce extrapyramidal side effects.

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14. Which of the following statements pertaining to antipsychotic drugs is FALSE: A. Neuroleptic drugs are particularly effective against the positive symptoms of schizophrenia B. The majority of antipsychotic drugs are effective against the negative symptoms of schizophrenia C. Clozapine has proven effectiveness against the negative symptoms of schizophrenia D. All of the above ANS: B Most antipsychotics are useful on the positive symptoms of schizophrenia but the negative symptoms are harder to manage. Clozapine has been shown to have improved effect against negative symptoms compared to other antipsychotic agents.

15. Antipsychotic agents, in particular typical antipsychotics, primarily exert their effect via: A. Antagonism of acetylcholine B. Antagonism of serotonin C. Antagonism of dopamine D. Antagonism of GABA ANS: C There is good evidence that the mechanism of action of antipsychotics is by antagonism of dopamine receptors, especially the D2 subclass, which mediate the main inhibitory effects of dopamine in the CNS, particularly in the nigrostriatal, mesolimbic and tuberoinfundibular system.

16. A rare but potentially fatal adverse effect associated with typical antipsychotics, characterised by high temperature, muscle rigidity, altered consciousness and impaired autonomic homeostasis, is: A. Anticholinergic effects B. Extrapyramidal effects C. Neuroleptic malignant syndrome D. Serotonin syndrome ANS: C Neuroleptic malignant syndrome is a rare but potentially fatal adverse effect occurring in 0.5–1% of patients on typical antipsychotics. It involves high temperature, muscle rigidity, altered consciousness and impaired autonomic homeostasis. Treatment requires withdrawal of the drug, hydration and sometimes bromocriptine (a dopamine agonist) and dantrolene to control muscle spasms.

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17. Which of the following symptoms is NOT related to anticholinergic effects: A. Dry mouth B. Blurred vision C. Diarrhoea D. Urinary retention ANS: C Anticholinergic effects include blurred vision, dry mouth, constipation and urinary retention.

18. When compared to typical antipsychotics the second-generation ‘atypical’ antipsychotics are more likely to cause: A. Sedation B. Metabolic adverse effects C. Extrapyramidal effects D. Anorexia ANS: B The second-generation ‘atypical’ antipsychotics have less potential than earlier neuroleptics to cause extrapyramidal effects or sedation but are more likely to cause metabolic effects and weight gain.

19. The national distribution system in Australia requires the registration of doctors, pharmacists and patients involved with the clinical use of clozapine due to: A. The risk of neutropenia B. The risk of cardiomyopathies C. The risk of agranulocytosis D. All of the above ANS: D Treatment with clozapine is closely monitored. It can cause neutropenia, agranulocytosis and cardiomyopathies. The manufacturer recommends dispensing only weekly supplies and performing weekly white blood cell counts for the first 18 weeks.

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20. The condition characterised by wild mood swings, excessive energy, high pressure of speech, extravagant gestures and gifts and a seeming lack of need for sleep is best termed: A. Bipolar affective disorders B. Mania C. Hypomania D. Depression ANS: B Mania is the opposite pole of bipolar depressive illness. Mania is characterised by wild mood swings, excessive energy, high pressure of speech, extravagant gestures and gifts and a seeming lack of need for sleep.

21. Moclobemide is an example of a: A. Selective serotonin reuptake inhibitor B. Irreversible inhibitor of monoamine oxidase (MAO) isoenzymes C. Reversible inhibitor of MAO-A D. Noradrenaline reuptake inhibitor ANS: C Moclobemide is a reversible inhibitor of MAO-A (RIMA). This agent inhibits the MAO-A enzyme found in the mitochondria of nerve cells that is responsible for metabolising noradrenaline and serotonin. This results in a build-up of neurotransmitter available for release from the nerve terminal.

22. An example of a selective serotonin reuptake inhibitor (SSRI) is: A. Moclobemide B. Venlafaxine C. Raboxetine D. Escitalopram ANS: D Escitalopram is an example of an SSRI. These agents have a more potent effect on inhibiting 5-HT reuptake than on noradrenaline uptake.

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23. The greatest degree of sedation is seen with the antidepressant: A. Amitriptyline B. Fluoxetine C. Moclobemide D. Venlafaxine ANS: A Amitriptyline is a tricyclic antidepressant that displays marked levels of sedation when compared to other antidepressant agents.

24. Which of the following antidepressants interacts with tyramine-containing foods and drinks, resulting in a sudden and possibly severe hypertension that if untreated can progress to vascular collapse and fatality: A. Fluoxetine B. Venlafaxine C. Tranylcypromine D. Reboxetine ANS: C MAOIs impair the metabolism of many other drugs, including adrenaline and sympathomimetic amines, DA, methyldopa and pethidine, and enhance the activity of drugs that cause release of amine transmitters. Interactions can occur with prescription-only and over-the-counter medications, caffeine and tyramine-containing foods and beverages. The major adverse reaction with these agents is the occurrence of sudden and possibly severe hypertension that if untreated can progress to vascular collapse and fatality. These reactions are far more prevalent with the irreversible inhibitors of MAO (phenelzine and tranylcypromine).

25. Which of the following is an example of a reversible inhibitor of monoamine oxidase A (MAO-A): A. Citalopram B. Moclobemide C. Phenelzine D. Imipramine ANS: B Moclobemide is a reversible inhibitor of monoamine oxidase A (RIMA). It is much less likely to cause tyramine reactions, as tyramine and other amines can still be inactivated

by MAO-B. The fact that it is reversible means that MAO activity is restored within 1–2 days of stopping administration of the drug.

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26. An example of a selective serotonin and noradrenaline reuptake inhibitor (SNRI) is: A. Duloxetine B. Moclobemide C. Escitalopram D. Mitrazepine ANS: A Duloxetine is known as a selective serotonin and noradrenaline reuptake inhibitor.

27. The mechanism of action of mianserin is to: A. Inhibit the reuptake of serotonin B. Inhibit the reuptake of noradrenaline C. Inhibit the reuptake of serotonin and noradrenaline D. Enhance the action of postsynaptic 5-HT1A receptors ANS: D Mianserin has a tetracyclic chemical structure, rather than tricyclic. It does not inhibit the reuptake of monoamine transmitters but enhances postsynaptic 5-HT1A receptors, hence its antidepressant actions. A rare adverse effect unrelated to the antidepressant action is reversible neutropenia, which is monitored by blood counts before and during therapy.

28. Which of the following is/are linked to lithium’s mechanism of action: A. Inhibition of transmitter release at synapses B. Increases in the turnover of noradrenaline (NA) and serotonin (5-HT) C. Decreases in postsynaptic receptor sensitivity D. All of the above ANS: D The exact mechanism of lithium’s action has still not been established. Sodium in the cells has been reported to increase by as much as 200% in manic patients. Lithium and sodium are both actively transported across cell membranes but lithium cannot be pumped out of the cell as effectively as sodium can. Lithium can impair sodium actions in many physiological processes. It slows down G-protein coupling with receptors, adenylate cyclase activity, phosphoinositol cycling and various phosphokinase activities and affects neuroprotective proteins. Overall, it inhibits transmitter release at synapses, increases the turnover of NA and 5-HT in the brain and decreases postsynaptic receptor sensitivity, with the result that the presumed overactive catecholamine systems in mania are corrected.

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29. Lithium is indicated for all of the following conditions EXCEPT: A. Prevention of manic episodes in bipolar affective disorder B. Treatment of acute depressive episodes in bipolar affective disorder C. Treatment of acute mania D. Adjunct therapy in schizophrenia and treatment-resistant depression ANS: B Lithium is indicated for prevention of manic or depressive episodes in bipolar affective disorder and in treatment of acute mania. It is also used as adjunctive therapy in schizophrenia and treatment-resistant depression.

30. Which of the following statements relating to lithium’s clearance is CORRECT: A. Lithium is extensively metabolised in the liver B. Lithium is excreted unchanged by the kidneys C. Lithium is excreted by the kidneys after extensive liver metabolism D. Lithium is excreted via biliary elimination ANS: B Lithium is not metabolised so it is excreted unchanged by the kidneys. It is partly reabsorbed from the proximal tubule along with sodium.

31. Which of the following statements relating to lithium is INCORRECT: A. Therapeutic plasma concentrations of 0.8–1.2 mmol/L are desired for treatment of acute bipolar disorder B. Therapeutic plasma concentrations of 0.6–0.8 mmol/L are desired for maintenance treatment of bipolar disorder C. Lithium has a broad therapeutic range D. Early signs of toxicity include confusion, vomiting, tremors, slurred speech and drowsiness.

ANS: C Lithium has a very narrow therapeutic range, with concentrations only 1.5 times therapeutic concentration causing severe toxicity, so plasma levels must be monitored regularly. Therapeutic plasma concentrations for the treatment of bipolar disorder are 0.8–1.2 mmol/L for acute disorder and 0.6–0.8 mmol/L for maintenance. A clinical response is usually reported in 1–3 weeks. Levels are monitored weekly during dosage adjustment, then every 1–3 months once stabilised.

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32. Lithium levels are elevated by all of the following, EXCEPT: A. Diuretic use B. Low salt diet C. Excessive sweating caused by high fever or strenuous exercise D. High intake of sodium bicarbonate ANS: D Lithium levels are elevated by renal dysfunction, diarrhoea or vomiting, fluid or salt loss, diuretics or dehydration, low-salt diets, excess sweating, NSAIDs or ACE inhibitor use.

Lithium levels are decreased by high salt intake, high intake of sodium bicarbonate and pregnancy.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 16: Central Nervous System Stimulants Test Bank MULTIPLE CHOICE 1. Amphetamine-like drugs produce the following CNS effects, EXCEPT: A. Weight gain (appetite stimulation) B. Locomotor stimulation C. Euphoria D. Stereotyped behaviours ANS: A Amphetamine-like drugs have four main effects on the CNS, which include euphoria, locomotor stimulation (increased alertness and activity), anorexia (appetite suppression) and stereotyped behaviours (repeated inappropriate actions).

2. Proposed mechanisms of amphetamine-like drug action include: a. release of noradrenaline, dopamine and other monoamines from storage sites in nerve terminals b. direct stimulatory effects on α- and β-adrenoceptor sites c. enhancing dopamine transmission A. a alone B. a and b C. b and c D. a, b and c ANS: D Proposed mechanisms of action for the amphetamine-like drugs include the release of noradrenaline, dopamine and other monoamines from storage sites in nerve terminals (hence an indirect sympathomimetic effect). These agents also have direct effects on αand β-adrenoceptor sites and affect dopamine transmission.

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3. Dexamphetamine and methylphenidate are used for the management of: A. Schizophrenia B. Narcolepsy C. Depression D. Generalised anxiety disorder ANS: B Amphetamine-related drugs—dexamphetamine and methylphenidate—are indicated for the treatment of ADHD and narcolepsy.

4. Which of the following best describes the excretion of dexamphetamine: A. Extensively metabolised in the liver B. Excretion is independent of urine pH C. Half-life is decreased in acidic urine D. Half-life is decreased in alkaline urine ANS: D Some dexamphetamine is metabolised in the liver, and the remainder is excreted unchanged by the kidneys. Excretion (and therefore half-life) is pH-dependent; excretion is increased in acidic urine and decreased in more alkaline urine. Approximate half-lives are 6–8 hours in acidic urine with pH < 5 or 15–30 hours in alkaline urine of pH > 7.5.

5. An adverse effect NOT associated with dexamphetamine is: A. Insomnia B. Bradycardia C. Altered libido D. Euphoria ANS: B Important adverse reactions include CNS effects such as euphoria, increased irritability, insomnia, visual disturbances, dizziness, anorexia, dyskinesia and Tourette’s syndrome; cardiovascular effects such as tachycardia and angina; autonomic effects such as excessive sweating and dry mouth; GI effects such as nausea or vomiting; and endocrine effects such as impotence and alterations in libido.

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6. Which of the following drugs is a non-stimulant drug recommended as second-line treatment for ADHD: A. Dexamphetamine B. Methylphenidate C. Atomoxetine D. Amitriptyline ANS: C Atomoxetine is a non-stimulant drug now recommended as second-line treatment for ADHD. This agent inhibits the reuptake of noradrenaline. It appears not to cause CNS stimulation and does not cause dependence.

7. Which of the following amphetamine-related compounds is currently indicated as an anorectic: A. Dexamphetamine B. Methylphenidate C. Fenfluramine D. Phenteramine ANS: D Phenteramine is the only amphetamine-related compound indicated as an anorectic.

Acting on adrenergic pathways, it causes some CNS stimulation and mild euphoria, but is less liable to lead to dependence than are other amphetamines. As an appetite suppressant it is recommended only for the short term because tolerance to the anorectic effect may occur within a few weeks.

8. Caffeine’s mechanism of action is most likely due to: A. Reduction of cyclic adenosine monophosphate (cAMP) B. Enhancing the action of phosphodiesterase C. Antagonism of adenosine receptors D. All of the above ANS: C The mechanism of caffeine action was thought to involve raising cAMP levels through blockade of the enzyme phosphodiesterase. Recent studies indicate that caffeine’s effects are primarily due to antagonism of adenosine receptors, which indirectly leads to increased cAMP levels.

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9. Which of the following are NOT effects of caffeine: A. Bronchoconstriction B. Increased heart rate and cardiac output C. Increased force of skeletal muscle contraction D. Reduced muscle fatigue ANS: A The methylxanthines (caffeine and theophylline) are an important group of bronchodilator agents.

10. The recommended adult dose of caffeine is: A. 1000 mg daily B. 500 mg daily C. 250 mg daily D. 150 mg daily ANS: B The adult dose is 100–200 mg orally repeated in 3–4 hours to a maximum of 500 mg daily.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 17: Drugs for Neurodegenerative Disorders and Headache Test Bank MULTIPLE CHOICE 1. An example of an anticholinesterase agent (cholinesterase inhibitor) preferred for the treatment of myasthenia gravis is: A. Pilocarpine B. Pyridostigmine C. Neostigmine D. Pralidoxime ANS: B The anticholinesterase agents are generally divided into three groups based on their duration of action, which is determined largely by the type of binding to the enzyme. Of the medium-acting agents, pyridostigmine has better oral bioavailability than neostigmine, a longer half-life and fewer GIT adverse reactions, so it is the first-line drug for myasthenia gravis.

2. An adverse effect NOT associated with anticholinesterase agents (cholinesterase inhibitors) such as pyridostigmine is: A. Miosis B. Diarrhoea C. Urinary retention D. Bradycardia ANS: C Anticholinesterase agents (cholinesterase inhibitors) enhance cholinergic actions by inhibiting the effect of the cholinesterase enzymes that inactivate acetylcholine. This permits the accumulation of acetylcholine and enhanced effect at autonomic ganglia, parasympathetic neuroeffector junctions and neuromuscular junctions. These agents produce adverse effects associated with the increase in acetylcholine including miosis, diarrhoea, urination and bradycardia.

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3. Baclofen produces skeletal muscle relaxation via: A. Antagonism of GABAA receptors B. Agonism of GABAA receptors C. Antagonism of GABAB receptors D. Agonism of GABAB receptors ANS: D The effects of baclofen are mediated via gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in many pathways, especially in the grey matter in the brain, and at about 30% of CNS synapses. Baclofen is a GABA agonist, stimulating GABAB receptors and thus inhibiting release of transmitters from many types of nerve terminals; it depresses the CNS and has an antispasmodic action in the spinal cord, inhibiting activation of motor neurons.

4. An example of a non-depolarising neuromuscular blocking agent is: A. Baclofen B. Tetrabenazine C. Pancuronium D. Suxamethonium ANS: C The non-depolarising drugs, such as pancuronium, compete with acetylcholine at the neuromuscular end-plate and antagonise nicotinic receptors and thus cause flaccid paralysis.

5. Anticholinesterase agents acting concomitantly with skeletal muscle relaxants, such as suxamethonium, result in: A. Decreased duration of flaccid paralysis B. Increased duration of flaccid paralysis C. No effect on the duration of flaccid paralysis D. Increased muscle rigidity ANS: B Suxamethonium is a depolarising neuromuscular blocker, which activates nicotinic receptors leading to loss of excitability resulting in muscle twitching followed by short-duration paralysis. Anticholinesterase agents cause the accumulation of acetylcholine and enhanced effect at autonomic ganglia, parasympathetic neuroeffector junctions and neuromuscular junctions. This would potentiate the depolarisation block caused by suxamethonium, thereby increasing the duration of induced flaccid paralysis.

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6. Botulinum toxin decreases muscle tone and contractility by: A. Antagonising nicotinic receptors at the neuromuscular junction end-plate B. Stimulating the release of acetylcholine from cholinergic nerves C. Blocking release of acetylcholine from cholinergic nerves D. Blocking the action of acetylcholinesterase ANS: C The toxin blocks release of acetylcholine from cholinergic nerves and this causes a chemical denervation. It has a permanent toxic effect, decreasing muscle tone and contractility, leading to flaccid paralysis and atrophy of the affected muscles.

7. Which of the following skeletal muscle relaxants produces its effect by inhibiting the release of calcium from the sarcoplasmic reticulum to the myoplasm: A. Baclofen B. Tetrabenazine C. Pancuronium D. Dantrolene ANS: D Dantrolene acts directly on skeletal muscles to produce skeletal muscle relaxation by inhibiting the release of calcium from the sarcoplasmic reticulum to the myoplasm. This results in a decreased muscle response to the action potential and decreased muscle contraction. As an antispastic agent, dantrolene’s effect on skeletal muscles dissociates the excitation–contraction coupling.

8. Bradykinesia is best defined as: A. Tremors at rest B. Abnormal slowing of all voluntary movements and speech C. Muscle rigidity and weakness D. Forward flexion of the trunk ANS: B Bradykinesia is an abnormal slowing of all voluntary movements and speech. Parkinson’s disease is characterised by tremor at rest, bradykinesia, forward flexion of the trunk, muscle rigidity, loss of postural reflexes and muscle weakness.

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9. A drug that can worsen the symptoms of Parkinson’s disease is: A. Benztropine B. Apomorphine C. Haloperidol D. Carbidopa ANS: C Parkinsonism can be drug-induced especially in chronic administration of the antidopamine neuroleptic agents for schizophrenia. The typical antipsychotics, such as haloperidol, block D2 receptors and may worsen the clinical symptoms of Parkinson’s disease.

10. Drug therapy for Parkinson’s disease is focused on: A. Increasing dopamine (DA) levels or stimulating acetylcholine (ACh) effects B. Increasing dopamine (DA) levels or blocking acetylcholine (ACh) effects C. Decreasing dopamine (DA) levels or stimulating acetylcholine (ACh) effects D. Decreasing dopamine (DA) levels or blocking acetylcholine (ACh) effects ANS: B No agents have yet been found that cure the condition or slow its progression. Drug therapy is focused on correcting the DA/acetylcholine imbalance by raising DA levels or blocking acetylcholine effects.

11. Drugs that enhance brain dopamine (DA) have their major effects on: a. Bradykinesia b. Akinesia c. Rigidity d. Tremor A. a alone B. a and b C. a, b and c D. a, b, c and d ANS: C Drugs enhancing brain DA activity have their major effects on bradykinesia (slowed movements), akinesia (difficulty in initiating or the lack of ability to initiate muscle movement) and the rigidity caused in Parkinson’s disease by lowered levels of brain DA. The person with akinesia exhibits a mask-like facial expression, impairment of postural reflexes and eventually an inability to self-care. Dopamine enhancers are less effective in relieving the tremor associated with the condition.

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12. Drugs of choice in the treatment of Parkinson’s disease are: A. Those that raise the brain levels of dopamine B. Those that reduce the release of dopamine C. Directly acting cholinergic agonists D. Dopa decarboxylase enhancers ANS: A The drugs of choice in the treatment of Parkinson’s disease are those that raise the brain levels of dopamine (DA); drugs that stimulate DA receptors to enhance dopaminergic mechanisms; or anticholinergics.

13. First-line treatment for the majority of Parkinson’s patients is with the drug: A. Bromocriptine B. Levodopa C. Apomorphine D. Benztropine ANS: B The precursor to dopamine (DA), levodopa, is administered as first-line treatment for most patients with Parkinson’s disease.

14. Levodopa is converted to dopamine (DA) by the enzyme: A. Adenylate cyclase B. Cholinesterase C. Dopa decarboxylase D. Phosphodiesterase ANS: C Of the orally administered dose of levodopa, about 99% is metabolised in the periphery by the enzyme dopa decarboxylase (DDC)—allowing only 1% to cross the blood–brain barrier to be converted to DA. 15. Which of the following is NOT a peripheral adverse effect of dopamine?

A. Constipation B. Hypertension C. Difficult urination D. Severe nausea and vomiting ANS: B Peripheral adverse effects of levodopa include constipation, difficult urination, orthostatic hypotension, irregular heart rate and severe nausea and vomiting.

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16. Carbidopa or benserazide is administered orally in conjunction with levodopa because: A. These agents reduce the required oral dose B. These agents reduce peripheral adverse reactions C. These agents inhibit peripheral dopa decarboxylase D. All of the above ANS: D The DDC inhibitors (DDCI) used clinically, administered orally in conjunction with levodopa, are carbidopa and benserazide. Both are structural analogues of DA and competitive inhibitors of the decarboxylase enzyme. By inhibiting the DCC enzyme in the peripheral nervous system, a greater proportion of the levodopa dose enters the CNS. This strategy reduces the dose of levodopa required and the peripheral adverse reactions.

17. Which of the following drug interactions can lead to hypertensive crisis: A. Levodopa and metoclopramide B. Levodopa and selegiline C. Levodopa and MAO-A inhibitors D. Levodopa and ferrous sulfate ANS: C The concomitant use of levodopa and monoamine oxidase-A inhibitors (MAO-A) such as phenelzine and tranylcypromine may result in severe hypertensive crisis. MAO-A inhibitors should be discontinued 2–4 weeks before starting levodopa therapy.

18. ‘Off’ symptoms associated with prolonged levodopa therapy are managed by: A. Less frequent levodopa administration B. Addition of haloperidol to control symptoms C. Addition of entacapone D. All of the above ANS: C ‘On–off’ syndrome refers to a complication following prolonged levodopa therapy. The patient fluctuates from being symptom-free (‘on’) to demonstrating full-blown Parkinson’s symptoms (‘off’) during therapy. Treatment may require more frequent administration of levodopa or levodopa–DDCI, and perhaps the addition of a direct-acting dopamine agonist. Concurrent administration of a COMT inhibitor, such as entacapone, helps reduce ‘off’ times.

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19. The ‘on–off’ syndrome associated with prolonged levodopa therapy might be due to: A. Decreased delivery of levodopa centrally B. Alteration in sensitivity of DA receptors C. Dopamine metabolite interference D. All of the above ANS: D ‘On–off’ syndrome might be due to a decrease in delivery of dopamine centrally, an alteration in sensitivity of the dopamine (DA) receptors, a variation in the amount and rate of drug absorption, dopamine metabolite interference or a combination of effects.

20. An example of a central dopamine agonist used to inhibit lactation and treat hyperprolactinaemia is: A. Haloperidol B. Domperidone C. Pergolide D. Cabergoline ANS: D Dopamine agonists inhibit lactation. Cabergoline is used as a lactation inhibitor and to treat hyperprolactinaemia.

21. A peripheral DA antagonist sometimes given concurrently with dopamine-enhancing agents to minimise peripheral dopamine effects (nausea and hypotension) is: A. Metoclopramide B. Domperidone C. Bromocriptine D. Prochlorperazine ANS: B Domperidone, an antiemetic, is a peripheral DA antagonist sometimes given concurrently to minimise peripheral dopamine effects such as nausea and hypotension.

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22. The following agent is associated with sudden sleepiness and compulsive behaviours: A. Apomorphine B. Bromocriptine C. Pramipexole D. Pergolide ANS: C Pramipexole, a new non-ergoline DA agonist, acts at D2 and D3 receptors. When added to levodopa therapy, it has been shown to improve the patient’s motor fluctuations and reduce ‘off’ time from levodopa. A similar drug, rotigitine, is formulated as a skin patch.

Both drugs can cause sudden sleepiness and compulsive behaviours.

23. Selegiline enhances or prolongs levodopa’s antiparkinson effect by: A. Irreversible inhibition of MAO-A B. Irreversible inhibition of MAO-B C. Reversible inhibition of MAO-A D. Inhibition of COMT ANS: B Selegiline irreversibly inhibits MAO-B, thus preventing the breakdown of DA, and blocks DA reuptake. As a result it will enhance or prolong levodopa’s antiparkinson effect, which might result in a lowering of the daily dose of levodopa. Monoamine oxidase B metabolises mainly DA, whereas MAO-A is relatively specific to metabolism of noradrenaline (NA) and serotonin (5-HT).

24. Entacapone is contraindicated in which of the following situations?

A. Hypertension B. Parkinson’s disease with motor fluctuations C. Renal impairment D. Hepatic impairment ANS: D Entacapone, a reversible and specific COMT inhibitor, is always used with a levodopa–DDC inhibitor combination. Entacapone is contraindicated in hepatic impairment, and liver function is monitored as a similar drug (tolcapone) was withdrawn from use due to severe hepatic reactions.

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25. An example of a synthetic tripeptide indicated for the treatment of multiple sclerosis is: A. Glatiramer B. Natalizumab C. Diazepam D. Methotrexate ANS: A Glatiramer is a new unusual drug specifically for use in multiple sclerosis, to reduce the frequency of relapses. A simple tripeptide, it appears to block T-lymphocyte action against myelin antigens. As a peptide it must be injected daily, and reactions at the infection site are common. Other adverse effects include chest pain, dyspnoea, anxiety, oedema, tremor and delayed development of antibodies to the drug.

26. First-line therapy for multiple sclerosis (MS) is aimed at: A. Stimulating the impaired immune response B. Inhibiting the excessive immune response C. Immunising patients against the disease D. None of the above ANS: B First-line therapy of MS is directed at damping-down the excessive immune response against components of the nervous system, thus reducing the frequency and severity of attacks and the number and size of lesions.

27. Donepezil, indicated for the treatment of Alzheimer’s disease, acts by: A. Enhancing the neurotransmitter actions of acetylcholine in the CNS pathways B. Decreasing the neurotransmitter actions of acetylcholine in the CNS pathways C. Enhancing the neurotransmitter actions of acetylcholine in the periphery D. Decreasing immune response ANS: A Donepezil, galantamine and rivastigmine act to enhance neurotransmitter actions of acetylcholine in CNS pathways by inhibiting acetylcholinesterase.

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28. Memantine is thought to reduce neuronal degeneration in Alzheimer’s disease by: A. Inhibiting sodium channels B. Stimulating GABA receptors C. Inhibiting NMDA receptors D. Stimulating kainate receptors ANS: C Memantine is a new non-competitive antagonist at receptors for N-methyl-D-aspartame (NMDA). This agent is thought to reduce neuronal degeneration due to excess glutamate present in Alzheimer’s disease. It is approved for use in moderate-to-severe dementia, and can be used in combination with an anticholinesterase.

29. Migraine is a severe unilateral headache involving fluctuating levels of: A. Acetylcholine B. Serotonin C. Dopamine D. Histamine ANS: B In acute migraine, fluctuating levels of 5-HT cause vasoconstriction then vasodilation of cerebral blood vessels. For treatment of acute attacks, analgesics and 5-HT agonists—triptans—are used.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 18: Drugs Affecting the Eye and Ear Test Bank MULTIPLE CHOICE 1. Noradrenaline acts on: A. α1 adrenoreceptors to dilate pupillae B. β1 receptors to relax ciliary muscles C. β1 receptors to contract ciliary muscles D. None of the above ANS: A Adrenaline acts on α1 adrenoreceptors in the smooth muscle of the iris to dilate pupils and cause mydriasis. Stimulation of β2 receptors in ciliary muscles causes relaxation.

2. Acetylcholine acts on: A. α1 adrenoreceptors to dilate pupillae B. β1 receptors to relax ciliary muscles C. M3 receptors and causes miosis D. None of the above ANS: C Acetylcholine acts on M3 receptors in the smooth muscle of the iris and causes miosis.

3. Pilocarpine lowers intraocular pressure in glaucoma by: A. Activating α1 adrenoreceptors to dilate pupillae B. Inhibiting β1 receptors to relax ciliary muscles C. Constricting constrictor and ciliary muscles via actions on M3 receptors D. None of the above ANS: C Pilocarpine is a miotic (cholinergic, muscarinic agonist) causing constriction of constrictor and ciliary muscles via actions on M3 receptors, enhancing outflow of aqueous humour and decreasing intraocular pressure.

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4. Betaxol is useful in treating open-angle glaucoma because: A. It activates α1 adrenoreceptors to dilate pupillae B. It activates β1 receptors to relax ciliary muscles C. It selectively blocks β1 receptors D. All of the above ANS: C Betaxol selectively blocks β1 receptors (β blocking agent), antagonising β-receptor-mediated stimulation of ciliary epithelium, reducing aqueous humour formation.

5. Latanoprost, which reduces intraocular pressure, is a: A. Selective α1-adrenoreceptor agonist B. Selective β1-adrenoreceptor agonist C. Non-selective β-adrenoreceptor agonist D. Prostaglandin F2α analogue ANS: D Latanoprost is a prostaglandin F2α analogue (prostaglandin agonist) that reduces intraocular pressure by enhancing uvoscleral outflow of the aqueous humour.

6. Dorzolamide, which reduces intraocular pressure, is a: A. Carbonic anhydrase inhibitor B. Selective β1-adrenoreceptor agonist C. Non-selective β-adrenoreceptor agonist D. Prostaglandin F2α analogue ANS: A Dorzolamide is a carbonic anhydrase inhibitor that decreases aqueous humour production.

7. Common pathogen/s causing ocular infections is/are: A. Staphylococcus aureus B. Herpes simplex C. Chlamydia D. All of the above ANS: D Bacteria (staphylococcus, streptococci, pneumococci), viruses (adenovirus, herpes), chlamydia and acanthamoebae (protozoa) are common ocular pathogens.

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8. A broad-spectrum bacteriostatic agent is: A. Tobramycin B. Chloramphenicol C. Propamidine D. Acyclovir ANS: B Chloramphenicol is a broad-spectrum bacteriostatic agent used for a wide variety of Gram-positive and Gram-negative organisms. Tobramycin is an aminoglycoside used for Gram-negative organisms such as Proteus and Klebsiella. Propamidine is an anti-amoeba agent and acyclovir is the only ophthalmic antiviral preparation in Australia.

9. A diagnostic tool in eye disease is: A. Silver stain B. Fluorescein C. Alexa Fluor D. None of the above ANS: B Fluorescein is a non-toxic water soluble fluorescent dye. Normal corneal epithelium is impermeable to the dye and not stained. However, areas of abrasion fluoresce green.

Fluorescein applied to the cornea permits detection of defects caused by injury or infection.

10. Agent/s likely to produce ocular adverse effects is/are: A. Isoniazid B. Opiates C. Phenothiazines D. All of the above ANS: D Isoniazid can cause optical neuritis. Opiates can produce miosis and nystagmus.

Phenothiazines can produce corneal and conjunctival deposits, cataracts, retinopathy and oculogyric crisis.

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11. The aminoglycoside antibiotics, framycetin and neomycin, which are administered topically for ear infections, are associated with: A. Serum sickness B. Ototoxicity C. Bleeding D. Localised tissue necrosis ANS: B Aminoglycoside antibiotics are associated with ototoxicity.

12. A fluoroquinolone antibiotic preferred in patients with a perforated tympanic membrane (eardrum) or a patent grommet is: A. Norfloxacin B. Chloramphenicol C. Ciprofloxacin D. Neomycin ANS: C Ciprofloxacin is not ototoxic whereas the topical aminoglycoside antibiotics (framycetin and neomycin) are liable to cause ototoxicity, so ciprofloxacin is preferred in patients with a perforated tympanic membrane (eardrum), a patent grommet or chronic suppurative OM infections.

13. The risk of combining triamcinolone (a corticosteroid anti-inflammatory agent) with antibiotics in antimicrobial ear formulations is: A. Increased risk of inflammation B. Antagonism C. Drug allergy D. Predisposition to infection ANS: D Corticosteroids such as triamcinolone, flumethasone, dexamethasone and hydrocortisone are indicated for anti-inflammatory, antipruritic and anti-allergic effects, whereas antibiotics treat external ear canal infections and mastoidectomy cavity infections.

However, corticosteroids are immunosuppressants and predispose to infections.

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14. Ototoxic drugs that affect cochlear function are likely to cause: A. Balance problems B. Impaired auditory function C. Nasal pain D. None of the above ANS: B Ototoxic drugs that affect cochlear function are likely to cause impaired auditory function.

15. Ototoxic drugs that affect balance are likely to be affecting the: A. Cochlear function B. External ear C. Vestibular function D. None of the above ANS: C Ototoxic drugs that affect balance are likely to be affecting the vestibular function.

16. Tinnitus is best defined as: A. Impaired balance B. Auditory impairment C. Ringing in the ears D. Local irritation ANS: C The most common symptom reported in tinnitus is ‘ringing in the ears’.

17. Which of the following mechanisms has been associated with aminoglycoside-induced ototoxicity?

A. Inhibition of mitochondrial protein synthesis B. Free-radical cell damage C. Stimulation of NMDA receptors D. All of the above ANS: D The total aminoglycoside dosage of patients should be noted, and both ototoxicity and nephrotoxicity monitored in clinical use.

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18. Reversible and irreversible hearing loss has been associated with diuretic therapy using: a. Hydrochlorothiazide b. Frusemide c. Ethacrynic acid A. a alone B. a and b C. b and c D. a, b and c ANS: C The loop diuretics (bumetanide, ethacrynic acid, frusemide) have been linked to reversible and irreversible hearing loss, usually with too-rapid IV injection, high diuretic dosages or concurrent use with other ototoxic medications and in people with renal impairment.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 19: Drug Dependence and Social Pharmacology Test Bank MULTIPLE CHOICE 1. The definition of 'A physical state in which repeated doses of a drug cause decreasing effect’ is BEST termed: A. Addiction B. Psychological dependence C. Physical dependence D. Tolerance ANS: D Tolerance is a physical state in which repeated doses of the drug can cause decreasing effects, or doses must be increased to maintain the same effects.

2. Psychological dependence is best described as: A. A withdrawal syndrome B. A behavioural pattern characterised by out-of-control craving for the pleasure of the drug’s effect C. A physical state in which repeated doses of the drug causes decreased effect D. All of the above ANS: B Psychological dependence is a behavioural pattern characterised by out-of-control craving for the pleasure of a drug’s effect, plus denial of excessive drug use and continuing abuse of the drug despite personal, social or legal difficulties.

3. In Australia, drugs of dependence are generally listed as: A. Schedule 2 B. Schedule 4 C. Schedule 8 D. Schedule 9 ANS: C In Australia, drugs of dependence are generally listed in Schedule 8: Controlled Drugs, and thus are subject to the strictest controls in terms of availability, storage, labelling and Copyright © 2019 Elsevier Australia

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prescribing. As such, most drugs of dependence are illegal other than on prescription, and outside of approved medical use are considered illicit.

4. The neurotransmitter effect that has been shown to play a potentially pivotal role in addiction is: A. Dopamine (DA) B. Acetylcholine (ACh) C. Histamine D. All of the above ANS: A The role of dopamine appears to be in signalling incentives, driving motivated behaviour and consolidating memory. Evidence shows that all dependence-producing drugs increase the release of dopamine in the mesolimbic dopaminergic pathway.

5. Tolerance may potentially be associated with: A. Neuroadaptations B. Receptor downregulation C. Alteration of drug clearance D. All of the above ANS: D Tolerance may be associated with both receptor and metabolic changes. Receptor-site tolerance depends on both the concentration of the drug and the duration of exposure.

Receptor synthesis may be downregulated, receptors may be lost or desensitised or there may be exhaustion of chemical mediators or transmitters. Prolonged exposure to a drug may be associated with increased drug clearance.

6. Withdrawal syndrome associated with rapid cessation from chronic benzodiazepine use is likely to present as: a. anxiety b. agitation c. depressed mood d. drowsiness A. a alone B. a and b C. c and d D. None of the above ANS: B Withdrawal syndromes manifest as a rebound in the systems affected by the drug. The withdrawal from chronic use of benzodiazepines (antianxiety agents and CNS depressants) is likely to lead to feelings of anxiety and agitation.

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7. Symptoms associated with withdrawal from amphetamines are likely to present as: a. anxiety b. agitation c. depressed mood d. drowsiness A. a alone B. a and b C. c and d D. None of the above ANS: C Withdrawal syndromes manifest as a rebound in the systems affected by the drug. The withdrawal from amphetamines (CNS stimulants) leads to depressed mood and drowsiness.

8. Which of the following statements relating to naltrexone is CORRECT: A. Naltrexone is a competitive opioid antagonist B. Naltrexone can precipitate a withdrawal syndrome in opioid-dependent people C. Naltrexone reduces alcohol cravings D. All of the above ANS: D Naltrexone is a competitive opioid antagonist with no agonist actions. It reversibly blocks the effects of all opioids. It can precipitate a withdrawal syndrome in opioid-dependent people. It has been shown to reduce alcohol cravings, alcohol consumption and relapse rates.

9. The pharmacological action of diacetylmorphine (heroin) is best described as: A. GABA receptor agonism B. Opioid receptor antagonism C. Opioid receptor agonism D. None of the above ANS: C Heroin is a synthetic morphine derivative exhibiting opioid receptor agonism actions.

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10. Which of the following statements relating to methadone is CORRECT: A. Methadone is a synthetic opioid antagonist B. Methadone has a similar mechanism to naltrexone C. Methadone has a much slower onset of action and longer half-life than heroin D. All of the above ANS: C Methadone is a synthetic opioid agonist with analgesic effect. The agent has a slower onset of action than heroin and a much longer half-life.

11. A centrally acting α2-adrenoreceptor partial agonist, specifically useful in treating the sympathetic nervous system symptoms associated with withdrawal syndrome is: A. Methyldopa B. Clonidine C. Apomorphine D. All of the above ANS: B Clonidine is specifically useful in treating sympathetic nervous system symptoms and is helpful in lessening discomfort of the withdrawal syndrome.

12. The adverse effect NOT associated with methadone use is: A. Euphoria B. Respiratory depression C. CNS depression D. Diarrhoea ANS: D The adverse-reaction profile of methadone is similar to that of all opioids. Opioid agonists are associated with decreased gastrointestinal motility and resulting constipation.

13. Buprenorphine acts as: A. An opioid receptor agonist B. A partial agonist at μ-opioid receptors C. A μ-opioid receptor antagonist D. None of the above ANS: B

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Buprenorphine is a partial agonist at μ-opioid receptors.

14. Which of the following is considered safest in overdose: A. Methadone B. Buprenorphine C. Heroin D. Cocaine ANS: B Buprenorphine is a partial agonist at μ-opioid receptors and as such is considered safer in overdose and can block the effects of any heroin taken simultaneously.

15. Miosis is associated with all of the following drugs, EXCEPT: A. Buprenorphine B. Methadone C. Methamphetamine D. Benzodiazepines ANS: C Amphetamines such as methamphetamine produce mydriasis (dilated pupils) in contrast to opioids, such as buprenorphine and methadone, and benzodiazepines such as diazepam, which produce miosis (pinpoint pupils).

16. A drug that causes the accumulation of acetaldehyde by inhibiting the enzyme aldehyde dehydrogenase is: A. Fomepizole B. Disulfiram C. Naltrexone D. None of the above ANS: B Disulfiram inhibits the enzyme aldehyde dehydrogenase. Enzyme inhibition permits acetaldehyde to accumulate and cause unpleasant toxic effects, such as vasodilation, hyperventilation, raised heart rate, pounding headache and copious vomiting. As a result this agent is an alcohol-sensitising agent.

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17. The drug of choice for treating chronic alcohol abuse is: A. Disulfiram B. Naltrexone C. Acamprosate D. None of the above ANS: C The drug of choice in treating chronic alcohol abuse is now acamprosate. This agent is chemically related to the neurotransmitters GABA, glutamate and taurine, and may restore inhibitory neurotransmission in these pathways.

18. A benzodiazepine receptor antagonist used for treatment of benzodiazepine toxicity is: A. Naltrexone B. Buprenorphine C. Flumazenil D. None of the above ANS: C Flumazenil is a specific benzodiazepine-receptor antagonist that is administered intravenously to reverse sedation from benzodiazepine used during anaesthesia and for treatment of benzodiazepine toxicity.

19. Tobacco smoking induces which of the following drug-metabolising enzymes: A. CYP1A2 B. CYP3A4 C. CYP2D6 D. All of the above ANS: A Tobacco smoking induces CYP1A2 drug-metabolising enzyme.

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20. Nicotine replacement therapy (NRT) should be used with caution people with: A. Cardiovascular disease B. Insulin-dependent diabetes mellitus C. Hyperthyroidism D. All of the above ANS: D NRT should be used with caution in people with cardiovascular disease, insulin-dependent diabetes mellitus, hyperthyroidism, peptic ulcer disease or phaeochromocytoma. Its use should be avoided in patients with nicotine hypersensitivity, severe angina pectoris or life-threatening cardiac dysrhythmias, and after myocardial infarction. Use is not recommended in pregnancy or breastfeeding. However, NRT is less dangerous than smoking.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 20: Drugs Affecting Cardiac Function

Test Bank MULTIPLE CHOICE 1. The area of the heart that primarily regulates heart rate is: A. Pacemaker cells in the sinoatrial node B. Pacemaker cells in the atrioventricular node C. Purkinje fibres D. Bundle of His ANS: A Normally, the pacemaker cells in the SA node predominate as the only functional pacemaker of the heart. Sometimes, when the SA node substantially slows its rates of impulse formation, the AV node can take over.

2. Conduction through the heart occurs in the following sequence: A. SA node→AV node→purkinje fibres→bundle of his B. SA node→AV node→ bundle of his → purkinje fibres C. SA node→ purkinje fibres → AV node →bundle of his D. SA node→ purkinje fibres → bundle of his → AV node ANS: B Conduction through the heart begins at the SA node through the atria to the AV node.

Following this, calcium enters the cell and conduction continues to the bundle of his and purkinje fibres, ultimately resulting in ventricles contracting.

3. Depolarisation (phase 0) during a cardiac action potential is MAINLY characterised by: A. Calcium influx into the cardiomyocyte B. Potassium influx into the cardiomyocyte C. Potassium efflux out of the cardiomyocyte D. Sodium influx into the cardiomyocyte ANS: D Copyright © 2019 Elsevier Australia

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Phase 0 in the cardiac action potential is referred to as rapid depolarisation. During this stage the membrane becomes permeable to sodium, which rapidly flows into the cell.

4. Repolarisation (phase 3) during a cardiac action potential is MAINLY characterised by: A. Calcium influx into the cardiomyocyte B. Potassium influx into the cardiomyocyte C. Potassium efflux out of the cardiomyocyte D. Sodium influx into the cardiomyocyte ANS: C Phase 3 in the cardiac action potential is referred to as rapid repolarisation. During this stage there is rapid outflow of potassium from the cardiomyocyte.

5. The QRS complex on an electrocardiogram represents: A. Atrial depolarisation B. Atrial systole C. The duration of the whole ventricular action potential D. Ventricular depolarisation ANS: D The QRS complex represents ventricular depolarisation and the ventricles contract shortly after it begins.

6. Cardiac output is the function of: A. Preload and afterload B. Preload and stroke volume C. Heart rate and afterload D. Stroke volume and heart rate ANS: D Cardiac output (CO) is a function of both stroke volume (SV) and heart rate (HR), where CO = SV × HR.

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20-3

7. Which of the following statements is true?

A. Class Ia drugs used to treat dysrhythmias include disopyramide B. Class Ia drugs used to treat dysrhythmias include lignocaine and disopyramide C. Class Ia drugs used to treat dysrhythmias include flecainide D. Class Ia drugs used to treat dysrhythmias include atenolol ANS: A Class Ia drugs include disopyramide. Lignocaine is a class Ib drug while flecainide is a class Ic drug.

8. Disopyramide used to treat cardiac arrhythmias acts by: A. Blocking calcium influx into the myocardial cell B. Blocking potassium efflux out of the myocardial cell C. Blocking sodium influx into the myocardial cell D. None of the above ANS: C Disopyramide is a class Ia antidysrhythmic drug that blocks voltage-sensitive sodium channels interfering with sodium influx into the myocardial cell and decreases rate of depolarisation (phase 0).

9. Disopyramide has the potential to interact with: A. Lignocaine B. Phenytoin C. Tricyclic antidepressants D. All of the above ANS: D Disopyramide may interact with other antidysryhthmic agents. Phenytoin promotes induction of liver-metabolising enzymes reducing disopyramide plasma concentrations.

Co-administration with tricyclic antidepressants results in prolonged QT interval.

10. Which of the following statements is TRUE: A. Quinidine use has declined due to increased mortality in chronic use B. Disopyramide is one of the oldest antidysrhythmic drugs C. Procainamide was previously included as a class Ia drug D. All of the above.

ANS: D Copyright © 2019 Elsevier Australia

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Class Ia drugs (e.g. disopyramide) are the oldest antidysrhythmic drugs and previously included quinidine and procainamide.

11. Amiodarone is useful in treating dysrhythmias. It acts primarily by: A. Blocking sodium, potassium and calcium channels B. β1-adrenoreceptor agonism C. Blocking α1 adrenoreceptors D. β2 receptors agonism ANS: A As a Class III antidysrhythmic drug, amiodarone acts primarily by blocking potassium and sodium (class I effect). It also has the ability to block calcium channels (class IV effect) as well as blocking β adrenoreceptors (class II effect).

12. Adverse effect/s associated with the use of amiodarone is/are: A. Skin discolouration B. Peripheral neuropathies C. Pulmonary fibrosis D. All of the above ANS: D Adverse effects include dizziness, bitter taste, headache, flushing, nausea and vomiting, constipation, ataxia, weight loss, tremors, paraesthesiae of fingers and toes, photosensitivity, blue-grey skin discolouration, pulmonary fibrosis, cough, fever, allergic reaction and blurred vision.

13. Amiodarone has the potential to interact with: A. Digoxin B. Phenytoin C. Warfarin D. All of the above ANS: D Amiodarone increases plasma concentrations of digoxin and phenytoin, thereby potentially increasing their toxicity. It also inhibits metabolism of warfarin, potentially increasing its anticoagulant effect.

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20-5

14. Which of the following statements is TRUE: A. Torsades de pointes can be caused by drugs that prolong QT intervals B. Torsades de pointes can be prevented by drugs that prolong QT intervals C. Torsades de pointes is not an adverse effect of amiodarone D. None of the above ANS: A Drugs such as amiodarone and tricyclic antidepressants prolong QT intervals and increase the risk of Torsade de pointes, which is a polymorphic ventricular tachycardia.

15. Digoxin is a positive inotropic drug that increases force of myocardial contraction by: A. Blocking potassium efflux in the myocardial cell B. Blocking calcium entry into the myocardial cell C. Inhibiting Na+/K+-ATPase and increasing calcium levels D. Activating Na+/K+-ATPase and increasing calcium levels ANS: C Digoxin is a cardiac glycoside that inhibits Na+/K+-ATPase. The disruption to calcium and sodium exchange results in increased calcium levels that influence contraction in the heart.

16. Digoxin can be used to treat: A. Hypertension B. Angina C. Cardiac dysrhythmias D. None of the above ANS: C Digoxin slows AV node conduction and is useful in treating some cardiac dysrhythmias, especially atrial fibrillation, atrial flutter and paroxysmal atrial tachycardia.

17. Adverse effects associated with the use of digoxin include: A. Gastrointestinal disturbances B. Visual disturbances C. Dysrhythmias D. All of the above ANS: D

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Digoxin can cause significant GIT disturbances and CNS effects include confusion, but visual disturbances have also been reported. Dysrhythmias are associated with digitalis toxicity and include PVCs, PAT with AV block, VT and VF. 18. Digoxin has the potential to interact with which of the following drugs: A. Amiodarone B. Quinine C. Suxamethonium D. All of the above ANS: D Amiodarone and quinine increase plasma concentrations of digoxin, thereby increasing the risk of toxicity. Use with suxamethonium poses the risk of bradydysrhythmias.

19. Digoxin toxicity can be treated with: A. Thiazide diuretics B. Loop diuretics C. Digoxin immune fab D. None of the above ANS: C Digoxin-specific immune antigen binding fragment is used for life-threatening digoxin toxicity because it binds digoxin molecules. Hypokalemia and hypomagnesaemia caused by thiazide and loop diuretics can worsen digoxin toxicity.

20. Milrinone is a positive inotropic drug that acts by: A. Inhibiting phosphodiesterase III, increasing cAMP and calcium levels B. Inhibiting phosphodiesterase V, increasing cAMP and calcium levels C. Activating phosphodiesterase III, increasing cAMP and calcium levels D. Activating phosphodiesterase III, decreasing cAMP and calcium levels ANS: A Milrinone inhibits the cardiac-specific form of phosphodiesterase (phosphodiesterase 3).

Inhibition of the breakdown of cAMP results in elevated levels of cAMP within the tissues. This increases calcium influx and uptake, contributing to increased force of myocardial contractility and vasodilation.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 21: Drugs Affecting Vascular Smooth Muscle Test Bank MULTIPLE CHOICE 1. Smooth muscle relaxation produced by nifedipine most likely occurs from: A. Increased levels of cGMP B. Increased activation of calcium–calmodulin binding C. Increased α1-adrenoreceptor agonism D. Increased myosin light chain kinase activity ANS: A Nifedipine is a calcium channel blocker that modulates calcium concentration in the vascular system. Calcium channel blockers are capable of blocking the slow calcium ion influx in smooth muscle. This blockade results in reduced smooth muscle contraction by interfering with ion selective channels resulting in decreased triggering of the calcium–calmodulin complex that activates myosin light chain kinase activity.

2. A patient is prescribed diltiazem to manage chronic angina. The effect of this drug is: A. Decreased cardiac output B. Decreased blood pressure C. Increased heart rate D. Increased contractility ANS: B Diltiazem is a benzothiazepine-type calcium channel blocker. It reduces contractility, may reduce heart rate and may increase cardiac output. Its main action is to dilate coronary arteries and arterioles and dilate peripheral arterioles resulting in lowered arterial blood pressure.

3. A patient is taking antianginal medication that increases cGMP levels in vascular smooth muscle. The drug is responsible for this action by: A. Inhibition of phosphodiesterase B. Release of nitric oxide C. Blockade of calcium channels D. Blockade of β-adrenoreceptors ANS: B Copyright © 2019 Elsevier Australia

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Organic nitrates are used as antianginal agents. Nitrate drugs activate soluble guanylyl cyclase in vascular smooth muscle, which increases cGMP. The presence of cGMP leads to changes in the degree of phosphorylation of smooth muscle proteins.

Dephosphorylation of the myosin light chain leads to relaxation.

4. Variant angina: a. is extremely common and attacks have similar characteristics b. occurs due to plaque rupture and symptoms may occur at rest c. occurs due to acute vasospasms near an atherosclerotic area d. occurs due to acute vasospasms and symptoms may occur at rest or during sleep A. a and b B. a and d C. c and a D. c and d ANS: D Variant or Prinzmetal angina is uncommon and caused by acute coronary vasospasms near an area of atherosclerosis. Symptoms often occur at rest or without any cause.

5. Angiotensin receptor blockers (ARBs) such as losartan act by: A. Inhibiting angiotensin-converting enzyme B. Selectively targeting AT2 receptors C. Selectivity targeting AT1 receptors D. Selectively targeting renin release ANS: C Angiotensin receptor blockers (ARBs) prevent binding of angiotensin II to angiotensin receptors (AT). All agents in this class act preferentially on AT1 receptors.

6. A significant advantage of angiotensin receptor blockers over ACE inhibitors is that: A. ARBs reduce peripheral vascular resistance and decrease blood pressure B. ARBs decrease heart rate C. ARBs do not produce the dry cough due to effects of bradykinin D. ARBs are available as combination products ANS: C ACE inhibitors inhibit the breakdown of bradykinin, which is mainly responsible for the dry cough reported in approximately 20% of patients using these drugs. Both receptor Copyright © 2019 Elsevier Australia

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21-3

blockers and enzyme inhibitors decrease peripheral vascular resistance and blood pressure. Although they can cause reflex tachycardia, neither agent has any significant effects on heart rate. Both ACEI and ARBs are available as combination products.

7. ACE inhibitors can potentially interact with: A. Loop and thiazide diuretics B. Potassium-sparing diuretics C. Potassium supplements D. All of the above ANS: D ACE inhibitors can interact with loop and thiazide diuretics to potentially cause first-dose hypotension. Interactions with potassium-sparing diuretics and supplements increase the risk of hyperkalaemia.

8. An antihypertensive drug that can safely be used in pregnancy is: A. Methyldopa B. Captopril C. Losartan D. All of the above ANS: A Captopril and losartan can cause fetal and neonatal morbidity (Pregnancy Safety category D). Methyldopa has a pregnancy safety rating of A. 9. Renin release is triggered by: A. Decreased renal sympathetic activity B. Increased blood pressure C. Increased sodium delivery to the nephron D. None of the above ANS: D Increased renal sympathetic activity, decreased blood pressure and decreased sodium delivery to the distal tubule in the nephron all trigger renin release from the kidney.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 22: Lipid-Lowering Drugs Test Bank MULTIPLE CHOICE 1. An example of a HMG-CoA reductase inhibitor to reduce cholesterol biosynthesis is: A. Simvastatin B. Cholestyramine C. Niacin D. Fish oil ANS: A Drugs with the suffix –statins act as competitive inhibitors of HMG-CoA reductase.

Primary hypercholesterolaemia can be controlled by inhibiting the rate-limiting enzyme responsible for cholesterol biosynthesis.

2. A patient with hyperlipidaemia is prescribed an agent that increases the expression of lipoprotein lipase. The therapeutic effect would be: A. Increased LDL-C levels B. Increased plasma triglyceride levels C. Decreased plasma triglyceride levels D. Decreased HDL-C levels ANS: C Fibric acid derivatives such as gemfibrozil activate PPAR-α receptors and increase the expression of lipoprotein lipase. This enzyme is responsible for the removal of triglycerides from VLDL and thereby decreases plasma triglyceride levels.

3. Adverse effects associated with the use of statins is/are: A. Gastrointestinal discomfort B. Myalgia and rhabdomyolysis C. Elevated hepatic enzyme activity D. All of the above ANS: D Adverse effects associated with statin use include GIT upset. In addition, a common adverse effect is muscle toxicity that ranges from myalgia to less common occurrences of Copyright © 2019 Elsevier Australia

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22-2

myopathy, myositis and rhabdomyolysis. Elevated liver enzymes are dose related and can be seen in the first few weeks of treatment. Starting at the lower end of the dosage range is recommended.

4. A lipid-lowering drug known to cause flushing of the skin is: A. Simvastatin B. Niacin C. Fish oil D. Cholestyramine ANS: B The large doses of niacin used to lower serum lipid levels cause vasodilation and flushing of the skin and can be accompanied by pruritus.

5. Flushing associated with large doses of niacin can be reduced by: A. Taking the drug before meals B. Taking the drug at bedtime C. Taking aspirin 30–60 minutes before each dose D. Taking the drug after meals ANS: C Flushing and pruritus caused by niacin are prostaglandin-mediated and therefore taking aspirin is beneficial. Flushing is not affected by time of day or meals.

6. Combination of niacin and simvastatin is potentially dangerous because: A. They can cause hypotension B. They can cause severe hyperkalaemia C. They increase the risk of myopathies and rhabdomyolysis D. None of the above ANS: C Concurrent use of statins and niacin can cause myopathies. If used concurrently the statin should be used at no more than 25% of its maximum dose. CK levels should be monitored since myopathies have been reported after several years of concurrent use.

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22-3

7. An example of a bile acid-binding resin that moderately lowers cholesterol levels and has an excellent safety record is: A. Simvastatin B. Gemfibrozil C. Fish oil D. Cholestyramine ANS: D Cholestyramine is a bile acid-binding resin. It binds bile acids and promotes excretion of the resulting complex preventing enterohepatic cycling of bile acids. The liver is obliged to synthesise replacement bile acids from cholesterol, resulting in increased hepatic LDL receptors and a decrease in plasma LDL-C. Bile acid-binding resins are moderately effective drugs with few side effects and are a useful alternative in patients who cannot tolerate other drugs.

8. Ezetemibe lowers lipid levels by: A. Inhibiting cholesterol absorption B. Inhibiting HMG-CoA reductase C. Activating PPAR-α receptors and increasing the expression of lipoprotein lipase D. None of the above ANS: A Ezetemibe is a novel lipid-lowering drug that inhibits intestinal absorption of cholesterol and phytosterols.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 23: Drugs Affecting the Kidney and Bladder Test Bank MULTIPLE CHOICE 1. Diuretics that inhibit sodium reabsorption in the loop of Henle are referred to as: A. Loop diuretics B. Thiazide diuretics C. Osmotic diuretics D. Potassium-sparing diuretics ANS: A Loop diuretics inhibit sodium, potassium and chloride reabsorption in the thick ascending limb of the loop of Henle.

2. The MOST common adverse effect associated with the use of loop diuretics is: A. Hyperuricaemia B. Electrolyte disturbances including hypokalaemia C. Hearing disturbances D. Increased LDL-C ANS: B Although loop diuretics can cause hyperuricaemia, hearing disturbances and increased LDL-C, the most commonly reported adverse effects are electrolyte disturbances including hypokalaemia, hypomagnesaemia and hypocalcaemia.

3. Frusemide could potentially interact with: A. Amphotericin B. ACE inhibitors C. NSAIDs D. All of the above ANS: D Amphotericin potentiates the hypokalaemic effect of frusemide while ACE inhibitors increase the risk of first-dose hypotension with people on a high dose of the diuretic.

NSAIDs reduce the potency of loop diuretics.

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23-2

4. Which of the following statements is TRUE: a. Frusemide is a potassium-sparing diuretic b. Frusemide is a high ceiling diuretic c. Hydrochlorothiazide is low ceiling diuretic d. Hydrochlorothiazide is not a sulfonamide-derived diuretic A. a and b B. b and c C. a and d D. c and d ANS: B Loop diuretics like frusemide are called high ceiling diuretics because they produce a dose-dependent diuresis throughout their clinical dose range. By contrast, thiazide diuretics that are sulfonamide derivatives are classified as low ceiling diuretics because they produce a rather flat dose–response curve.

5. Hydrochlorothiazide could potentially interact with: A. Digitalis B. ACE inhibitors C. NSAIDs D. All of the above ANS: D Hydrochlorothiazide increases the risk of digitalis toxicity while ACE inhibitors increase the risk of first-dose hypotension with people on a high dose of the diuretic. NSAIDs reduce the natriuretic and hypertensive effects of the diuretic.

6. The diuretic of choice in hypertensive patients is: A. Frusemide B. Mannitol C. Hydrochlorothiazide D. Acetazolamide ANS: C Thiazide diuretics are the preferred diuretic in treating patients with hypertension. Loop diuretics are preferred for oedema-associated conditions such as heart failure. Mannitol and acetazolamide are seldom used as diuretics today.

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23-3

7. A drug/s that increases the risk of hyperkalaemia is/are: A. Amiloride B. Spironolactone C. Triamterene D. All of the above ANS: D All three drugs are potassium-sparing diuretics that increase plasma potassium levels and thereby increase the risk of hyperkalaemia.

8. A diuretic that can produce antiandrogenic effects is: A. Amiloride B. Spironolactone C. Frusemide D. Mannitol ANS: B Spironolactone is a steroid congener of aldosterone and competitively blocks binding of aldosterone to the mineralocorticoid receptor in epithelial cells of the late distal tubule and collecting ducts. Spironolactone has antiandrogenic effects that can be useful in treating polycystic ovary disease but can produce impotence and gynaecomastia in men.

9. Drug therapy contributing to urinary incontinence includes: A. Diuretics B. Benzodiazepines C. Anticholinergics D. All of the above ANS: D Diuretics cause excessive urine production, which can lead to urge incontinence; benzodiazepines decrease urethral pressure leading to stress incontinence; and anticholinergics cause incomplete bladder emptying leading to overflow incontinence.

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23-4

10. Oxybutynin controls detrusor activity in an overactive bladder by: A. Adrenergic antagonism B. Noradrenergic agonism C. Muscarinic receptor antagonism D. Muscarinic receptor agonism ANS: C Overactivity or spontaneous involuntary contraction of the detrusor muscle that leads to urge incontinence can be controlled by drugs that block the action of acetylcholine (muscarinic receptor antagonists). Drugs in this class include oxybutynin.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 24: Drugs Affecting Thrombosis and Haemostasis Test Bank MULTIPLE CHOICE 1. Anticoagulation produced by heparin is initiated by its binding with: A. Antithrombin III B. Thrombin factor IIa C. ADP D. None of the above ANS: A Heparin produces its anticoagulant effect by combining with antithrombin III. This complex then acts rapidly at multiple sites in the normal coagulation system, inactivating thrombin factor IIa and factors IXa, Xa, XIa and XIIa. 2. Heparin is indicated for use in: A. Prophylaxis—to prevent blood clotting during heart surgery B. Prophylaxis—to prevent blood clotting during blood transfusions C. Disseminated intravascular coagulation (DIC) D. All of the above ANS: D Heparin is used to prevent and treat all types of venous thromboembolism in surgical and high-risk medical patients.

3. Common adverse reactions associated with heparin use include: A. Osteoporosis B. Bleeding C. Pruritus and urticaria D. All of the above ANS: B Bleeding or haemorrhage is the most common side effect associated with heparin.

Osteoporosis, pruritus and urticaria may occur but these are rare.

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24-2

4. Heparin could potentially interact with: A. Aspirin B. Dipyridamole C. Alteplase D. All of the above ANS: D Aspirin (antiplatelet), dipyridamole (P2Y12 inhibitor) and alteplase (rt-PA) increase the risk of bleeding when used concurrently with heparin.

5. Which of the following statements are TRUE: a. Low-molecular-weight heparin can only be administered subcutaneously b. Heparin has low protein binding c. Low-molecular-weight heparin does not affect vascular permeability d. Protamine is completely effective for bleeding associated with low-molecular-weight heparin A. a & b B. b & c C. a & c D. c & d ANS: C LMWH is administered subcutaneously and does not increase vascular permeability.

Regular heparin is highly protein bound while protamine is only partially effective for bleeding associated with use of low-molecular-weight heparin.

6. The anticoagulant effect produced by warfarin occurs due to: A. Inhibition of Thromboxane A2 B. Binding to antithrombin III C. Inhibition of vitamin K epoxide reductase complex 1 D. All of the above ANS: C Warfarin interferes with hepatic synthesis of the vitamin K-dependent clotting factors through inhibition of the vitamin K epoxide reductase complex 1 (VKORC1). As a consequence, interference in the gamma-carboxylation of the glutamic acid residues on factors II, VII, IX and X and on various anticoagulant proteins by gamma-glutamyl carboxylase leads to the production of non-functional coagulation factors.

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24-3

7. Aspirin’s antiplatelet actions are mediated by: A. Inhibition of COX enzymes and decreased synthesis of thromboxane A2 B. Binding to antithrombin III C. Inhibition of vitamin K epoxide reductase complex 1 D. None of the above ANS: A Aspirin causes a long-lasting functional deficit in platelets by irreversibly inhibiting cyclo-oxygenase, an enzyme necessary for thromboxane A2 synthesis. Thromboxane A2 promotes platelet aggregation and vasoconstriction, and thus aspirin suppresses these actions. Platelets lack the metabolic capacity to synthesise new cyclo-oxygenase, and the deficit induced by aspirin lasts 8–10 days until new platelets are synthesised.

8. Which of the following statements is INCORRECT: A. Clopidogrel inhibits the ADP-mediated activation of the GPIIb/IIIa complex B. Clopidogrel decreases thromboxane A2 production C. Clopidogrel is a structural analogue of ticlopidine D. Clopidogrel is a prodrug that is metabolised by CYP enzymes to its active metabolite ANS: B Clopidogrel is a second-generation thienopyridine derivative structurally related to ticlopidine. It irreversibly binds to the P2Y12 platelet receptor preventing ADP mediation.

It is a prodrug that is predominantly metabolised (85%) to an inactive carboxylic acid metabolite.

9. The mechanism by which dipyridamole produces its antiplatelet effects may include: A. Decreased thromboxane A2 production B. Reduced uptake of adenosine by red blood cells C. Inhibition of phosphodiesterase D. All of the above ANS: D The mechanism of action of dipyridamole is unclear but is thought to include inhibition of thromboxane A2 formation; inhibition of phosphodiesterase activity, which results in an increase in platelet cAMP; and inhibition of red blood cell uptake of adenosine, a platelet aggregation inhibitor.

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24-4

10. Dipyridamole has the potential to interact with which: A. Adenosine B. Aspirin C. Warfarin D. All of the above ANS: D Dipyridamole inhibits cellular uptake of adenosine and a reduction in dose of adenosine might be necessary. Combined use with either aspirin or warfarin increases the potential for bleeding episodes.

11. Dipyridamole is used in combination with warfarin for the prevention of postsurgical thromboembolic complications after cardiac valve replacement, in combination with aspirin for the secondary prevention of ischaemic stroke and transient ischaemic attacks and IV for cardiac stress testing.

Which of the following statements is INCORRECT: A. Alteplase converts plasminogen in the blood to plasmin B. Alteplase is indicated for ST-segment-elevation myocardial infarction (STEMI) C. Alteplase has a biphasic elimination half-life of 25 minutes initially and terminal half-life at 130 minutes D. Alteplase is indicated for use in acute ischaemic stroke ANS: C Alteplase has an elimination half-life of 35 minutes.

12. Which of the following statements is INCORRECT: A. Protamine sulfate dissociates the heparin–antithrombin complex and is indicated for the treatment of an overdose of LMWH or standard heparin B. Protamine has strong anticoagulant properties C. Tranexamic acid is a competitive inhibitor of plasminogen activation D. Vitamin K deficiency leads to hypoprothrombinaemia and haemorrhage ANS: B

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 25: Drugs Affecting the Haemopoietic System Test Bank MULTIPLE CHOICE 1. A patient complains of lethargy and fatigue and is found to have low blood haemoglobin levels. The most appropriate drug therapy is: A. Vitamin K B. Filgrastim C. Iron D. None of the above ANS: C A condition in which there is a reduced oxygen-carrying capacity of the blood (due to reduced amount or functionality of haemoglobin) is referred to as anaemia and often manifests as fatigue. Iron deficiency anaemia is characterised by small red cells with reduced haemoglobin. Agents commonly used to treat this condition are the haematinics: folic acid, iron and vitamin B12.

2. Folic acid can be used to: A. Treat folate-deficiency anaemia B. Prevent neural tube defects in the growing fetus C. Prevent toxicity from methotrexate D. All of the above ANS: D Folic acid is essential for DNA synthesis, and dietary folic acid is reduced to tetrahydrofolate (FH4). Folic acid is used to treat folate-deficiency anaemia, to prevent neural tube defects in the growing fetus and to treat or prevent toxicity from the antimetabolite drug methotrexate.

3. Common adverse reactions associated with erythropoietin include: A. Hypertension B. Flu-like symptoms C. Peripheral oedema D. All of the above ANS: D Copyright © 2019 Elsevier Australia

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Adverse reactions associated with erythropoietin use are common and include hypertension (due to a rapid rise in haemoglobin), flu-like symptoms (e.g. headache, bone pain, myalgia and fever) and rash, peripheral oedema, dyspnoea and GI disturbances (e.g. nausea, vomiting and diarrhoea).

4. A middle-aged woman exhibits severe neutropenia following a course of chemotherapy for breast cancer. The most appropriate drug therapy to treat her is: A. Aspirin B. Vitamin K C. Filgrastim D. Iron ANS: C Colony-stimulating factors are cytokines that regulate cell proliferation, differentiation and growth through an action on progenitor cells. Currently available CSFs include ancestim, a recombinant stem cell factor, which is produced by bone marrow fibroblasts, and the granulocyte colony-stimulating factors (G-CSF) filgrastim and pegfilgrastim and lenograstim. G-CSF is primarily regarded as a haematopoietic growth factor of the granulocyte lineage controlling the development of neutrophils. The G-CSFs are indicated for the treatment of chemotherapy/drug-induced neutropenia, severe chronic neutropenia and autologous and allogeneic bone marrow transplantation.

5. An elderly patient with diabetic nephropathy and end-stage renal disease exhibits symptoms of pernicious anaemia. The most appropriate drug therapy is: A. Aspirin B. Streptokinase C. Cyanocobalamin D. All of the above ANS: C Cyanocobalamin (also known as Vitamin B12) is used principally to treat pernicious anaemia and optic neuropathies (the vitamin is essential to nerve development).

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 26: Drugs Used in Respiratory Disorders Test Bank MULTIPLE CHOICE 1. Which of the following statements is INCORRECT: A. Pulmonary surfactant is a phosphatidylcholine–apoprotein lipoprotein mixture secreted from alveolar epithelial cells B. Pulmonary surfactant is present in the secretions lining the alveoli C. Pulmonary surfactant increases surface tension in the lung, which destabilises the alveoli D. Beractant and poractant are commercially available forms of surfactant ANS: C Pulmonary surfactant is a phosphatidylcholine–apoprotein lipoprotein mixture secreted from alveolar epithelial cells and present in the secretions lining the alveoli. Surfactant reduces surface tension in the lung, stabilises the alveoli and improves lung mechanics.

2. Surfactant can be purified from animal lung sources or synthesised commercially.

Beractant (a modified bovine product) and poractant alfa (derived from pigs’ lungs) are commercially available forms of surfactant available in Australia and are supplied as solutions for intratracheal administration. Both agents are normally used only in neonatal intensive care units.

An advantage of aerosol therapy is: A. Drug administration is convenient B. Lower doses can be given than by systemic administration C. Systemic adverse effects are minimised D. All of the above.

ANS: D Drug delivery by inhalation has many advantages, not least that the drug is delivered directly to the desired site of action.

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3. Which of the following statements is INCORRECT: A. Nitric oxide (NO) can be used to improve tissue oxygenation in neonates suffering hypoxic respiratory failure resulting from meconium aspiration or pulmonary hypertension B. CO2 in oxygen is sometimes used to treat carbon monoxide poisoning C. Symptoms of CO2 overdose are dyspnoea, breath-holding, markedly increased chest and abdominal movements, nausea and raised systolic blood pressure D. NO constricts the blood vessels in the lungs ANS: D Nitric oxide is a mediator generated locally in tissues, with many physiological actions including vasodilation produced by actions on guanylate cyclase. When administered as a gas, NO dilates the blood vessels in the lungs, and thus enhances oxygenation.

4. Which of the following statements regarding dornase alfa is INCORRECT: A. Dornase alfa is administered via a nebuliser for 6–12 months B. Adverse effects associated with its use include chest pain, sore throat and laryngitis C. It acts by splitting disulfide bonds in mucoproteins D. All of the above ANS: C Dornase alfa is a respiratory inhalant with proven mucolytic efficacy. As recombinant human deoxyribonuclease, a DNA-degrading enzyme, it acts by digesting extracellular DNA released from degenerating neutrophils and cellular debris in sputum.

Acetylcysteine is an older mucolytic with little proven efficacy.

5. An asthmatic patient being treated for a severe exacerbation experiences tachycardia.

The most likely drug responsible for the adverse reaction is: A. Budesonide B. Cromolyn C. Salbutamol D. None of the above ANS: C Salbutamol is a short-acting β2 agonist indicated for symptomatic relief of acute asthma via inhalation. Tachycardia is a known adverse effect. While agonists with specific actions on β2-adrenoceptors are available, it needs to be remembered that any substrate specificity in pharmacology is relative, and such agonists may stimulate also α and β1 Copyright © 2019 Elsevier Australia

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receptors, especially in high doses, so adverse effects in the cardiovascular system (tachycardia), skeletal muscle (tremor) and CNS (anxiety) may occur.

6. An example of a short-acting β2 agonist is: A. Budesonide B. Cromolyn C. Eformoterol D. Terbutaline ANS: D Eformoterol is a long-acting β2 agonist, budesonide is a steroid and cromolyn is a mast cell stabiliser. Short-acting β 2 agonists like terbutaline are fast-acting bronchodilators used as relievers in first-line treatment for acute relief of asthma symptoms.

7. An elderly patient with emphysema has been placed on a drug that inhibits the breakdown of cAMP. A drug that acts in this way is: A. Budesonide B. Cromolyn C. Theophylline D. Salbutamol ANS: C The mechanism of action of the xanthine derivatives such as theophylline is not well understood. The simple mechanism long held to account for their bronchodilator effect is inhibition of phosphodiesterase (the enzyme that metabolises cAMP), leading to increased intracellular levels of cAMP, smooth muscle relaxation and bronchodilation. It is most commonly prescribed for maintenance treatment of poorly-controlled moderate-to-severe asthma and COPD. 8. Theophylline has the potential to interact with which of the following drugs: A. Diuretics B. Lithium C. Phenytoin D. All of the above ANS: D There are many drug interactions with theophylline, see Drug Interactions 26.1.

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9. An example of a drug that blocks mediator release from mast cells is: A. Salbutamol B. Cromolyn C. Theophylline D. All of the above ANS: B Cromolyn is referred to as a mast cell stabiliser. Although the mechanism is not yet fully understood, it prevents mediator release from mast cells by blocking calcium influx.

10. A patient has been placed on a drug that decreases leukotriene synthesis. The mechanism responsible for this pharmacological effect is: A. Inhibition of calcium influx B. Activation of β2 adrenoreceptors C. Inhibition of 5-lipoxygenase D. None of the above ANS: C New drugs under clinical trial act by preventing leukotriene synthesis. Zileuton is a 5-liopoxygenase inhibitor in this category. Montelukast and zafirlukast are leukotriene-receptor antagonists and block receptors for the cysteinyl leukotrienes (C4, D4 and E4).

11. Which of the following statements regarding the use of inhaled corticosteroids in asthma is INCORRECT: A. Prophylactic use prevents late-phase inflammatory responses B. Use in acute asthma attacks produces bronchodilation C. Reduce both early and late stages of the inflammatory response D. Indicated for use in prophylactic treatment of severe asthma and COPD ANS: B Corticosteroids do not cause bronchodilation. They are indicated prophylactically in maintenance treatment of severe asthma and COPD to reduce both early and late stages of the inflammatory response.

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12. Adverse effects of inhaled corticosteroids include: A. Candida infections B. Decrease in bone mineral density (BMD) C. Hoarse voice D. All of the above ANS: D Local effects of inhaled corticosteroids include hoarse voice and oral thrush. Patients are advised to rinse their mouth out with water after use of their inhaler. Frequent use of inhaled steroids may lead to reduced BMD and increased risk of osteoporosis.

13. An example of an anticholinergic drug used in severe asthma and COPD is: A. Ipratropium B. Salmeterol C. Beclomethasone D. Omalizumab ANS: A Ipratropium acts at muscarinc M3 receptors providing bronchodilation actions after inhalation. It should not be used for relief of symptoms but as adjunctive controller therapy with corticosteroids.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 27: Drugs Affecting the Upper and Lower Gastrointestinal Tract

Test Bank MULTIPLE CHOICE 1. Which of the following facts relating to nystatin is FALSE: A. Used for treatment of systemic candidiasis B. Not absorbed from mucous membranes of the mouth, GIT and vagina C. Not absorbed systemically from the skin D. Induces leakiness of the fungal cell membrane ANS: A Because of systemic toxicity, this agent is used for the treatment of cutaneous, intestinal, oropharyngeal and vulvovaginal candidiasis.

2. Xerostomia (dry mouth) is caused by which of the following: A. Nortriptyline B. Hyoscine C. Clozapine D. All of the above ANS: D Xerostomia (dry mouth) is associated with anticholinergic drugs that have atropine-like effects such as nortriptyline (anticholinergic), clozapine (antipsychotic) and hyoscine (antimuscarinic).

3. Protrusion of a part of the stomach through the diaphragm is termed: A. Oesophagitis B. Hiatal hernia C. Dysphagia D. Zollinger–Ellison syndrome ANS: B Protrusion of a part of the stomach through the diaphragm is termed hiatal hernia.

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4. Inhibition of gastric acid secretion is due to the action of: A. Histamine B. Acetylcholine C. Gastrin D. PGE2 ANS: D Prostaglandins E2 (PGE2) and I2 (PG I2) inhibit gastric acid secretion.

5. Histamine directly stimulates gastric acid release from parietal cells via its action at: A. H1 receptors B. H2 receptors C. All histamine receptors D. None of the above ANS: B Histamine acts via histamine (H2) receptors to increase acid secretion.

6. A major causative agent in peptic ulcer disease is the organism: A. E. coli B. Clostridium difficile C. Helicobacter pylori D. Campylobacter spp.

ANS: C Helicobacter pylori, a common Gram-negative bacillus, has been identified as a major causative agent in individuals with peptic ulcer disease not caused by NSAIDs. 7. Constipation is associated with the antacid: a. magnesium hydroxide b. aluminium hydroxide c. Mylanta A. a alone B. a and b C. b alone D. a, b and c ANS: C Copyright © 2019 Elsevier Australia

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Antacids should be avoided in the presence of coexisting conditions such as constipation (worsened by aluminium) or diarrhoea (worsened by magnesium). Mylanta is a magnesium-aluminium combination that also contains simethicone—a defoaming agent that relieves flatulence by dispersing and preventing the formation of mucous surrounding gas pockets in the gastrointestinal tract.

8. Milk–alkali syndrome is associated with: A. Aluminium hydroxide B. Calcium carbonate C. Sodium bicarbonate D. Magnesium salts ANS: B Calcium carbonate is associated with milk–alkali syndrome. Milk–alkali syndrome is caused by the ingestion of large amounts of calcium and absorbable alkali with resulting hypercalcaemia. If unrecognised and untreated, milk–alkali syndrome can lead to metastatic calcification and renal failure.

9. Aluminium hydroxide is contraindicated in: A. Pregnancy B. Hyperparathyroidism C. Oedema associated with heart failure D. Chronic renal failure ANS: D Chronic renal failure because of increased risk of aluminium toxicity.

10. Concomitant use of aluminium–magnesium containing antacids with quinolone antibiotics such as ciprofloxacin is likely to: A. Increase the tendonitis associated with ciprofloxacin use B. Reduce the absorption of quinolones C. Increase the antibiotic effect of quinolones D. Have no effect ANS: B Combination antacids can reduce the absorption and effect of quinolones. Patients are advised to take the antacid at least 6 hours before or 2 hours after the quinolone antibiotic.

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11. An adverse reaction NOT associated with the use of the cytoprotective agent Sucralfate is: A. Dizziness B. Dry mouth C. Diarrhoea D. Back pain ANS: C Sucralfate is composed of sulfated sucrose and aluminium hydroxide. The most common adverse reaction is constipation, which occurs in 1–5% of patients. Infrequently, there are reports of dizziness, dry mouth, rash, headache and back pain.

12. Misoprostol, the PGE1 analogue indicated for cytoprotection, should not be used in: A. Pregnant women B. Patients taking NSAIDs C. Patients with gastric ulcers D. All of the above ANS: A The Pregnancy Safety Category of Misoprostol is X. It can induce premature labour and may be teratogenic in large doses. It should not be used in pregnant women or in those contemplating pregnancy.

13. An agent that competitively blocks H2 receptors reducing gastric acid secretion by approximately 70% is: A. Misoprostol B. Sucralfate C. Omeprazole D. Ranitidine ANS: D Cimetidine, ranitidine, famotidine and nizatidine are H2-receptor antagonists.

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14. Concomitant use of cimetidine with the antiepileptic agent, phenytoin, is likely to result in: A. Increased risk of seizure for the patient B. Decreased plasma levels of phenytoin C. Increased risk of dose-dependent adverse effects associated with phenytoin D. No effect ANS: C Cimetidine inhibits the metabolism of other drugs by CYP1A2, CYP2C9 and CYP2D6 inhibitory effects. This will increase the plasma levels of substrates for these isoenzymes, potentially increasing dose-dependent adverse reactions.

15. Adverse reactions associated with cimetidine use are: a. impotence b. gynaecomastia c. GORD A. a alone B. a and b C. a, b and c D. None of the above ANS: B Common adverse reactions associated with cimetidine use include diarrhoea, constipation, headache, dizziness, rash and confusion in the elderly (usually resolves with discontinuation). The agent can also cause breast swelling (gynaecomastia), impotence and decreased libido. The less common and rare effects include hypotension, hepatitis, agranulocytosis, thrombocytopenia and bradydysrhythmias.

16. There is a higher risk of drug interactions with one of the following H2-receptor antagonists. Multiple interactions have been noted with: A. Cimetidine B. Famotidine C. Nizatidine D. Ranitidine ANS: A Cimetidine has the highest risk of drug interactions. Unlike other H2-receptor antagonists, it inhibits the metabolism of other drugs by CYP1A2, CYP2C9, CYP2D6 and CYP3A4.

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17. Omeprazole reduces gastric acid secretion by: A. Non-competitive antagonism of parietal H2 receptors B. Irreversibly inhibiting the hydrogen–potassium ATPase enzyme C. Stimulating the release of PGE2 and PGI2 D. None of the above ANS: B Omeprazole is a proton pump inhibitor. PPIs suppress gastric acid secretion by inhibiting the hydrogen–potassium adenosine triphosphate (ATPase) enzyme system at the secretory surface of the gastric parietal cells.

18. Concomitant use of omeprazole with warfarin is likely to result in: A. Increased risk of bleeding B. Increased risk of thromboembolism (DVT) C. Decreased plasma levels of warfarin D. No effect ANS: A Omeprazole is an inhibitor of CYP2C19 and co-administration of warfarin can lead to an increased anticoagulation. Monitoring of the INR should be considered.

19. Current triple therapy regimen that achieves >90% eradication of H. pylori is: A. PPI, clarithromycin and amoxycillin B. PPI, clarithromycin and metronidazole C. PPI, amoxycillin and metronidazole D. All of the above ANS: A The 7-day treatment with PPI, clarithromycin and amoxycillin achieves >90% eradication of H. pylori and is the preferred regimen for treatment.

20. Tropisetron reduces emesis associated with chemotherapy by: A. Blocking muscarinic receptors B. Blocking 5-HT3 receptors C. Antagonising NK1 receptors D. Blocking D2 receptors ANS: B

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Ondansetron, dolasetron, granisetron and tropisetron are selective 5-HT (serotonin) antagonists acting at 5-HT3-receptors in the GIT, CTZ and vomiting centres.

21. A faecal softening agent that acts as a detergent, permitting water and fatty substances to penetrate and mix with faecal matter, is: A. Psyllium B. Docusate C. Bisacodyl D. Lactulose ANS: B Docusate, liquid paraffin and poloxamer are faecal softening agents.

22. An example of an osmotic laxative is: a. Bisacodyl b. Lactulose c. Saline laxatives A. a alone B. a and b C. b and c D. a, b and c ANS: C Saline laxatives, lactulose, glycerol and sorbitol are osmotic laxatives. Osmotic laxatives are not absorbed and, because they exert an osmotic effect, they increase the volume of fluid in the lumen of the bowel.

23. Which of the following statements in relation to lactulose is INCORRECT: A. Lactulose is metabolised to lactic, acetic and formic acids in the GIT by bacteria B. Lactulose increases ammonia levels C. Avoid use in people with intestinal obstruction D. Avoid use in patients with lactose intolerance ANS: B Lactulose is indicated for constipation and is used to decrease blood ammonia levels in people with hepatic encephalopathy secondary to chronic liver disease. The latter effect is thought to result from the trapping by lactulose of intestinal ammonia (as NH4+) and hence the excretion of excess ammonia into the faeces.

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27-8

24. Diphenoxylate is chemically related to: A. Pethidine B. Codeine C. Morphine D. Atropine ANS: A The antidiarrhoeal agent, diphenoxylate, is chemically related to pethidine and inhibits intestinal propulsive motility.

25. Loperamide, diphenoxylate and codeine inhibit intestinal propulsive motility by: A. Stimulating muscarinic receptors B. Stimulating serotonergic receptors C. Stimulating opioid (µ) receptors D. Blocking opioid (µ) receptors ANS: C These agents act by directly stimulating mu-opioid receptors on the intestinal smooth muscles.

26. Atropine is combined with diphenoxylate in the product Lomotil® because: A. Atropine enhances the action of diphenoxylate B. Atropine discourages abuse C. Atropine reduces side effects associated with diphenoxylate D. None of the above ANS: B The addition of atropine has no therapeutic benefit but is included in the formulation to discourage abuse. Accidental or intentional overdose results in flushing, hyperthermia, tachycardia, dry mouth, agitation, pinpoint pupils, lethargy, respiratory depression and coma.

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27-9

27. Current therapy for inflammatory bowel disease includes: a. Budesonide b. Sulfasalazine c. Infliximab A. a alone B. a and b C. a, b and c D. c alone ANS: C Current therapy includes corticosteroids (e.g., prednisolone and budesonide) and 5-aminosalicylates (5-ASA) (e.g., basalazide, sulfasalazine, mesalazine, and olsalazine).

28. Sulfasalazine is split by bacteria into: a. Sulfapyridine b. Mesalazine c. 5-aminosalicylic acid A. a alone B. a and b C. a, b and c D. c alone ANS: C Sulfasalazine is spilt into the sulfonamide antibiotic sulfapyridine and 5-ASA, which is also called mesalazine.

29. Mesalazine is contraindicated in: A. People with a history of hypersensitivity to antibiotics B. People with a history of hypersensitivity to salicylates C. People with severe liver dysfunction D. All of the above ANS: B Mesalazine is contraindicated in people with known hypersensitivity to salicylates or sulfasalazine, and in the presence of impaired renal function.

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30. Ultimately, mesalazine exerts an anti-inflammatory effect by: A. Inhibiting the production of inflammatory mediators B. Inhibiting the production of platelet activating factor (PAF) C. Inhibiting the production of interleukin-1 D. All of the above ANS: D The anti-inflammatory effect of mesalazine has been linked to inhibiting inflammatory mediators, PAF and interleukin-1 and TNF-α. In addition, it also inhibits activation of B cells and the production of oxygen radicals.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 28: The Neuroendocrine System and Pituitary Gland Test Bank MULTIPLE CHOICE 1. A synthetic octapeptide analogue of somatostatin (growth hormone release-inhibiting factor) is: A. Somatropin B. Octreotide C. Goserelin D. Nafarelin ANS: B Octreotide is a synthetic octapeptide analogue of GHRIF (somatostatin). It is a potent agent that also inhibits secretion of many gastrointestinal hormones, including insulin, glucagon, gastrin and VIP (vasoactive intestinal peptide).

2. Goserelin is: A. A leuprorelin analogue that stimulates the release of FSH and LH B. Used in the treatment of acromegaly C. A synthetic analogue of GnRH with selectivity for LH release D. A synthetic analogue of GHRIF ANS: C LHRH analogues (goserelin, triptorelin) are synthetic analogues of GnRH with selectivity for LH release. They are used in the treatment of advanced and metastatic prostate cancer.

3. Natural chemical substances that are secreted into the bloodstream from endocrine glands and initiate or regulate the activity of an organ or groups of cells in another part of the body are termed: A. Neurotransmitters B. Enzymes C. Endogenous mediators D. Hormones ANS: D Hormones are active, natural chemical substances that are secreted into the bloodstream from endocrine glands and initiate or regulate the activity of an organ or group of cells in Copyright © 2019 Elsevier Australia

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another part of the body. They have specific, well-defined physiological effects on metabolism, growth, homeostasis and integration of bodily functions.

4. The recombinant form of growth hormone is: A. Somatropin B. Octreotide C. Goserelin D. Nafarelin ANS: A The recombinant form of growth hormone is somatropin. It is the main growth factor influencing the development of the body. It promotes skeletal, visceral and general growth. Somatropin products are all synthesised by recombinant DNA technology and are identical in amino acid sequence to the human growth hormone. Somatropin is used to stimulate linear growth in patients who lack sufficient endogenous GH. 5. Treatment with bromocriptine results in: A. Inhibition of hypothalamic dopamine receptors B. Decreased synthesis and release of prolactin in the anterior pituitary gland C. Increased synthesis and release of prolactin in the anterior pituitary gland D. Decreased release of growth hormone ANS: B The natural inhibitor of GH secretions is the hypothalamic factor GHRIF. Dopamine agonists such as bromocriptine bind to dopamine receptors on GH-producing cells and decrease GH production.

In galactorrhoea (excessive production of milk other than after pregnancy), dopamine is used to mimic the action of hypothalamic inhibitory factor PRIF to decrease the synthesis and release of prolactin and prevent lactation.

6. The drug most likely to be associated with galactorrhoea due to hyperprolactinaemia is: A. Chlorpromazine B. Apomorphine C. Levodopa D. Cabergoline ANS: A Galactorrhoea can occur in both men and women, and is due to hyperprolactinaemia.

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PRIF (dopamine). This can occur in hypothalamic lesions and tumours, and also after use of dopamine-blocking agents such as the phenothiazine antipsychotic drugs.

7. A drug indicated for pituitary diabetes insipidus and used intranasally for primary nocturnal enuresis is: A. Carbamazepine B. Sertraline C. Lithium D. Desmopressin ANS: D Vasopressin analogues include lypressin and felypressin, which are predominantly vasoconstrictors. Desmopressin (1-desamino-8-D-arg-vasopressin), a specific V2-receptor agonist, has mainly antidiuretic properties.

8. A tetracycline antibiotic derivative that is used to produce diuresis in the syndrome of inappropriate secretion of ADH (SIADH) is: A. Methoxyflurane B. Lithium C. Doxycycline D. Demeclocycline ANS: D Demeclocycline is a tetracycline antibiotic. It acts as an ADH antagonist and is used to produce diuresis in the syndrome of inappropriate secretion of ADH (SIADH).

9. A new synthetic analogue of oxytocin with prolonged duration of action is: A. Carbetocin B. Demeclocycline C. Leuprolide D. Desmopressin ANS: A Carbetocin, a new synthetic analogue of oxytocin, is an octapeptide with similar therapeutic actions (stimulating uterine contractions and milk excretion) but a prolonged duration of action, for up to one hour. It is given by single IV injection after caesarean section to prevent excessive postpartum haemorrhage.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 29: Pharmacology of the Adrenal Cortex Test Bank MULTIPLE CHOICE 1. Increased cortisol production in a situation of stress is due to: A. α1 adrenoreceptors agonism B. Activation of cyclo-oxygenase C. Inhibition of cyclo-oxygenase D. Release of CRF from the hypothalamus ANS: D Stress triggers the release of CRF from the hypothalamus, which triggers the release of ACTH from the pituitary gland stimulating the release of hydrocortisone (cortisol) from the adrenal cortex.

2. Glucocorticoids have multiple effects in the body including: A. Increasing gluconeogenesis B. Facilitating the breakdown of protein in muscle C. Mobilising fatty acids from adipose tissue D. All of the above ANS: A Glucocorticoids have general metabolic effects in the body that include decreased uptake and utilisation of glucose into cells while increasing gluconeogenesis. They also increase glycogen storage (due to insulin secreted in response to the increase in blood sugar).

Effects on protein metabolism include decreased protein synthesis and increased protein breakdown. Effects on fat metabolism are complex but involve mobilisation of fatty acids from adipose tissue. Calcium levels are decreased because calcium absorption from the gut is impaired.

3. Anti-inflammatory effects of glucocorticoids are due to: A. Inhibition of phospholipase A2 production B. Increased lipocortin production C. Increased lipocortin release D. All of the above ANS: D Glucocorticoids stimulate the production of the mediator protein lipocortin (annexin-1) that inhibits phospholipase A2 production from the damaged cell membrane, preventing Copyright © 2019 Elsevier Australia

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PG synthesis via cyclo-oxygenases. The inhibition of phospholipase A2 production so early in the inflammatory pathway means that many more mediators are affected than with NSAIDs. 4. An example of a long-acting glucocorticoid is: A. Cortisone B. Dexamethasone C. Prednisolone D. None of the above ANS: B Dexamethasone has a plasma half-life of approximately 6 hours and a duration of action of 2–3 days. Cortisone is a short-acting drug, only effective for 8–12 hours, while prednisolone is considered to be intermediate-acting since its effects last approximately 1 day.

5. Adverse effects associated with long-term use of glucocorticoids include: A. Growth retardation in children B. Osteoporosis C. Immunosuppression D. All of the above ANS: D Growth retardation occurs either by inhibiting growth hormone secretion in children or by inhibiting the effects of insulin-like growth factor. Osteoporosis can occur due to decreased calcium absorption from the gut. Immunosuppression occurs due decreased cytokine production affecting the immune response.

6. Glucocorticoids have the potential to interact with: A. Amphotericin B B. Antacids C. Itraconazole D. All of the above ANS: D A drug interaction with amphotericin B may result in severe hypokalaemia (monitor plasma K+ levels closely). Antacids decrease absorption of oral steroids. Itraconazole reduces metabolism of steroids and increases risk of toxicity so dose adjustments are required for chronic use.

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7. A patient on chronic corticosteroid therapy is to undergo major surgery. The steroid dose will need to be: A. Decreased B. Increased C. Maintained at the same dose D. Ceased ANS: B Although the basal production rate of cortisol averages 30 mg every 24 hours, under stressful conditions such as trauma, infection or major surgery there is a reserve capacity production of up to 300 mg daily. Steroid hormones are not stored in the body so they are synthesised when they are needed.

8. The following statement about corticosteroid potency is CORRECT: A. Prednisolone is 30 times more potent than hydrocortisone B. Betamethasone is 4 times more potent than hydrocortisone C. Dexamethasone is 30 times more potent than hydrocortisone D. Aldosterone is 4 times more potent than hydrocortisone ANS: C Three glucocorticoid drugs are more potent than hydrocortisone: prednisolone 4 times the potency; dexamethasone 30 times and betamethasone 30 times. Aldosterone is a mineralocorticoid that is 500 times more potent than hydrocortisone.

9. Withdrawal from corticosteroids for treatment periods >3 weeks requires a tapering down protocol because of: A. Suppression of the hypothalamic–pituitary–adrenal axis (HPA axis) B. Activation of the hypothalamic–pituitary–adrenal axis (HPA axis) C. Suppression of the renin–angiotensin–aldosterone system (RAAS) D. Activation of the renin–angiotensin–aldosterone system (RAAS) ANS: A Chronic administration of corticosteroids leads to suppression of the HPA axis. RAAS is primarily involved in regulating blood pressure—abnormal activation plays a key role in hypertension.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 30: Pharmacology of the Endocrine Pancreas Test Bank MULTIPLE CHOICE 1. The body’s main fuel storage hormone is: A. Glucagon B. Somatostatin (GHRIF) C. Insulin D. None of the above ANS: C Insulin is the body’s main fuel storage hormone.

2. The actions of insulin are physiologically antagonised by: A. Thyroxine B. Glucocorticoids C. Adrenaline D. All of the above ANS: D The actions of insulin are physiologically antagonised by the catabolic hormones, i.e. adrenocorticotrophic hormone [ACTH], glucocorticoids, adrenaline, growth hormone [GH] and thyroxine.

3. Which of the following statements relating to the actions of glucagon is FALSE: A. Secreted by alpha cells of the islets of Langerhans in response to hypoglycaemia B. Considered a fuel-mobilising hormone C. Glucagon’s effects are inhibited by cAMP synthesis D. Secretion is inhibited by insulin and hyperglycaemia ANS: C Glucagon’s effects are accelerated by cyclic 3’,5’-adenosine monophosphate (cyclic AMP).

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4. Actions of the incretins (i.e., glucagon-like peptide-1 [GLP-1) and glucose-dependent insulotropic polypeptide [GIP]) include: A. Stimulating glucose-dependent insulin release B. Enhancing β-cell proliferation C. Delaying gastric emptying D. All of the above ANS: D Incretins are peptide hormones secreted from the GIT into the circulation in the presence of food. They ‘alert’ the pancreatic β-cell to an impending rise in blood glucose levels and cause increased insulin secretions via raised cAMP levels and calcium-induced exocytosis. Both incretins stimulate glucose-dependent insulin release, enhance β-cell proliferation and delay gastric emptying.

5. The following characteristic/s more likely associated with type 1 diabetes is/are: a. Insulin resistance b. Insulin dependence c. Ketoacidosis d. Defective insulin receptors A. a alone B. a and c C. b and c D. None of the above ANS: C Insulin dependence and ketoacidosis are associated with type 1 diabetes. Insulin resistance and the presence of either low receptor numbers or defective receptors are more frequently associated with type 2 diabetes.

6. In gestational diabetes, insulin resistance can develop in the second and third trimesters. Hyperinsulinaemia can result in: A. Increased fetal growth B. Organomegaly C. Neonatal hypoglycaemia D. All of the above ANS: D Hyperinsulinaemia may cause increased fetal growth, organomegaly and neonatal hypoglycaemia.

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7. An adult patient is found unconscious with severe hypoglycaemia. Glucagon is administered: A. 0.5–1 mg IM, IV or SC B. 10 mg IM, IV, or SC C. 10% solution IM, IV or SC D. 50% solution IM, IV or SC ANS: A The adolescent and adult dose of glucagon for hypoglycaemia is 0.5–1mg IM, IV or SC repeated in 20 minutes when necessary. For patients with inadequate glycogen reserves (malnourished or alcoholic) glucose 50% solution may be given IV. 8. Glycosylated Hb (HbA1c) is an indication of: A. The average blood glucose concentration over the past 36 hours B. The average blood glucose concentration over the past 6 weeks C. The average blood glucose concentration over the past 3 months D. The average blood glucose concentration over the past 6 months ANS: C HbA1c is a form of haemoglobin that has a glucose molecule attached. This is normally about 7% and is increased in people with poorly controlled diabetes. The glucose remains attached to the haemoglobin for the life of the red blood cell and reflects the average blood concentration over the past 3 months. It should be measured every 3 to 6 months and levels above 9% indicate poor control.

9. Insulin lispro is a new, ultra-short-acting synthetic analogue insulin that can be administered as a 'bolus' immediately before meals compared to insulin glargine, which is released slowly and is used as a basal insulin. The varying pharmacokinetic characteristics of glargine are due to: A. The attachment of fatty acid compounds to the insulin molecule B. The formation of microcrystals in the tissues after injection C. Major changes to the amino acid sequence D. None of the above ANS: B The rate at which insulin glargine acts and is inactivated is due to minor changes in amino acid sequences that make it more soluble in the acidic solution of the vial but, after injection, microcrystals form in the tissues, from which insulin is released slowly.

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10. A basal-bolus regimen of insulin involves: A. 2/3 of the daily dose administered before breakfast and the other 1/3 before the evening meal B. 1/3 of the daily dose administered before breakfast and the other 2/3 before the evening meal C. A dose of ultra-short-acting insulin given before each meal plus short-acting insulin at bedtime D. A dose of short-acting insulin given before each meal plus some intermediate- or long-acting insulin at bedtime ANS: D A basal-bolus regimen of insulin involves a dose of short-acting insulin given before each meal plus some intermediate- or long-acting insulin at bedtime. This regimen mimics the body's natural rhythms of insulin release, i.e. a continuous basal level with peaks in response to carbohydrate loads.

A split-mixed regimen involves 2/3 of the estimated daily dose administered before breakfast and the other 1/3 before the evening meal (the dose is split between 1/3 is short-acting and 2/3 intermediate insulins).

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 31: Pharmacology of the Thyroid Glands and Parathyroid Glands Test Bank MULTIPLE CHOICE 1. Which of the following statements relating to thyroxine (T4) is FALSE: A. T4 is more potent than T3 B. T4 is 99.95% protein-bound to thyroxine-binding globulin and other proteins C. T4 is converted to T3 D. T4 has a low turnover rate ANS: A T4 is present as a large pool in the circulation, 99.95% protein-bound to thyroxine-binding globulin and other proteins. This binding is decreased by salicylates, dicoumarol and other drugs. T4 has a low turnover rate, with a half-life of about 6–7 days.

As it circulates and enters cells, most T4 is converted to T3. T3 is present as a small pool, mainly stored intracellularly. It is more potent than T4, less strongly protein-bound and has a faster turnover rate, with a half-life of about 2 days.

2. Low circulating levels of T4 and T3: A. Have no effect on TSH and TRH release B. Stimulate the release of TSH from the hypothalamus C. Stimulate the release of TSH from the pituitary gland D. Inhibit the release of TSH from the pituitary gland ANS: C Low levels of circulating thyroid hormones increase the release of thyroid-stimulating hormone (TSH, thyrotrophin) from the pituitary gland and appear to influence the secretion of TRH from the hypothalamus. TSH binds to thyroid cells (and cells of thyroid tumours).

3. Patients with primary hypothyroidism are like to have: A. Low T3, T4 and TSH levels B. High T3, T4 and TSH levels C. Low T3 and T4 levels and elevated TSH levels D. High T3 and T4 levels and decreased TSH levels ANS: C Patients with primary hypothyroidism have low T3 and T4 levels despite an elevated TSH level.

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4. Hypothyroidism associated with the presence of destructive autoantibodies to thyroid antigens is best termed: A. Graves’ disease B. Myxoedema C. Thyrotoxicosis D. Hashimoto’s disease ANS: D Hashimoto’s thyroiditis is characterised by autoantibodies to thyroid antigens.

5. The adverse effect UNLIKELY to be associated with thyroxine (levothyroxine T4) use is: A. Somnolence B. Diarrhoea C. Increased irritability D. Tachycardia ANS: A Adverse effects generally correspond to symptoms of hyperthyroidism: tachycardia, elevated temperature, diarrhoea, hand tremors, increased irritability, weight loss and insomnia. A rare adverse reaction is an allergic skin rash. Adverse effects are dose-related and may occur more rapidly with T3 than with T4, mainly because the former has a faster onset of action.

6. A symptom/s LIKELY to be associated with inadequate dosing of levothyroxine is: A. Cold, dry skin B. Constipation C. Tiredness and lethargy D. All of the above ANS: D The general signs of underdosage are those of hypothyroidism: coldness, dry skin, constipation, lethargy, headaches, drowsiness, tiredness, weight gain and muscle aching.

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7. A drug capable of causing both hyperthyroidism and hypothyroidism is: A. Carbimazole B. Propylthiouracil C. Amiodarone D. Levothyroxine ANS: C Amiodarone is an antidysrhythmic agent with two atoms of iodine per drug molecule. It can cause either hypothyroidism, by blocking release of T3 and T4, or hyperthyroidism, by causing focal thyroiditis.

8. A thionamide antithyroid drug that inhibits thyroid hormone synthesis, and inhibits the conversion of T4 to T3 in the peripheral tissues, is: A. Carbimazole B. Propylthiouracil C. Ketoconazole D. 5-Fluorouracil ANS: B Propylthiouracil inhibits thyroid hormone synthesis, and additionally it inhibits the conversion of T4 to T3 in peripheral tissues, which may make it more effective for treatment of thyroid crisis or storm.

9. Large amounts of iodine: A. Cause sustained thyroid hormone synthesis and release B. Increase TRH and TSH release C. Cause inhibition of thyroid hormone synthesis and release D. None of the above ANS: C Iodine is the oldest of the antithyroid drugs. Although a small amount of iodine is necessary for normal thyroid function and to synthesise thyroid hormones, large amounts of iodine depress TRH and TSH release. In a patient with thyrotoxicosis high-dose iodine administration causes inhibition of thyroid hormone synthesis and release from the hyperfunctioning thyroid gland.

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10. Which of the following statements relating to carbimazole and propylthiouracil is FALSE: A. Indicated for the treatment of hyperthyroidism B. Pregnancy Safety Category A C. Adverse effects include agranulocytosi D. Methimazole is the active metabolite of carbimazole ANS: B The thionamides act as antithyroid drugs for the treatment of hyperthyroidism. Both are classified as Pregnancy Safety Category C because they cross the placenta and can cause fetal hypothyroidism and goitre. As they are excreted in breast milk, the lowest effective dose should be used during breastfeeding. Carbimazole is preferred in 2nd and 3rd trimesters and propylthiouracil in the 1st trimester.

11. Which of the following statements relating to the parathyroid glands is INCORRECT: A. Primary function is to secrete parathyroid hormone (PTH) B. Parathyroid glands are under control of the pituitary gland C. Respond directly to the blood calcium levels D. None of the above ANS: B The primary function of the parathyroids is to secrete parathyroid hormone (PTH), which maintains adequate levels of calcium in the blood and extracellular fluid. Note that the parathyroid glands are not subject to higher control from the pituitary gland or hypothalamus but respond directly to, and help control, blood calcium levels (analogous to the pancreas responding to and controlling blood glucose).

12. Which of the following is NOT an effect of parathyroid hormone (PTH): A. Increases the reabsorption of calcium in the distal convoluted tubule B. Increases the reabsorption of phosphate and bicarbonate C. Indirectly increases calcium reabsorption in the intestine by increasing activation of vitamin D in the kidneys D. Stimulates bone resorption by osteoclasts ANS: B The main effects of PTH are: increases the reabsorption of calcium in the distal convoluted tubule of the kidney; inhibits reabsorption of phosphate and bicarbonate; indirectly increases calcium absorption in the intestine via increased activation of vitamin D in the kidneys; stimulates bone resorption by osteoclasts, thus mobilising calcium from bone.

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13. A drug that is a PTH analogue indicated for the treatment of osteoporosis when other agents are unsuitable and there is a high risk of fractures is: A. Alendronate B. Cinacalcet C. Strontium ranelate D. Teriparatide ANS: D Teriparatide, a recombinant form of the active fragment of human PTH, is referred to as a ‘bone formation agent’, as it activates osteoblasts via binding to specific PTH cell surface receptors. Teriparatide is indicated for treatment of osteoporosis in men and postmenopausal women when other agents are unsuitable and there is a high risk of fractures. Calcium and vitamin D supplements are administered concurrently.

Teriparatide has been shown to increase bone mineral density in the spine and reduce the risk of new bone fractures.

14. An agent used to treat hyperparathyroidism is: A. Teriparatide B. Vitamin D C. Cinacalcet D. PTH ANS: C The calcimimetic compound cinacalcet is an allosteric modulator at the calcium-sensing receptor used to treat hyperparathyroidism. It acts by modulating the calcium-sensing receptors, increasing the receptors’ sensitivity to calcium and thus reducing PTH secretion.

15. Low circulating levels of calcium trigger: A. Increased release of PTH B. Increased release of vitamin D C. Decreased release of calcitonin D. All of the above ANS: D Low calcium levels trigger increased release of PTH and vitamin D and inhibit release of calcitonin leading to conservation of calcium from the intestine, kidneys and bone, resulting in raised plasma calcium levels.

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16. A vitamin D analogue used to control moderate hypocalcaemia is: A. Calcitonin B. Calcitriol C. Cinacalcet D. Salcatonin ANS: B Moderate hypocalcaemia can be controlled with the vitamin D analogue calcitriol.

17. Which of the following is NOT used in the treatment of hypercalcaemia?

A. Saline rehydration B. Pamidronate C. Cinacalcet D. Calcitriol ANS: D The most common cause of hypercalcaemia is hyperparathyroidism, due to an adenoma of the parathyroid gland causing excessive secretion of PTH. Excess vitamin D also causes excess calcium to be retained and, in various malignancies, osteolytic bone metastases and hypercalcaemia occur. Moderate hypocalcaemia can be controlled with the vitamin D analogue calcitriol.

18. Symptoms of hypercalcaemia include: A. Dysrhythmias B. Constipation C. Ectopic calcification D. All of the above ANS: D The manifestations of hypercalcaemia are weakness, dysrhythmias, nausea and vomiting, constipation and ectopic calcification.

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19. A calcium-lowering hormone that inhibits bone resorption indicated for the treatment of hypercalcaemia is: A. Salcatonin B. Cinacalcet C. Calcium gluconate D. None of the above ANS: A Sources of calcitonin used in the past have included active extracts of porcine, human and salmon thyroid tissue. The salmon hormone is particularly potent, has a slightly longer half-life and has been given the approved name salcatonin. Porcine and human products have been discontinued in Australia. Salcatonin is indicated for the treatment of hypercalcaemia and, rarely, Paget's disease.

20. Which of the following statements relating to calcitonin is INCORRECT: E. Is secreted when there is a high calcium concentration in the blood A. Inhibits calcium bone resorption and calcium reabsorption in the kidney B. Lowers plasma calcium levels C. Mimics the actions of PTH and vitamin D ANS: D Calcitonin acts as a natural antagonist of the actions of PTH and vitamin D. It is a polypeptide secreted by thyroid C cells when there is a high calcium concentration in the blood, especially when this is due to conditions of increased bone resorption. Calcitonin inhibits bone resorption and calcium reabsorption in the kidney leading to rapid lowering of plasma calcium levels.

21. Vitamin D3 is also termed: A. Ergocalciferol B. C(h)olecalciferol C. Calcifidiol D. Calcitriol ANS: B Vitamin D3 is also termed C(h)olecalciferol.

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22. The most active form of vitamin D is: A. Ergosterol B. Ergocalciferol C. Calcitriol D. Calcifidiol ANS: C Vitamin D is converted to its most active form, calcitriol (1,25-dihydroxycholecalciferol), in the kidneys.

23. Which of the following statements is INCORRECT: A. Vitamin D tends to increase calcium reabsorption from the kidney tubules B. PTH tends to conserve calcium but remove phosphate C. PTH tends to increase phosphate reabsorption from the kidney tubules D. None of the above ANS: C Although the specific mechanisms regulating phosphate levels are not well identified, overall, vitamin D and PTH tend to increase calcium reabsorption from the kidney tubules while increasing phosphate excretion, thus conserving calcium but removing phosphate.

24. The quantity of elemental calcium that should be recommended as adjunctive therapy in people with osteoporosis is: A. 300 mg/day B. 0.5–1 g/day C. 1–1.5 g/day D. 0.175 g/day ANS: C Calcium 1–1.5 g/day—to maintain bone minerals—should be adjunctive therapy for all people with osteoporosis unless contraindicated, ie. hypercalcaemia.

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25. A class of antiresorptive drugs associated with significant risk of oesophagitis is: A. Bisphosphonates B. Selective oestrogen receptor modulators (SERMs) C. Strontium compounds D. Vitamin D analogues ANS: A Adverse effects associated with bisphosphonates include gas production, acid regurgitation, oesophageal ulcer, gastritis, dysphagia, constipation, diarrhoea, muscle pain and headaches. Due to the risk of oesophagitis, it is recommended that bisphosphonates (e.g. alendronate, risedronate) be taken with a full glass of liquid and that the patient remain upright for at least the next 30 minutes, to facilitate delivery of the dose to the stomach.

26. Osteonecrosis of the jaw is associated with the antiresorptive drug: A. Raloxifene B. Strontium ranelate C. Alendronate D. Calcitonin ANS: C Osteonecrosis of the jaw is a rare (0.1–0.3% risk) but potentially severe adverse effect apparently triggered in susceptible patients by dental extractions, periodontal disease or oral trauma. Patients should have a dental assessment before starting on bisphosphonates and regular dental checks thereafter.

27. Which of the following statements relating to SERMs is INCORRECT: A. Raloxifene, tamoxifen and lasofoxifene are examples of SERMs B. These agents have selective partial agonist and partial antagonist oestrogenic properties C. These agents have agonistic properties on bone and lipid metabolism D. These agents stimulate breast and uterine tissue ANS: D The SERM raloxifene has partial agonist and partial antagonist oestrogenic properties. It has positive effects on bone and lipid metabolism and antagonistic effects on the uterus and breast, minimising the risk of oestrogen-dependent cancers. Consequently, raloxifene prevents bone resorption without stimulating breast or uterine tissue. Recent evidence is emerging that raloxifene is as effective as tamoxifen, another SERM, at preventing oestrogen-receptor positive breast cancer in women at increased risk of breast cancer.

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Lasofoxifene, a new SERM, is currently in clinical trials in post-menopausal osteoporosis.

28. An agent known to increase the risk of osteoporosis is: A. Vitamin D B. Prednisolone C. Alendronate D. Raloxifene ANS: B Corticosteroids are known to increase the risk of osteoporosis. Osteoporosis-related fractures occur in 30–50% of patients receiving long-term glucocorticoids in daily doses of 2.5 mg prednisolone or equivalent.

29. Drug therapy recommended to patients with a high risk of fractures secondary to corticosteroid use is: A. Calcium B. Vitamin D C. Bisphosphonates D. All of the above ANS: D Current recommendations are that all patients on corticosteroid therapy should routinely receive concurrent calcium and vitamin D supplements, and those with higher risk of fractures (with low bone density and post-menopausal women) should also receive a bisphosphonate.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 32: Drugs Affecting the Female Reproductive System Test Bank MULTIPLE CHOICE 1. A releasing factor secreted by the hypothalamus that stimulates the anterior pituitary gland to release gonadotrophins is: A. LH B. FSH C. GnRH D. CRF ANS: C The hypothalamus secrets a releasing factor, gonadotrophin-releasing hormone (GnRH), which stimulates the anterior pituitary gland to release the gonadotrophins, follicle-stimulating hormone (FSH) and luteinising hormone (LH).

2. Continuous administration of high- (supra-physiological) dose gonadotrophin-releasing hormone (GnRH): A. Stimulates pituitary synthesis and release of FSH and LH B. Desensitises and ultimately decreases production of FSH and LH C. Is used to increase production of sex hormones D. Increases the growth of steroid-dependent tumours ANS: B The actions of GnRH depend on how it is administered: at low (physiological) doses, and given in a pulsatile intermittent dose schedule, it stimulates pituitary synthesis and release of the pituitary gonadotrophins FSH and LH. By contrast, continuous administration of higher doses results in desensitisation and, ultimately, in decreased pituitary production of LH and FSH; hence, there is a suppression of production of sex hormones in the target glands (ovaries, testes), which can be used to inhibit the growth of steroid-dependent tumours.

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3. Goserelin is a: A. Synthetic luteinising hormone B. Synthetic follicle-stimulating hormone C. Synthetic GnRH analogue D. Synthetic hCG ANS: C Goserelin, leuprorelin, nafarelin and triptorelin are synthetic gonadotrophin-releasing hormone (GnRH) analogues.

4. Danazol suppresses menstruation and inhibits ovulation by: A. Stimulating GnRH release B. Inhibiting the release of GnRH C. Increasing production of LH and FSH D. Increasing release of CRF ANS: B Danazol inhibits release of GnRH and is used to suppress the pituitary–ovarian axis, suppress menstruation and inhibit ovulation. It has complicated actions: it is an androgen agonist; it also alters sex hormone metabolism, interacts with sex hormone receptors and has weak androgenic and anabolic effects. It is mainly used in endometriosis, menorrhagia and fibrocystic breast disease.

5. Which of the following statements relating to the drug gestrinone is INCORRECT: A. This agent inhibits gonadotrophin release B. This agent is used in the treatment endometriosis C. This agent has some antiprogesterone actions D. This agent has oestrogenic activity ANS: D Gestrinone is a GnRH inhibitor that inhibits gonadotrophin release and is used to treat endometriosis. It has no oestrogenic activity although it does have some partial agonist actions at both progesterone and androgen receptors.

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6. A glycoprotein hormone promoting the maturation of the follicle, the formation of the corpus luteum and the secretion of oestrogen is: A. FSH B. LH C. Gestrinone D. All of the above ANS: B Luteinising hormone (also known in the male as interstitial-cell-stimulating hormone, ICSH) acts in the female to promote the maturation of the follicle, the formation of the corpus luteum and the secretion of oestrogen.

7. A hormone that is measurable in urine of pregnant women within a few days of fertilisation is: A. LH B. hCG C. Choriogonadotrophin alfa D. Lutropin alfa ANS: B Human chorionic gonadotrophin (hCG) is secreted by the chorion, the outer membrane enveloping the fetus, and is measurable in the urine of pregnant women within a few days of fertilisation. It is the antigen detected in pregnancy tests. hCG has mainly LH-type actions and is used to induce ovulation and to treat hypogonadism. New recombinant forms of chorionic gonadotrophin are choriogonadotrophin alfa and lutropin alfa.

8. Dysmenorrhoea is a term describing: A. Absence of menstruation B. Excessive menstrual bleeding C. Painful menstruation D. Bleeding from uterus other than during a normal menstrual period ANS: C Dysmenorrhoea is painful menstruation. It occurs in 40% of young women and is painfully incapacitating in about 3%. The pain and spasms of uterine muscles are thought to be due to prostaglandins (PGF2a) released from the degenerating endometrium.

Effective treatment is with levonorgestrel IU contraceptive system, OC progestogen formulations and COC preparations. The non-steroidal anti-inflammatory agent, naproxen, has analgesic actions and decreases the contractions, symptoms and blood loss.

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9. Which of the following is NOT a metabolic action associated with oestrogens: A. Increased coagulability of blood B. Retention of salt and fluids C. Increased risk of atheroma D. Decreased rate of bone resorption ANS: C Oestrogens decrease the risk of atheroma.

10. Oestrogen-containing oral contraceptives (OC) are not recommended for women over 35 years who smoke because of the: A. Increased incidence of thromboembolic disorders B. Increased risk of fluid retention C. Diminished efficacy of OC D. Increased nausea and vomiting ANS: A The OC pill is not recommended for women over 35 years who smoke because of an increased incidence of thromboembolic disorders, such as deep vein thrombosis and stroke.

11. The interaction between orlistat and ethinyloestradiol (EE) is likely to: A. Increase the adverse effects associated with EE B. Reduce oestrogen levels C. All of the above D. None of the above ANS: B Orlistat-induced diarrhoea may reduce oestrogen levels so additional contraception may be necessary.

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12. Adverse effects associated with oestradiol valerate are: a. increased risk of thromboembolism b. oedema c. chloasma A. a alone B. a and b C. a, b and c D. None of the above ANS: C Adverse effects of oestradiol valerate are typical oestrogenic effects including: breast pain and enlargement, changes in menstrual bleeding, headaches, nausea, vomiting, a change in female libido, oedema of the lower extremities and chloasma (darkened patches of skin on the face). There is an increased risk of thromboembolism.

Administration by skin patch can cause irritation and dermatitis.

13. Raloxifene, a selective oestrogen receptor modulator (SERM), is associated with all of the following effects, EXCEPT: A. Antagonistic actions on oestrogen receptors in breast and uterus B. ERβ agonist actions at oestrogen receptors in bone C. Decreases bone mineral density D. Increases risk of DVT and stroke ANS: C Raloxifene increases bone mineral density, reduces bone resorption and vertebral fractures and improves the blood lipid profile, with no stimulation of the endometrium or breast tissue. However, hot flushes associated with menopause may be exacerbated.

There is a potential increased risk of venous thromboembolism and stroke. Pregnancy Safety Category X.

14. Progesterone produces all of the following effects, EXCEPT: A. Stimulating the secretory phase of the menstrual cycle B. Causing relaxation of the uterine smooth muscles C. Increasing levels of LH and oestrogen receptors D. Maintaining the endometrium ANS: C Progesterone decreases the levels of LH and reduces the number of oestrogen receptors.

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15. Which of the following facts relating to norethisterone is FALSE: A. Norethisterone is a testosterone derivative B. Norethisterone is a selective oestrogen receptor modulator C. Norethisterone has some androgenic and oestrogenic actions D. Norethisterone is associated with hirsuitism and acne ANS: B Norethisterone is a testosterone derivative with androgenic and oestrogenic effects.

16. A testosterone derivative with antiandrogenic actions is: A. Norethisterone B. Medroxyprogesterone C. Cyproterone D. Mifepristone ANS: C Cyproterone is a testosterone derivative with significant antiandrogenic actions, used mainly as an OC and in HRT in women suffering masculinisation effects.

17. Hormone replacement therapy (HRT) in low doses is useful for: A. 6 months B. 1 year C. 3 years D. Up to 5 years ANS: D The consensus is that HRT in low doses is useful up to 5 years to relieve moderate-to-severe menopausal symptoms and to prevent osteoporosis. Long-term safety depends on the woman’s family history and predisposition to cardiovascular disease, epilepsy, osteoporosis and specific cancers such as breast, endometrial and colorectal.

18. A PGE2 analogue used for induction or augmentation of labour at term is: A. Gemeprost B. Dinoprostone C. Dinoprost D. Misoprostol ANS: B

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Dinoprostone, a PGE2 analogue, is used for induction or augmentation of labour at term, given by vaginal gel or pessary.

19. A drug that relaxes the uterus and delays labour is termed: A. Oxytocic B. Tocolytic C. Gonadotrophin D. None of the above ANS: B Drugs that relax the uterus and delay labour or inhibit threatened abortion are termed 'tocolytics'.

20. A tocolytic drug that relaxes uterine smooth muscle by stimulating β2 adrenoceptors is: A. Nifedipine B. Magnesium sulfate C. Salbutamol D. Atosiban ANS: C Salbutamol is a β2-adrenoceptor agonist used to delay labour. It is indicated for uncomplicated preterm labour (24–34 weeks gestation).

21. A tocolytic drug that is preferred for delaying labour in threatened preterm labour is: A. Nifedipine B. Magnesium sulfate C. Salbutamol D. Atosiban ANS: A The preferred drug for delaying labour is now nifedipine, a calcium channel blocker.

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22. A drug that stimulates labour is: A. Salbutamol B. Oxytocin C. NSAIDs D. Bromocriptine ANS: B Oxytocin means ‘rapid birth’, a term derived from its ability to contract the pregnant uterus.

23. A drug that suppresses lactation through dopamine receptor agonism is: A. Metoclopramide B. Chlorotrianisene C. Cabergoline D. Prolactin ANS: C The dopamine agonists, bromocriptine and cabergoline, inhibit the release of prolactin from the anterior pituitary gland, resulting in suppression of lactation.

24. A drug that promotes lactation is: A. Metoclopramide B. Chlorotrianisene C. Cabergoline D. Prolactin ANS: A The dopamine antagonist, metoclopramide, normally prescribed as an antiemetic or to stimulate motility of the upper GI tract has been used to stimulate lactation.

25. The clinical indication for clomifene is: A. Abortifacient B. Dysmenorrhoea C. Anovulatory infertility D. All of the above ANS: C Clomiphene is indicated to treat female anovulatory infertility.

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26. Increased incidence of multiple pregnancies is associated with: A. Ethinyloestradiol B. Clomiphene citrate C. Levonorgestrel D. Sildenafil ANS: B Clomiphene and urofollitrophin are ovulatory stimulants. These treatments carry the risk of excessive stimulation, leading to multiple pregnancies or potentially fatal ovarian hyperstimulation syndrome.

27. The estrogenic drug present in MOST combined oral contraceptive (COC) formulations is: A. Ethinyloestradiol B. Mestranol C. Norethisterone D. Oestradiol ANS: A Most combined oral contraceptives in Australia contain ethinyloestradiol (EE). The only other oestrogen used is mestranol.

28. Progestogens with fewer androgenic effects are: a. Norethisterone b. Gestodene c. Drospirenone A. a alone B. a and b C. b and c D. c alone ANS: C Desogestrel, gestodene and drospirenone are less likely to have androgenic effects.

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29. A contraceptive method NOT recommended for breastfeeding women is: A. Progestogen-only minipill B. Combined oral contraceptive (COC) C. Copper IUD D. Progestogen-only implant ANS: B Combined oral contraceptives (COCs) are not recommended during breastfeeding.

30. The timing of taking low-dosage progesterone-only oral contraceptives (OCs), termed the minipill, is critical. Additional methods of contraception are recommended if: A. The user takes the tablet 1 hour later than normal B. The user takes the tablet 2 hours later than normal C. The user takes the table 3 hours later than normal D. The user takes the table 4 hours later than normal ANS: C If taking the tablet is delayed by more than 3 hours, an additional method of contraception should be used for the next 48 hours.

31. The drug used as the agent of choice for emergency contraception is: A. Medroxyprogesterone B. Levonorgestrel C. Ethinyloestradiol D. Mestranol ANS: B One 1.5-mg levonorgestrel tablet is now the preferred agent for emergency contraception.

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32. Emergency contraception is indicated for use within: A. 1 hour of unprotected intercourse B. 48 hours of unprotected intercourse C. 24 hours of unprotected intercourse D. 72 hours of unprotected intercourse ANS: D Emergency contraception is indicated for use within 72 hours of unprotected intercourse or in possible failure of a contraceptive method in women not wanting to conceive.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 33: Drugs Affecting the Male Reproductive System Test Bank MULTIPLE CHOICE 1. Which of the following statements relating to hypothalamic and pituitary control is INCORRECT: A. FSH stimulates the seminiferous tubules in the testes to increase production of spermatozoa B. ICSH stimulates interstitial cells to increase secretion of androgens C. Dihydrotestosterone is converted enzymatically to the more potent testosterone D. High levels of androgens will inhibit pituitary release of FSH and ICSH ANS: C Testosterone is converted to a more potent metabolite, dihydrotestosterone (DHT).

2. The enzyme involved in the conversion of testosterone to dihydrotestosterone is: A. Catechol-O-methyl-transferase B. Monoamine oxidase C. Cholinesterase D. 5α-reductase ANS: D The actions of androgens are mediated in cells in androgen-sensitive tissues after conversion of testosterone by 5α-reductase to the more active metabolite 5α-dihydrotestosterone (DHT).

3. Androgenic effects include all of the following EXCEPT: A. Masculinisation of the reproductive tract and external genitalia B. Spermatogenesis C. Catabolic effects on bone and skeletal muscle D. Development of male secondary sexual characteristics ANS: C Non-reproductive functions of androgenic effects include: anabolic effects on bone and skeletal muscle, neuroprotective effects in central and peripheral nervous system, bone Copyright © 2019 Elsevier Australia

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protection (possibly after aromatisation to oestrogens), stimulation of vascular cell adhesion molecules in endothelial cells.

4. Adverse effect/s associated with anabolic steroid use is/are: A. Testicular atrophy B. Liver disease C. Gynaecomastia D. All of the above ANS: D Adverse reactions are those of excessive androgenic actions. Weight gain may be caused by fluid retention, an adverse effect of androgen therapy. Other potential adverse reactions include testicular atrophy, sterility, gynaecomastia, increased risk of coronary heart disease, liver disease, mood swings and aggressiveness, and induction of psychotic disorders.

5. An example of a non-steroidal antiandrogen is: A. Cyproterone B. Flutamide C. Spironolactone D. All of the above ANS: B Flutamide and analogues (nilutamide, bicalutamide) are more specific as orally active non-steroidal antiandrogens. They act by inhibiting androgen uptake or binding to receptors.

6. In benign prostatic hypertrophy, tamsulosin and alfuzosin improve urine outflow by: A. Inhibition of 5α-reductase B. α2-Adrenoceptor antagonism C. α1-Adrenoceptor antagonism D. α1-Adrenoceptor stimulation ANS: C These agents block α1-adrenoceptors, which mediate smooth muscle tone in the bladder outlet and prostate.

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7. Adverse effect/s associated with prazosin use is/are: A. Hypertension B. Bradycardia C. Bronchoconstriction D. Orthostatic hypotension ANS: D Prazosin blocks α1 adrenoceptors, which mediate vascular smooth muscle tone.

Antagonism of this receptor results in significant vasodilation and may cause orthostatic hypotension. This effect is less marked with tamsulosin, which is more selective at blocking urogenic α1 adrenoceptors.

8. A 5α-reductase inhibitor indicated for the treatment of benign prostatic hyperplasia (BPH) is: A. Tamsulosin B. Finasteride C. Cyproterone D. Flutamide ANS: B Finasteride is a 5α-reductase inhibitor. This agent is highly effective at reducing the levels of DHT in the bloodstream and in the prostate, and as a result markedly reduces the hypertrophy of the gland and reduces resistance to urinary outflow.

9. A 5α-reductase inhibitor that is less specific for the prostate enzyme is: A. Goserelin B. Flutamide C. Dutasteride D. Leuprolide ANS: C Dutasteride is a 5α-reductase inhibitor but is less specific for the prostate enzyme.

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10. The main adverse effect associated with 5α-reductase inhibitors is: A. Hypotension B. Hypertension C. Hypersexuality D. Sexual dysfunction ANS: D Adverse reactions include decreased libido, impotence, decreased amount of ejaculate, gynaecomastia and allergic reactions.

11. A synthetic PGE1 analogue, second-line drug used to treat erectile dysfunction (ED) is: A. Papaverine B. Sildenafil C. Alprostadil D. Bromocriptine ANS: C Alprostadil, a synthetic form of PGE1, is given by penile injection (into the corpus cavernosa) or transurethral application. It dilates the cavernosal arteries and thus assists erectile function.

12. Sildenafil potentiates the vasodilator actions of nitrates released during sexual excitement by: A. B. C. D.

Enhancing the breakdown of cGMP Inhibiting the release of phosphodiesterase 4 Preventing the breakdown of cGMP None of the above

ANS: C Sildenafil (Viagra) is a selective inhibitor of cGMP-specific PDE5 (phosphodiesterase type 5). This potentiates the vasodilator effects of nitrates.

13.

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Sildenafil should not be taken when: A. A patient is taking other forms of organic nitrate therapy B. A patient has retinal disorders C. A patient for whom sexual intercourse is inadvisable D. All of the above ANS: D Sildenafil is indicated for erectile dysfunction except for those patients where sexual intercourse is inadvisable. Sildenafil interacts with other vasodilators, especially nitrate preparations, and is contraindicated in retinal disorders.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 34: Overview of the Treatment of Cancer Test Bank MULTIPLE CHOICE 1.

Which of the following statements about the phases of the cell cycle, is incorrect: A. G0 refers to the resting phase when cells are not cycling B. G1 refers to the first gap, between previous nuclear division and beginning of DNA synthesis C. G2 refers to the second gap, between DNA replication and nuclear division, and takes about 4.5 hours D. S refers to the phase when mitoscis occurs and takes about 30 minutes

ANS: D During the S phase in the cell cycle, the genetic material, the DNA in chromosomes, doubles in preparation for cell division. Phase M refers to when mitosis occurs and takes about 30 minutes.

2.

What are the role(s) of Phosphoinositide 3-kinases (PI3Ks) enzymes?

A. B. C. D.

Cell growth Cell proliferation Cell differentiation and survival All of the above

ANS: D Phosphoinositide 3-kinases (PI3Ks) are a family of intracellular kinases. PI3Ks are involved in cell growth, proliferation, differentiation and survival. Mutations in some PI3Ks activate enzymes and contribute to cellular transformation and cancer.

3.

Which of the following statements about angiogenesis is INCORRECT ?

A. Members of the TGFβ family, particularly vascular endothelial growth factors (VEGF), are involved in tumour angiogenesis B. Some cancer cells have the ability to induce angiogenesis C. Angiogenesis inhibitors can accelerate growth and metastasis of cancers by increasing their blood supply.

D. Antibodies against vascular endothelial growth factors VEGF are important drugs for the treatment of certain types of cancer

ANS: C Angiogenesis inhibitors are used to treat or slow down the cancer progress by reducing the blood supply to cancer cells. The ability to induce angiogenesis is another hallmark of cancer Copyright © 2019 Elsevier Australia

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cells. Members of the TGFβ family, particularly vascular endothelial growth factors (VEGF), are involved in tumour angiogenesis. Angiogenesis inhibitors can slow growth and metastasis of cancers by reducing their blood supply. Antibodies against VEGF (e.g. bevacizumab) and small molecules that inhibit its receptor (VEGFR inhibitors; e.g. sunitinib) are important drugs for the treatment of multiple solid organ tumours, including breast, colorectal, gastrointestinal, renal and thyroid cancers.

4.

Which of the following statements about p53 protein is INCORRECT? A. The p53 protein is involved in some of the cell functions, such as reproduction, metabolic regulation, longevity and development of the nervous and immune systems, and skin B. Supressing p53 genes can supress tumour growth in certain types of cancerå C. In case of a severe DNA damage, p53 protein activates expression of genes leading to enhanced apoptosis D. Mutations in the p53 gene impair normal ‘braking mechanisms’, allowing cancer cells to evade immune destruction and lead to uncontrolled proliferation of altered cells.

ANS: B P53 protein has a protective role against cancer. The p53 family of genes and their associated isoform proteins are involved in a wide variety of functions, including reproduction, metabolic regulation, longevity and development of the nervous and immune systems, and skin. p53 is a phosphoprotein with molecular weight 53 kDa and is a major regulator of the G1 checkpoint in response to cellular stress. If DNA damage is severe, p53 protein activates expression of genes leading to enhanced apoptosis, which normally prevents accumulation of damaged DNA. Mutations in the p53 gene impair normal ‘braking mechanisms’, allowing cancer cells to evade immune destruction and lead to uncontrolled proliferation of altered cells. p53 has important checkpoint roles as a tumour suppressor, explaining why mutations in the p53 gene and decline in p53 activity are commonly associated with cancers, especially in older people.

5.

What factor(s) are important in determining the primary goal of the cancer treatment?

A. B. C. D.

Stage of the cancer progress Patient’s age and physical performance status Location of the tumour All of the above

ANS: D In treating cancer, the term ‘cure’ is used differently from the way it is understood for acute conditions that can be totally healed or eradicated. A cancer cure is defined as the disappearance of any evidence of the tumour for several years, with a high probability of a normal life span. This definition, referring to a probability, acknowledges the difficulty of removing every malignant cell and recognises the possibility of recurrence. The patient may go into remission after a course of chemotherapy when the tumour and signs and symptoms are no longer detectable, then relapse some months or years later. Medical oncology is a medical specialty that primarily deals with drug-based treatment of cancer. The primary goal of treatment is governed by a range of factors relating to the cancer and the patient: Copyright © 2019 Elsevier Australia

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location of the primary tumour extent (or stage) of disease molecular characteristics of the tumour or patient patient’s physical performance status patient’s mental status patient’s age patient’s preferences/wishes.

What does neoadjuvant therapy refer to?

A. Where surgery is followed by drug (or radiation) therapy to help decrease the risk of the cancer recurring.

B. Where a drug is given as a first step to shrink a tumour before the primary treatment, usually surgery, to make the treatment more effective C. Where a drug is given at the same time of radiation therapy to potentiate the effect of the treatment D. Where a drug is administered at same the same time of surgery or radiation therapy to reduce the side effects of the treatment.

ANS: B Neoadjuvant therapy means where a drug is given as a first step to shrink a tumour before the primary treatment, usually surgery, to make the treatment more effective.

7.

Colon cancer is usually treated by the combination of Cyclophosphamide, fluorouracil, prednisone, tamoxifen.

A. True B. False

Answer: B Colon cancer treatment includes the combination of leucovorin, fluorouracil (2 dose levels), oxaliplatin or leucovorin, fluorouracil (2 dose levels), irinotecan (+/− bevacizumab).

8.

Dacarbazine is associated with a high probability of nausea and vomiting.

A. True B. False

ANS: A Dacarbazine is considered as a drug with a high emetic potential. Refer to the Table 34.3.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 35: Antineoplastic Drugs Test Bank MULTIPLE CHOICE 1. A chemotherapeutic agent that acts by intercalation is: A. Doxorubicin B. Paclitaxel C. Topotecan D. None of the above ANS: A Doxorubicin, an anthracycline, is an agent that inhibits DNA synthesis by intercalation. It causes deformation and impairs DNA transcription. Paclitaxel is a mitotic inhibitor that affects microtubule assembly. Topotecan is a topoisomerase I inhibitor involved in untwisting, nicking and resealing of DNA strands during DNA duplication.

2. A chemotherapeutic agent that is classified as an alkylating agent is: A. Doxorubicin B. Paclitaxel C. Cyclophosphamide D. None of the above ANS: C Cyclophosphamide is an alkylating agent that cross-links DNA strands and inhibits protein synthesis and DNA replication. Doxorubicin is an agent that inhibits DNA synthesis by intercalation. Paclitaxel is a mitotic inhibitor that affects microtubule assembly.

3. Antimetabolites exert their cytotoxic effects by: A. Inhibiting DNA synthesis by intercalation between DNA base pairs B. Inhibiting RNA synthesis by intercalation between RNA base pairs C. Acting as false substitutions in the production of nucleic acids D. None of the above ANS: C Antimetabolite drugs, such as methotrexate, are folic acid antagonists. They compete with dihydrofolate for the active site of the enzyme. Blockade of biochemical reactions Copyright © 2019 Elsevier Australia

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dependent on folic acid impairs synthesis of macrotubules required for cell proliferation, and halts cell cycling.

4. Methotrexate (MTX) has the potential to interact with: A. Alcohol B. Aspirin C. Sulfonamides D. All of the above ANS: D Alcohol increases the risk of hepatotoxicity while use with aspirin can result in additive platelet inhibition. Use with sulfonamides can have additive antifolate actions and therefore enhanced toxicity.

5. Taxanes are used in cancer treatment because they: A. Are monoclonal antibodies acting against VEGF B. Act as alkylating agents C. Stabilise microtubules, inhibit mitosis and initiate apoptosis D. Inhibit topoisomerases and DNA replication ANS: C Taxanes, such as paclitaxel and docetaxel, have antimitotic and immunostimulatory effects.

6. Hormonal agents that are used in cancer treatment include: A. Tamoxifen B. Flutamide C. Prednisone D. All of the above ANS: D Tamoxifen is an anti-oestrogen used in the treatment of breast cancers while flutamide is an antiandrogenic agent used in the treatment of prostate cancers. Prednisone is a corticosteroid used for its antilymphocytic properties in the treatment of lymphocytic leukaemias and lymphomas.

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7. Adverse effects associated with use of tamoxifen include: A. Vaginal bleeding B. Hot flushes C. Polyps D. All of the above ANS: D Abnormal gynaecological reactions to tamoxifen are common.

8. Bortezomib, a proteasome inhibitor, acts by: A. Selectively inhibiting activated BRAF B. Inhibiting the TK in the receptor for Philadelphia chromosomal platelet-derived GF C. Inhibiting nuclear factor (NF)-kappa B D. Binding to the CD52 glycoprotein ANS: C Bortezomib acts by inhibiting nuclear factor (NF)-kappa B, a protein that mediates cell survival in some cancers, so reduces tumour growth and angiogenesis, and enhances cytotoxic effects of radiation and chemotherapy.

9. The oncogene, known as her2, is overexpressed in: A. 10% of women with breast cancer B. 30% of women with breast cancer C. 50% of women with breast cancer D. 65% of women with breast cancer ANS: B Human epidermal growth factor receptor 2 (her2) is overexpressed in about 30% of women with breast cancer, and in other cancers such as gastric and colorectal. By blocking HER2 receptors, monoclonal antibodies, such as trastuzumab, slow breast cancer progression.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 36: Overview of Antimicrobial Chemotherapy and Antibiotic Resistance Test Bank MULTIPLE CHOICE 1. Staphylococcus aureus is an: A. Aerobic, Gram-positive cocci B. Aerobic, Gram-negative bacilli C. Anaerobic, Gram-positive organism D. Anaerobic, Gram-negative organism ANS: A Staphylococcus aureus is an aerobic Gram-positive cocci commonly associated with burns, skin infections, decubital and surgical wounds, paranasal sinus and middle ear (chronic sinusitis and otitis), lung, lung abscess, pleura, endocardium, bone (osteomyelitis) and joint infection sites.

2. A Gram-positive aerobic cocci commonly associated with infections of the endocardium (infective endocarditis) is: A. Staphylococcus aureus B. Klebsiella pneumoniae C. Neisseria spp.

D. Streptococcus, viridans group ANS: D Streptococcus, viridans group, are aerobic Gram-positive cocci commonly found in infections of the endocardium (infective endocarditis).

3. Enteric Gram-negative bacilli associated with infections of the peritoneum, biliary tract, kidney and bladder are: A. Klebsiella pneumoniae B. Streptococcus pyogenes C. Escherichia coli D. Treponema pallidum ANS: C Escherichia coli are Gram-negative cocci commonly associated with infections of the peritoneum, biliary tract, kidney and bladder.

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4. Clostridium difficile is an: A. Aerobic Gram-positive organism associated with infections of the lungs B. Anaerobic Gram-positive organism associated with infections of the gut C. Aerobic Gram-negative organism D. Anaerobic Gram-negative organism associated with deep wound infections ANS: B Clostridium difficile is a Gram-positive anaerobic organism associated with infection of the gut (Clostridium difficile-associated pseudomembranous colitis) and deep wounds.

5. Antimicrobial agents that cause the cell to lyse are termed: A. Synergistic B. Bactericidal C. Bacteriostatic D. Antagonistic ANS: B Bactericidal agents cause bacterial cell death and lysis and eradicate infection. Any compound that inhibits any step in the synthesis of the cell wall weakens it and causes the cell to lyse. Antimicrobial agents with this mechanism of action are bactericidal.

6. Resistance due to innate chromosomal makeup that predictably specifies resistance is referred to as: A. Intrinsic resistance B. Acquired resistance C. Mutation resistance D. All of the above ANS: A Intrinsic resistance refers to the organism’s innate chromosomal (genetic) makeup that predictably specifies the resistance. For example, streptococci are intrinsically resistant to aminoglycosides because their inherent genetic composition results in a cell wall that does not permit penetration of this class of antibiotic to its site of action at the ribosome.

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7. VRSA refers to: A. Very resistant Staphylococcus aureus B. Vancomycin-resistant Staphylococcus aureus C. Virulent-release Staphylococcus aureus D. Visceral related Staphylococcus aureus infections ANS: B VRSA refers to vancomycin-resistant Staphylococcus aureus.

8. The enzyme that inactivates penicillins, cephalosporins and carbapenems is: A. β-Hydroxylase B. β-Oxidase C. β-Lactamase D. All of the above ANS: C β-Lactamases cleave the β-lactam ring on penicillins, cephalosporins and carbapenems.

There are hundreds of β-lactamases: some are chromosomal whereas others are located on plasmids (extrachromosomal pieces of DNA) or transposons (a small DNA sequence that is transferred from one bacterial cell to another). Extended-spectrum β-lactamases have arisen in the last 10 years, which leads to bacteria that are cross-resistant to penicillins and cephalosporins. Often these bacteria are also resistant to other antibiotic classes, e.g. fluoroquinolones and aminoglycosides. Broad-spectrum β-lactamases called carbapenemases degrade carbapenem antibiotics and, more recently, Klebsiella pneumoniae carbapenemases have been identified, which can inactivate all β-lactam antibiotics including the carbapenems.

9. S. aureus resistance to tetracycline is primarily due to: A. Extended-spectrum β-lactamases B. Alteration of outer membrane solubility C. Bypassing inhibited metabolic pathways D. Efflux pump activity ANS: D S. aureus resistance to tetracycline is primarily due to efflux pump activity.

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10. Bacterial resistance to sulfonamide antibiotics is primarily due to: A. Extended-spectrum β-lactamases B. Alteration of outer membrane solubility C. Bypassing inhibited metabolic pathways D. Efflux pump activity ANS: C Resistance to sulfonamide antibiotics is primarily due to target adaptation. The organisms bypass the inhibited metabolic pathway to ensure supply of the essential product.

11. An infection acquired during antimicrobial therapy is best termed: A. Pharmacoenhancements B. Superinfection C. Synergism D. Antagonism ANS: B Superinfection is an infection that occurs during antimicrobial therapy delivered for therapeutic or prophylactic reasons. Most antibiotics reduce or eradicate the normal flora of the body, which are then replaced by resistant exogenous or endogenous bacteria. If the number of these replacement organisms is large and the host conditions favourable, clinical superinfection can occur.

12. Which statement is NOT a general guideline for antibiotic use: A. Never treat viral infections with an antibiotic B. Attempt to identify the infecting microorganism where feasible C. Attempt to identify the susceptibility of the organism where feasible D. Use the broadest spectrum of activity for the known or likely organism ANS: D Several important principles guide the judicious and optimal use of the antibiotics. These include: never treating viral infections with an antibiotic; using an antibacterial drug only when there is clear evidence that spontaneous resolution is unlikely; identifying the infecting microorganism; determining susceptibility of the microorganism; using a drug with the narrowest spectrum of activity for the known or likely organism; using a single drug unless combination therapy is specifically indicated to ensure efficacy or reduce the emergence of resistance; using a dose of drug that is high enough to ensure efficacy with minimal toxicity and reduces the likelihood of resistance; and using a short duration (1 week) of treatment unless evidence indicates that a longer duration is required.

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13. Empirical therapy is defined as: A. Therapy chosen once the organism has been identified B. Antibiotic chosen to be effective against the suspected microorganisms C. Combination of antibiotics that decreases clinical effect D. Combination of antibiotics that increases clinical effect ANS: B Most antimicrobial agents have a specific effect on a limited range of microorganisms.

The prescriber must formulate a specific diagnosis about the potential pathogens or organisms most likely causing the infection. The drug most likely to be specifically effective against the suspected microorganism/s can then be selected. This is termed empirical therapy.

14. When considering antibiotic therapy in children, which of the following statements is INCORRECT: A. Antibiotic therapy should be continued until infection is no longer present B. Wherever possible, samples for culture should be taken before initiating antibiotic therapy C. Young children have smaller volumes of distribution than adults D. Prophylactic antibiotic therapy given after uncomplicated surgery is usually discontinued after 48 hours ANS: C Young children have larger volumes of distribution than adults, so dosing based on body weight is recommended.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 37: Antibacterial Drugs Test Bank MULTIPLE CHOICE 1. Penicillins weaken the bacterial cell wall by: A. Inhibiting protein synthesis B. Inhibiting transpeptidase enzymes C. Inhibiting dihydrofolate reductase D. Inhibiting DNA gyrase ANS: B Penicillins are cell wall synthesis inhibitors. They weaken the cell wall by inhibiting the transpeptidase enzymes responsible for cross-linking the glycan strands, resulting in cell lysis and death. The bacterial cell wall is a rigid cross-linked structure of peptidoglycan, which is composed of cross-linked glycan chains comprised of alternating molecules of the amino sugars N-acetylglucosamine and N-acetylmuramic acid.

2. An antibiotic that inhibits protein synthesis is: A. Cefaclor B. Erythromycin C. Gentamicin D. Ciprofloxacin ANS: C Aminoglycosides are potent bactericidal antibiotics. The mechanism of action involves irreversibly binding to the 30S ribosomal unit of susceptible bacteria, thus inhibiting protein synthesis and causing cell death.

3. An example of a β-lactamase inhibitor is: A. Aztreonam B. Imipenem C. Clavulanate D. Ticarcillin ANS: C Penicillins are considered to be bactericidal agents because they kill susceptible bacteria, Copyright © 2019 Elsevier Australia

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but they are ineffective in the presence of β-lactamase enzymes. Clavulanate and tazobactam are β-lactamase inhibitors. This extends the spectra of their antibiotic activity and improves their effectiveness but increases the cost.

4. Penicillin G is an example of: A. Narrow-spectrum penicillin B. Narrow-spectrum penicillinase-resistant penicillin C. Moderate-spectrum lactamase-sensitive aminopenicillin D. Antipseudomonal penicillin ANS: A Penicillin G (also known as benzylpenicillin) is a narrow-spectrum penicillin.

5. The repository forms of penicillin G, procaine and benzathine benzylpenicillin, must only be administered by: A. Oral route B. IV route C. Intrathecal route D. IM route ANS: D Procaine and benzathine benzylpenicillin are repository forms of penicillin G. These modified forms of penicillin G are only available in suspension form and must only be administered IM. The intravenous administration of these suspensions can be extremely dangerous.

6. An antibiotic resistant to β-lactamase inactivation and used against penicillinase-producing staphylococci is: A. Phenoxymethylpenicillin B. Flucloxacillin C. Amoxycillin D. Piperacillin ANS: B Dicloxacillin and flucloxacillin are resistant to β-lactamase inactivation. They are used to treat penicillinase-producing staphylococci, however are not effective against methicillin-resistant bacteria.

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7. As a single drug, an antibiotic effective against Pseudomonas aeruginosa is: A. Piperacillin B. Ticarcillin C. Tazobactam D. Clavulanate ANS: A Piperacillin, piperacillin–tazobactam and ticarcillin–potassium clavulanate have a broader spectrum of antimicrobial activity, but only piperacillin (as the single drug) is effective against the Gram-negative bacterium Pseudomonas aeruginosa.

8. The interaction of probenecid with penicillins results in: A. Increased risk of bleeding B. Increased risk of rash C. Elevated plasma level of the penicillin D. Shortened duration of penicillin activity ANS: C Probenecid decreases the renal tubular secretion of penicillins, resulting in elevated plasma concentration and an increase in half-life, thereby prolonging the activity of the penicillin.

9. Life-threatening allergic reactions associated with penicillins occur in approximately: A. 4–40% of users B. 0.01–0.05% of users C. 0.004–0.04% of users D. <0.001% of users ANS: B A life-threatening allergic reaction occurs in approximately 0.01–0.05% of exposed people, and about 0.001% will die as a result.

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10. The possibility of a cross-reaction with cephalosporin use in a patient with known penicillin allergy is: A. >20% B. 5–15% C. 1–5% D. <1% ANS: B Cephalosporin antibiotics may be prescribed for patients allergic to penicillins. However, the possibility of a cross-reaction is 5–15%, and cephalosporins should not be used if a person reports a history of a serious reaction or anaphylaxis in response to penicillin.

11. One property of ceftazidime is: A. It has increased activity against Gram-positive cocci B. It has less activity against β-lactamase-producing microbial strains C. It has increased activity against Gram-negative bacteria D. It is a first-generation cephalosporin ANS: C Ceftazidime is a third-generation cephalosporin. It is more active against Gram-negative bacteria. Ceftazidime is also effective against P. aeruginosa and β-lactamase-producing microbial strains but less effective against Gram-positive cocci.

12. Which of the following statements relating to cephalosporins is INCORRECT: A. First-generation cephalosporins are primarily active against Gram-positive bacteria B. Cefaclor is a second-generation cephalosporin C. Ceftriaxone is a first-line drug for many infections D. Second-generation cephalosporins have increased activity against Gram-negative bacteria ANS: C The first-generation cephalosporins are primarily active against Gram-positive bacteria, whereas the second-generation cephalosporins, such as cefaclor, have increased activity against Gram-negative bacteria. With only a few exceptions cephalosporins are rarely the drugs of first choice.

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13. Cell wall synthesis inhibitors that have the broadest spectrum of activity are: A. Penicillins B. Cephalosporins C. Carbapenems D. Monobactams ANS: C Carbapenems (ertapenem, imipenem and meropenem) have the broadest spectrum of activity of all the antimicrobials against Gram-positive and Gram-negative aerobic and anaerobic organisms.

14. Imipenem is contraindicated in the treatment of meningitis because: A. It is associated with a high incidence of seizures B. It does not cross the blood–brain barrier C. It is degraded by renal dipeptidase-1 D. All of the above ANS: A Meropenem is used for treating meningitis, whereas imipenem is contraindicated because of the high incidence of seizures. This is likely to apply also to ertapenem, which is likewise associated with seizures but no data exist on ertapenem use in meningitis.

15. Concomitant use of vancomycin with aminoglycosides increases the risk of: A. Anaphylaxis B. Therapeutic failure through antagonism C. Ototoxicity and nephrotoxicity D. All of the above ANS: C The combined use of vancomycin with aminoglycosides increases the potential for ototoxicity and nephrotoxicity.

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16. Vancomycin is indicated for the treatment of: a. MRSA b. Clostridium difficile-associated colitis c. Methicillin-sensitive Staphylococcus aureus A. a alone B. a and b C. b alone D. a, b and c ANS: B Vancomycin use should be reserved for MRSA, MRSE or in people with serious allergy to penicillins. Vancomycin is also a second-line agent for Clostridium difficile-associated disease in relapse or infections unresponsive to metronidazole treatment.

17. Which of the following statements relating to vancomycin-induced ‘red-neck’ or ‘red-man’ syndrome is CORRECT: A. Results from slow administration of the drug B. Incidence is common C. Associated with the appearance of IgE D. Non-immune-associated release of histamine ANS: D The ‘red-neck’ or ‘red-man’ syndrome is reported (rarely) after bolus or too rapid drug injection with vancomycin, which results in histamine release and chills, fever, tachycardia, itch, rash or red face, neck, upper body, back and arms. This is a pseudoallergy and is not associated with the appearance of IgE antibodies.

18. A monobactam that is only active against Gram-negative bacteria is: A. Imipenem B. Aztreonam C. Ceftriaxone D. Linezolid ANS: B Aztreonam, the first drug in the monobactam class of antibiotics, is a synthetic bactericidal antibiotic with activity similar to that of penicillin. It is active only against Gram-negative aerobic bacteria, such as P. aeruginosa.

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19. The potential for inhibiting the cytochrome P450 3A4 isoenzyme is less with the macrolide antibiotic: A. Azithromycin B. Clarithromycin C. Erythromycin D. Roxithromycin ANS: A Macrolides inhibit hepatic CYP3A4 and, as a consequence, are subject to numerous drug interactions. In general, they inhibit the metabolism of other drugs, leading to increased plasma concentrations and the risk of toxicity. The potential is greatest with erythromycin > clarithromycin > roxithromycin > azithromycin.

20. The mechanism by which macrolide antibiotics exert their growth inhibitory effect on bacteria is: A. Inhibition of cell wall formation B. Inhibition of bacterial RNA-dependent protein synthesis by binding to the 50S ribosomal subunit C. Inhibition of DNA synthesis by binding to DNA gyrase D. Inhibition of bacterial RNA-dependent protein synthesis by binding to the 30S ribosomal subunit ANS: B Macrolide antibiotics inhibit bacterial RNA-dependent protein synthesis by binding to the 50S ribosomal subunit. Macrolides are generally bacteriostatic to susceptible organisms.

21. The following adverse effects are associated with macrolide antibiotics: a. hepatotoxicity b. hypersensitivity c. cardiac dysrhythmias A. a alone B. a and b C. a, b and c D. None of the above ANS: C Macrolide antibiotics should be used with caution in people with severe liver function impairment. In addition, erythromycin should be used cautiously in patients with hearing loss, and clarithromycin in persons with severe kidney function impairment. These drugs Copyright © 2019 Elsevier Australia

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should be avoided in people with individual drug hypersensitivity. Erythromycin should be avoided in patients with cardiac dysrhythmias.

22. The concomitant use of erythromycin with benzodiazepines is likely to produce: A. Severe neurotoxicity B. Cardiotoxicity C. Nephrotoxicity D. Prolonged sedation ANS: D Erythromycin inhibits the cytochrome P450 3A4 isoenzyme, which will reduce the clearance and elimination of benzodiazepines. This will likely produce increased and prolonged sedation.

23. A significant adverse effect that limits the clinical usefulness of lincosamide and clindamycin is: A. Nephrotoxicity B. Potentiation of neuromuscular blockade C. Antibiotic-associated pseudomembranous colitis D. CNS depression ANS: C A significant adverse and limiting effect for clindamycin and lincosamide is antibiotic-associated pseudomembranous colitis. This is caused by the superinfection and selective colonisation of the Gram-positive anaerobic bacteria, Clostridium difficile.

24. Aminoglycosides (amikacin, gentamicin and tobramycin) produce bactericidal effect by: A. Inhibiting membrane formation B. Inhibiting bacterial RNA-dependent protein synthesis by binding to the 50S ribosomal subunit C. Inhibiting DNA synthesis by binding to DNA gyrase D. Irreversibly binding to the 30S ribosomal subunit ANS: D The mechanism of action of aminoglycosides involves irreversible binding to the 30S ribosomal subunit of susceptible bacteria, thus inhibiting protein synthesis (interferes with the mRNA–ribosome complex), leading to eventual cell death (bactericidal).

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25. The combination of aminoglycoside with cell wall inhibitor results in: A. Synergism B. Indifference C. Antagonism D. Impaired renal elimination ANS: A Aminoglycosides are used with penicillins, cephalosporins or vancomycin for their synergistic effects.

26.

Which of the following statements relating to aminoglycosides is INCORRECT: A. Aminoglycosides exhibit significant post-antibiotic effect B. Aminoglycosides are extensively absorbed after oral administration C. Aminoglycosides display concentration-dependent bactericidal activity D. Aminoglycosides are ototoxic and nephrotoxic

ANS: B Aminoglycosides are not absorbed from oral administration. Oral administration exerts a local antibiotic effect on susceptible bacteria within the GIT. 27. Concomitant use of aminoglycoside antibiotics with loop diuretics, such as frusemide, may result in: A. Increased risk of neuromuscular blockade B. Synergism C. Increased risk of irreversible hearing loss D. Nephrotoxicity ANS: C Using loop diuretics with aminoglycoside antibiotics (amikacin, gentamicin and tobramycin) increases the risk of irreversible hearing loss.

28. Tetracyclines produce bacteriostatic effects on many Gram-positive and Gram-negative organisms by the action of: A. Irreversible binding to the 30S ribosomal subunit B. Reversible blocking of the 30S ribosomal subunit C. Inhibition of DNA gyrase D. Inhibition of cell wall synthesis ANS: B Copyright © 2019 Elsevier Australia

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Tetracyclines inhibit protein synthesis by reversibly blocking the 30S subunit of the ribosome and preventing access of tRNA to the mRNA–ribosome complex.

29. Tetracyclines should not be given to children under the age of 8 years because of: A. Severe GI distress B. Oesophagitis C. Chelation with calcium in bones and teeth D. Superinfection ANS: C Tetracyclines should not be given to children under the age of 8 years because they chelate with calcium in bone and teeth during development, which discolours and alters their structure.

Adverse effects associated with tetracyclines include dizziness (minocycline), oesophagitis (doxycycline and minocycline), ataxia, GI distress, photosensitivity, skin and mucous membrane pigmentation (minocycline), dark or discoloured tongue and oral, rectal or genital fungal overgrowth. Tetracyclines are also rarely associated with hepatotoxicity, pancreatitis and benign intracranial hypertension.

30. Linezolid may interact with adrenergic, serotonergic and tyramine-rich foods or drinks because: A. It inhibits the metabolism of these agents B. It is a weak inhibitor of monoamine oxidase C. In causes the non-specific release of neurotransmitters D. It inhibits the reuptake of monoamines ANS: B Linezolid is a weak inhibitor of monoamine oxidase and hence has the potential to interact with adrenergic drugs (e.g. adrenaline, dopamine and ephedrine), serotonergic drugs (SSRIs) and tyramine-rich food and drinks.

31. Fluoroquinolones exert broad spectrum bactericidal activity by: A. Inhibition of dihydrofolate reductase B. Inhibition of the 50S ribosomal subunit C. Inhibition of the 30S ribosomal subunit D. Inhibition of topoisomerase II and IV ANS: D Fluoroquinolones interfere with bacterial topoisomerase II (DNA gyrase) and Copyright © 2019 Elsevier Australia

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topoisomerase IV, the enzymes involved in the supercoiling of DNA that is necessary for the duplication, transcription and repair of bacterial DNA. 32. Quinolone antibiotics should be used with caution in children under the age of 18 years, and in elderly patients taking corticosteroids, because of the risk of: A. Tendinitis B. CNS stimulation C. Seizure D. Hypersensitivity ANS: A Achilles tendinitis and tendon rupture injuries have been associated with quinolone antibiotics. The incidence of these injuries increases when quinolones are used in children under the age of 18 years and in elderly patients taking corticosteroids.

33. Sulfonamides act by: A. Competitively inhibiting dihydropteroate synthetase B. Generally producing bactericidal effects C. Antagonising the effects of trimethoprim D. Reducing the risk of methotrexate-induced bone marrow suppression ANS: A Sulfonamides competitively inhibit the bacterial enzyme dihydropteroate synthetase, which is required for incorporating PABA into dihydrofolic acid. The blocking of dihydrofolic acid synthesis results in a decrease in tetrahydrofolic acid, which interferes with the synthesis of purines, thymidine and DNA in the microorganism.

34. A urinary tract antimicrobial that is converted to formaldehyde in acidic conditions is: A. Cephalexin B. Trimethoprim C. Hexamine hippurate D. Nitrofurantoin ANS: C The effectiveness of hexamine hippurate depends on the release of formaldehyde, which requires an acidic medium. Formaldehyde may be bactericidal or bacteriostatic and its effects are believed to be the result of denaturation of bacterial protein.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 38: Antifungal and Antiviral Drugs Test Bank MULTIPLE CHOICE 1. Azole antifungals produce a fungistatic effect by: A. Inhibition of squalene epoxidase B. Inhibition of 14α-sterol demethylase C. Inhibition of fungal cell mitosis during metaphase D. Altering cell membrane permeability ANS: B Azole antifungals (fluconazole, itraconazole, ketoconazole, miconazole, posaconazole and voriconazole) are fungistatic and affect the biosynthesis of fungal ergosterols by interfering with the cytochrome P450 dependent enzyme lanosterol demethylase (also called 14α-sterol demethylase) that catalyses ergosterol formation.

2. Concomitant use of fungistatic azoles with amphotericin results in: A. Synergism B. Indifference C. Antagonism D. Pharmacoenhancement ANS: C The fungistatic effects of azole antifungals antagonise the fungicidal effects of amphotericin resulting in reduced antifungal activity.

3. The interaction of itraconazole with warfarin results in: A. Increased antifungal activity B. Increased ketoconazole metabolism and reduced efficacy C. Reduced warfarin metabolism and increased risk of bleeding D. Increased warfarin metabolism and sub-therapeutic anticoagulant action ANS: C Itraconazole is a potent inhibitor of human CYP3A4 isoenzyme and is subject to many drug interactions. Itraconazolee (and other azoles) may reduce the metabolism of warfarin and increase the risk of bleeding. Monitor INR and reduce dose if necessary.

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4. Amphotericin B produces fungicidal effects by: A. Binding to ergosterol thereby altering cell permeability B. Inhibition of 14α-sterol demethylase C. Inhibition of fungal cell mitosis during metaphase D. All of the above ANS: A Amphotericin B binds to ergosterol in the fungal cell membrane. This binding results in the formation of pores that alter cell permeability and results in a loss of potassium and other elements from the cell. Ergosterol is a major component of fungal cell membranes and not only provides the structure but is also involved in nutrient transport.

5. An antifungal agent that inhibits the synthesis of glucan, a vital component of the fungal cell wall, is: A. Ketoconazole B. Caspofungin C. Flucytosine D. Griseofulvin ANS: B Caspofungin is the first drug in a new class of antifungals, called echiocandins, which have significant activity against Candida spp. and Aspergillus spp. It acts by inhibiting synthesis of glucan, a vital component of the fungal cell wall.

6. An antifungal agent that is a prodrug and that is converted to an antimetabolite and interferes with pyrimidine metabolism is: A. Caspofungin B. Flucytosine C. Griseofulvin D. Terbinafine ANS: B Flucytosine enters fungal cells, where it is converted to fluorouracil, an antimetabolite that interferes with pyrimidine metabolism, thus preventing nucleic acid and protein synthesis.

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38-3

7. Aciclovir is indicated for the prophylaxis and treatment of infection caused by: A. HSV B. Influenza A C. Influenza B D. Cytomegalovirus ANS: A Aciclovir is used in the prophylaxis and treatment of genital herpes infections caused by the herpes simplex virus (types 1 and 2) and for the treatment of varicella (chickenpox) infections and herpes simplex virus (HSV) encephalitis.

8. A DNA polymerase inhibitor that is converted to aciclovir by first-pass intestinal and liver metabolism is: A. Famciclovir B. Ganciclovir C. Valaciclovir D. Valganciclovir ANS: C Valaciclovir is a prodrug that is converted to aciclovir by first-pass intestinal metabolism and liver metabolism. It is indicated for the treatment of varicella zoster infection and for primary and recurrent genital HSV. 9. Concomitant use of ganciclovir with imipenem increases the risk of: A. Gastric distress B. Hypersensitivity C. Seizures D. No effect ANS: C The combination of imipenem and ganciclovir should be avoided because of increased risk of seizures.

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10. An example of a neuraminidase inhibitor is: A. Ganciclovir B. Oseltamivir C. Amantadine D. Cidofovir ANS: B Oseltamivir and zanamivir are examples of neuraminidase inhibitors. Neuraminidase is an essential enzyme for replication of both influenza A and B because it plays an important role in releasing the virus from infected cells, enabling it to spread to other cells.

11. Zanamivir should be used with caution in: A. Patients infected with influenza A B. Patients infected with influenza B C. Patients suffering from asthma D. Children >5 years old ANS: C Zanamivir is generally well tolerated and in clinical trials the frequency of adverse effects is similar to that for placebo. Rarely, an allergic reaction has been reported (facial and oropharyngeal oedema), as have bronchospasm and dyspnoea.

12. A nucleoside reverse transcriptase inhibitor (NRTI) reported to cause a severe hypersensitivity reactions is: A. Abacavir B. Didanosine C. Emtricitabine D. Zidovudine ANS: A Abacavir adverse effects include a hypersensitivity reaction in at least 5% of people within 6 weeks. The severity of this reaction is such that the drug should be stopped immediately and never reintroduced as therapy, as fatalities have occurred on rechallenge.

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13. Lipodystrophy is associated with all of the following drugs, EXCEPT: A. Abacavir B. Zidovudine C. Stavudine D. Ritonavir ANS: D Significant adverse reactions of the NRTIs (abacavir, zidovudine and stavudine) include lipodystrophy (changes in cutaneous fat distribution): loss in the face, limbs and buttocks but accumulation in the abdominal, breast and dorsocervical region. Ritonavir is a protease inhibitor.

14. An NRTI associated with an increased incidence of dose-dependent peripheral neuropathy is: A. Efavirenz B. Stavudine C. Rilpivirine D. Ritonavir ANS: B Stavudine and zidovudine are associated with a higher incidence of dose-related peripheral neuropathy. It is important whenever possible to avoid combination with other drugs that can cause peripheral neuropathy.

15. An example of a protease inhibitor is: A. Tenofovir B. Atazanavir C. Efavirenz D. Zidovudine ANS: B Protease inhibitors include atazanavir, darunavir, fosamprenavir, indinavir, lopinavir with ritonavir, saquinavir and tipranavir.

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16. The purpose of the drug combination of lopinavir with ritonavir is: A. Antagonism B. Indifference C. Ritonavir increases the plasma concentration lopinavir D. Ritonavir induces hepatic metabolism of lopinavir ANS: C Ritonavir is a protease inhibitor but also an inhibitor of CYP3A4, which reduces the metabolism of lopinavir. This effectively increases the plasma concentration of the lopinavir (and other drugs metabolised by CYP3A4). Ultimately, this interferes with clearance of lopinavir and reduces the need for high and frequent oral dosing.

17. When compared to other antiretroviral agents, ritonavir and similar agents have a higher incidence of: A. Renal adverse effects B. Drug-induced ototoxicity C. Retinitis D. Drug-induced metabolic disturbances ANS: D Protease inhibitors are the most potent antiviral agents available. The PIs, including lopinavir, are associated with metabolic disturbances such as diabetes, hypertriglyceridaemia and hypercholesterolaemia.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 39: Antiprotazoal, Antimycobacterial and Anthelmintic Drugs Test Bank MULTIPLE CHOICE 1. The most lethal form of malaria usually resistant to chloroquine is: A. P. vivax B. P. ovale C. P. falciparum D. P. malariae ANS: C P. falciparum malaria is the most lethal form of malaria and is usually resistant to chloroquine.

2. The vector for transmission of malaria to humans is: A. Bats B. Vermin C. Tiger mosquito D. Anopheles mosquito ANS: D Malaria is transmitted to humans by the bite of an infected female Anopheles mosquito, as well as by blood transfusion (usually P. malariae).

3. The following antimalarial agent is associated with central nervous system toxicity and should be used with caution in people with a history of psychiatric problems (psychosis, hallucinations, anxiety, confusion and depression): A. Mefloquine B. Primaquine C. Quinine D. Atovaquone with proguanil ANS: A Mefloquine is associated with adverse effects on the central nervous system.

Mefloquine is usually dosed once a week for prophylaxis, commencing 2–3 weeks before departure, then on the same day of each week during and for 4 weeks after the visit to the endemic area.

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4. Haemolytic anaemia with primaquine is usually associated with: A. Children under the age of 12 B. G6PD deficiency C. NADH methaemoglobin reductase deficiency D. All of the above ANS: B Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme that is made in red blood cells.

G6PD also helps protect red blood cells from 'oxidative' stress. Lack of the enzyme G6PD means that red blood cells can be damaged and destroyed (leading to haemolytic anaemia) when the person is exposed to some chemicals, medicines or during some infections. Primaquine is one of the drugs that may cause haemolytic anaemia in people with G6PD deficiency.

5. Concomitant use of quinine with mefloquine increases the predisposition to: A. Bleeding B. Quinine accumulation C. Cardiac dysrhythmias D. No effect ANS: C When using quinine with mefloquine, increased incidences of convulsion and electrocardiogram (ECG) abnormalities have been reported. This predisposes the person to cardiac dysrhythmias. If possible, avoid this combination. If both drugs must be given concurrently, the patient should be hospitalised and closely monitored for cardiac dysrhythmias and seizure activity.

6. The following is the proposed mechanism by which atovaquone affects P. falciparum: A. Inhibits RNA synthesis and DNA replication B. Inhibits dihydrofolate reductase C. Inhibits mitochondrial electron transport D. Inhibits plasmodial haem polymerase ANS: C Atovaquone inhibits mitochondrial electron transport in P. falciparum. Atovaquone is used in combination with proguanil for synergistic effects. Proguanil, through its active metabolite cycloguanil, inhibits dihydrofolate reductase (like pyramethamine) and potentiates the ability of atovaquone to collapse the mitochondrial membrane potential.

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7. An aminoglycoside agent with antibiotic and amoebicidal activity indicated for amoebiasis is: A. Pentamidine B. Paromomycin C. Metronidazole D. Sulfadoxine ANS: B Paromomycin is an aminoglycoside antibiotic and amoebicidal agent that acts directly on intestinal amoebae (Entameoba histolytica).

8. The drug of choice for treating Trichomonas vaginalis is: A. Metronidazole B. Paromomycin C. Sulfadoxine D. Pyramethamine ANS: A 9. Metronidazole is the drug of choice for treating trichomoniasis, a disease of the vagina caused by Trichomonas vaginalis.

10. First-line drugs for the treatment of tuberculosis include: A. Isoniazid, rifampicin, pyramethamine and ethambutol B. Ethionamide, rifabutin, pyrazinamide and ethambutol C. Isoniazid alone D. Isoniazid, rifampicin, pyrazinamide and ethambutol ANS: D The recommended first-line drugs for tuberculosis (Mycobacterium tuberculosis) are isoniazid plus rifampicin, plus pyrazinamide, plus ethambutol.

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11. Adverse reactions to ethambutol include: A. Increased plasma uric acid concentrations B. Gastric distress C. Optic neuritis D. All of the above ANS: D Ethambutol is associated with acute gouty arthritis, gastric distress and optic neuritis.

12. Pyridoxine (25 mg) may be prescribed together with isoniazid to reduce the incidence of: A. Hepatotoxicity B. Peripheral neuropathy C. Nephrotoxicity D. Hypersensitivity ANS: B Pyridoxine (vitamin B6) may be prescribed concurrently with isoniazid to prevent peripheral neuropathy in at-risk individuals.

13. Patients deficient in the hepatic N-acetyltransferase (NAT) enzyme taking isoniazid are: A. More likely to be on higher doses B. Less likely to experience adverse effects at standard doses C. More likely to experience peripheral neuritis at standard doses D. More likely to develop hepatotoxicity ANS: C Isoniazid is metabolised in the liver by acetylation, a metabolic pathway that displays a genetic polymorphism in humans. People who metabolise the drug quickly are referred to as ‘fast acetylators’. ‘Slow acetylators’ have a decrease in hepatic N-acetyltransferase, the enzyme that catalyses the acetylation reaction. Slow acetylators may require lower drug dosages and are more apt to develop adverse effects, particularly peripheral neuritis if pyridoxine is not administered concurrently.

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14. The antitubercular drug likely to discolour sputum, sweat and tears red-orange and stain soft contact lenses is: A. Isoniazid B. Rifampicin C. Pyrazinamide D. Ethambutol ANS: B Rifampicin discolours urine, faeces, saliva, sputum, sweat and tears red-orange.

Rifampicin can stain soft contact lenses.

15. The following drug is indicated for M. leprae: A. Isoniazid B. Dapsone C. Sulfadoxine D. Pyramethamine ANS: B Dapsone is an antibacterial (antileprosy) agent that is bacteriostatic, with an action and adverse effect profile similar to the sulfonamides.

16. Which of the following statements relating to albendazole is INCORRECT: A. It is extensively absorbed from the GIT B. Absorption is increased by consumption of a fatty meal C. It is contraindicated in pregnancy D. It is metabolised to an active sulfoxide metabolite ANS: A Albendazole is poorly absorbed and essentially remains within the GIT. Absorption is, however, significantly increased by consumption of a fatty meal. The small amount of drug absorbed is rapidly metabolised by the liver to an active sulfoxide metabolite that is thought to be the active drug against tissue infestations. It is contraindicated in pregnancy because of possible teratogenic effects.

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17. Pyrantel, a depolarising neuromuscular-blocking agent, is indicated for: a. Roundworm b. Threadworm c. Hookworm d. Whipworm A. a alone B. a and b C. a, b and c D. c and d ANS: C Pyrantel is indicated for the treatment of Ascaris lumbricoides (roundworm), Enterobius vermicularis (threadworm) and hookworm, but is ineffective against whipworm.

18. An anthelmintic drug classed as a benzimidazole is: A. Pyrantel B. Praziquantel C. Mebendazole D. Ketoconazole ANS: C The main class of anthelmintic drugs is the benzimidazoles, which include albendazole and mebendazole.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 40: Antiinflammatory and Immunomodulating Drugs Test Bank MULTIPLE CHOICE 1. The anti-inflammatory actions of non-steroidal anti-inflammatory drugs (NSAIDs) are due to: A. α1-Adrenoreceptor agonism B. Activation of lipo-oxygenase C. Inhibition of cyclo-oxygenase D. Inactivation of IgG antibodies ANS: C Inhibition of COX-1 and COX-2 and subsequent reduction in proinflammatory prostaglandins is responsible for a reduction in inflammation.

2. The NSAID, ibuprofen, is chemically classified as: A. Propionic acid B. Coxib C. Fenamate D. Salicylate ANS: A Coxibs include celecoxib and parecoxib, while aspirin is a salicylate. Mefenamic acid is an NSAID classified as a fenamate.

3. The main function/s of PGI2 (prostacyclin), produced as a result of cyclo-oxygenase action, is/are to: A. Produce vasodilation B. Decrease platelet aggregation C. Decrease gastric acid secretion D. All of the above ANS: D Prostacyclin is produced in vascular endothelium and gastric mucosa and causes vasodilation and decreases platelet aggregation and gastric acid secretion.

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4. Aspirin is often used at low doses to prevent platelet aggregation by inhibiting the production of: A. Leukotriene B. Arachidonic acid C. Thromboxane A2 D. All of the above ANS: C Aspirin binds irreversibly to COX-1 in platelets to decrease thromboxane A2 levels, which normally increase platelet aggregation. Since platelets do not contain nuclei they cannot synthesise more thromboxane A2 and the effect of aspirin lasts several days until platelets are removed from circulation.

5. NSAIDs have the potential to interact with: A. Lithium B. Warfarin C. Probenecid D. All of the above ANS: D NSAIDs may decrease the excretion of lithium, which increases the potential of lithium toxicity. If administered with warfarin there is increased risk of haemorrhage since warfarin may be displaced from proteins. Probenecid increases plasma levels of NSAIDs, increasing the risk of toxicity.

6. An NSAID with the greatest risk of cardiovascular toxicity is: A. Aspirin B. Ibuprofen C. Rofecoxib D. None of the above ANS: C Selective COX-2 inhibitors such as celecoxib and rofecoxib pose the greatest risk of cardiovascular toxicity, which may be greater with increased use of the drug. Increased cardiovascular toxicity is believed to occur due to inhibition of endothelial cell prostacyclin production resulting in the unopposed actions of thromboxane A2. Rofecoxib was removed from the market in 2004.

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40-3

7. Sulfasalazine used to treat rheumatoid arthritis is: A. Highly absorbed after oral administration B. A relatively safe drug with few adverse effects C. Safe in patients with renal and hepatic impairment D. A drug combination of a sulfonamide with a salicylate ANS: D Sulfasalazine is poorly absorbed and produces both common (nausea, rashes and tinnitus) and serious adverse effects such as haematological disturbances. Close monitoring is required in patients with renal or hepatic impairment.

8. Which of the following statements is TRUE: A. Auranofin is a gold salt that is well absorbed B. Auranofin is a gold salt that is has a long half-life C. Concurrent use of auranofin and penicillamine is very safe D. None of the above ANS: B Auranofin is a gold salt used in the treatment of rheumatoid arthritis. It is poorly absorbed from the gut and concurrent use with penicillamine increases the risk of serious blood dyscrasias and renal failure.

9. The following agent/s augment/s the physiological concentrations of IL-1 receptor antagonist protein: A. Leflunomide B. Etanercept C. Anakinra D. All of the above ANS: C Anakinra is a recombinant form of the endogenous IL-1 receptor antagonist and inhibits the cation of IL-1. Etanercept is a bioengineered protein consisting of TNF receptors coupled with a portion of IgG and acts as an antagonist of TNF activity. Leflunomide is an immunosuppressant drug that inhibits pyrimidine synthesis and T-cell proliferation.

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10. Colchicine, used in the treatment of gout, is reported to inhibit: A. Leukotriene synthesis B. Prostaglandin synthesis C. Uric acid production D. Neutrophil migration ANS: D Colchicine’s mechanism of action is unclear. However, it is reported to decrease release of a glycoprotein-produced phagocytosis of urate crystals. Its anti-inflammatory actions are believed to occur by disrupting microtubules and inhibiting neutrophil migration.

11. Allopurinol decreases the production of uric acid by: A. Stimulating xanthine oxidase B. Decreasing the reuse of hypoxanthine C. Decreasing the reuse of xanthine D. Inhibiting xanthine oxidase ANS: D Allopurinol decreases the production of uric acid by inhibiting xanthine oxidase. It also increases the reuse of both hypoxanthine and xanthine for nucleic acid synthesis, resulting in a decrease in uric acid plasma and urine concentration.

12. Probenecid lowers the serum concentration of uric acid by: A. Competitively inhibiting the reabsorption of urate at the proximal renal tubule B. Increasing the reuse of hypoxanthine C. Stimulating xanthine oxidase D. Increasing the reuse of hypoxanthine ANS: A Probenecid is indicated for treating hyperuricaemia and chronic gouty arthritis. It inhibits renal reabsorption of urate and increases the urinary excretion of uric acid.

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13. Probenecid has the potential to interact with: A. NSAIDs B. Penicillin C. Methotrexate D. All of the above ANS: D Probenecid decreases the excretion of methotrexate, penicillin and weak acids such as NSAIDs, increasing their plasma concentration and potential for toxicity.

14. Cyclosporin suppresses the immune system by: A. Binding to FKBP and increasing IL-2 production B. Binding to NF-κB and disrupting the production of inflammatory mediators C. Decreasing prostanoid production D. Binding to cyclophilin, inhibiting calcineurin and decreasing IL-2 production ANS: D Cyclosporin is an immunosuppressant drug that binds to cyclophilin, thereby blocking the action of calcineurin in activated T cells.

15. Adverse effect/s associated with the use of cyclosporin is/are: A. Nephrotoxicity B. Hepatotoxicity C. Gingival hyperplasia D. All of the above ANS: D Cyclosporin can produce all of the adverse effects listed above in a dose-dependent manner. Gingival hyperplasia is a very common problem but usually resolves 6 months after treatment is stopped.

16. Cyclosporin has the potential to interact with: A. Spironolactone B. Cimetidine C. Gentamcin D. All of the above ANS: D Cyclosporin interacts with spironolactone, a potassium-sparing diuretic, to increase the risk of hyperkalaemia. Cimetidine inhibits metabolism of cyclosporin, increasing plasma Copyright © 2019 Elsevier Australia

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concentrations and the risk of adverse effects. Combination with gentamicin, an aminoglycoside, increases the risk of renal toxicity.

17. With regard to antihistamines which of the following statements is FALSE: A. The H1 antihistamines have the greatest therapeutic effect on nasal allergies B. There are two categories of antihistamines: sedating drugs and non-sedating antihistamines C. Non-sedating antihistamines are used primarily for vertigo, nausea and motion sickness D. Antihistamines are primarily metabolised in the liver and the metabolites excreted by the kidneys.

ANS: C The newer, non-sedating antihistamines are used primarily for allergic disorders.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 41: Drugs Affecting the Skin Test Bank MULTIPLE CHOICE 1. A severe reaction involving widespread mucocutaneous lesions usually on the face, neck, arms, legs, hands and feet associated with carbamazepine, phenytoin and sulfonamide use is known as: A. Lupus erythmatous B. Stevens–Johnson syndrome C. Acneiform reaction D. Purpura ANS: B Stevens–Johnson syndrome is associated with many drugs including: carbamazepine, penicillins and cephalosporins, phenytoin, sulfonamides and tetracyclines.

2. A term used to describe loss of hair from areas of skin where hair is normally present is: A. Hirsutism B. Purpura C. Alopecia D. Lichenoid reactions ANS: C Lack or loss of hair from areas of the skin where hair is normally present is termed alopecia. Alopecia has been linked to alkylating agents, anticoagulants, antimetabolites, antitumour antibiotics, heparin, lithium, sodium valproate, norethisterone and spironolactone.

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41-2

3. The following drugs is/are associated with photosensitivity reactions: a. Tetracyclines b. Hydrochlorothiazide c. Phenytoin A. a alone B. a and b C. a, b and c D. c alone ANS: C Many drugs are associated with photosensitivity reactions, which are defined as an abnormal response of the skin to sunlight or artificial lights at wavelengths of 280–400 nm. It may take the form of photoallergy or phototoxicity. Among other drugs, tetracyclines, hydrochlorothiazide (thiazide diuretics) and phenytoin have been linked to photosensitivity reactions.

4. A skin product with astringent properties is: A. Calamine lotion B. Triclosan C. Povidone–iodine D. Menthol ANS: A Astringents are solutions that, when applied topically, cause precipitation of proteins, vasoconstriction and reduced cell permeability. Examples include aluminium acetate or calcium hydroxide solutions, calamine lotion, hamamelis (witch hazel), potassium permanganate and the alcohol vehicle in aftershave lotions.

5. Salicylic acid (5–20%), resorcinol, alpha-hydroxy acids and urea make the penetration of other medicinal substances easier due to: A. Astringent properties B. Antiseptic properties C. Keratolytic action D. Emollient action ANS: C Keratolytics (keratin dissolvers) are skin products that soften skin squames (scales) and loosen the outer horny layer of the skin.

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6. Keratoplastics are defined as: A. Agents that loosen the outer horny layer of skin B. Agents that cause thickening of the cornified layer C. Agents that cause precipitation of proteins D. Agents that soften and sooth irritated skin ANS: B Keratoplastics stimulate the epidermis and cause thickening of the cornified layer.

Examples include coal tar and sulfur preparations and low concentrations of salicylic acid (1–2%).

7. Which of the following statements relating to mupirocin is INCORRECT: A. Mupirocin is applied topically once daily B. Mupirocin is used to treat impetigo C. Mupirocin is used to eradicate nasal S. aureus carrier status D. Mupirocin is mainly active against Gram-positive aerobic bacteria ANS: A This agent is used topically and usually applied to affected areas 3 times a day.

8. The mechanism that best describes the action of imiquimod, an agent indicated for the treatment of external genital and perianal warts, is: A. Keratolytic action B. Antiviral activity C. Immunostimulant action D. Antibacterial activity ANS: C Although warts are caused by a virus (human papillomavirus, HPV), they are not treated with specific antiviral drugs. Imiquimod acts via agonist activity at toll-like receptor-7 to enhance the body’s immune response.

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41-4

9. The acaricide of choice for the treatment of parasitic infestations caused by Sarcoptes scabiei is: A. Crotamiton B. Permethrin C. Benzyl benzoate D. Maldison ANS: B Permethrin 5% cream or lotion is the treatment of choice for mite infestations caused by Sarcoptes scabiei.

10. The mechanism of anti-parastic action of permethrin is: A. Cholinesterase inhibition B. Disruption of parasite mitochondrial function C. Disruption of sodium channel depolarisation D. All of the above ANS: C Permethrin acts on nerve cell membranes of lice, ticks, mites and fleas. It disrupts the sodium channel depolarisation, thus paralysing the parasite.

11. Fluorinated steroids such as triamcinolone are recommended for topical application to thickened skin because of: A. Lipid solubility B. Low tendency to cause sodium retention C. Potency D. All of the above ANS: D Fluorinated corticosteroids have high anti-inflammatory potency (high glucocorticoid action), high lipid solubility and low tendency to cause sodium and water retention (low mineralocorticoid action).

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12. Retinoids (vitamin A analogues) such as tretinoin and isotretinoin, should not be used: A. In pregnant women B. In people suffering from acne vulgaris C. Topically D. Orally ANS: A Topical retinoids may cause birth defects and are rated Pregnancy Safety Category D. Oral retinoids are Category X. Women who are prescribed these drugs must use efficient contraceptive methods for 1 month before starting the treatment, continuously during treatment, and for 1 month (isotretinoin) or 2 years (acitretin) after cessation of treatment.

13. A fungal infection of the nail is termed: A. Dermatophytosis B. Tinea versicolor C. Onychomycoses D. Tinea pedis ANS: C Onychomycoses is the fungal infection of the nail.

14. The only topical antifungal shown to be effective in treating fungal nail infections is: A. Nystatin B. Amorolfine C. Terbinafine D. Miconazole ANS: B Onychomycoses are particularly resistant to treatment by the usual topical or oral formulations. Amorolfine nail varnish is the only antifungal agent that is sufficiently well absorbed through fingernails and toenails to be effective topically in treating fungal nail infections. However, it is expensive and may have limited clinical efficacy.

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15. Silver sulfadiazine used in the treatment of burns should not be used in: A. Pregnancy B. History of sulfonamide allergy C. Long-term use D. All of the above ANS: D Sulfonamides can cause kernicterus in babies if used by pregnant women (Pregnancy Category C). They also retard re-epitheliasation, so should be discontinued once the wound starts healing. The drug should not be used in patients with a history of sulfonamide allergy.

16. An example of an immunomodulator anti-TNF agent used in the treatment of psoriasisis is: A. Etanercept B. Adalimumab C. Infliximab D. All of the above ANS: D Etanercept, adalimumab and infliximab are classed as anti-TNF agents used for the treatment of psoriasis.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 42: Drugs in Sport Test Bank MULTIPLE CHOICE 1. The World Anti-Doping Agency (WADA) includes the following drugs as banned or restricted: A. Anabolic agents B. Diuretics C. Cannabinoids D. All of the above ANS: D 2. An athlete may require a prohibited drug to manage a medical condition such as diabetes or asthma. An application can be made via: A. WADA B. TUE C. ASADA D. AFL ANS: B Approval to take a prohibited drug can be obtained using the Therapeutic Use Exemption (TUE).

3. Adverse effects associated with use of anabolic steroids are: A. Androgenic effects B. Anabolic effects C. Priapism in males D. All of the above ANS: D Androgenic effects include increased growth of seminal vesicles and prostate gland, increased body and facial hair. Anabolic affects include increased organ and muscle mass, protein synthesis and haemoglobin concentration.

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4. EPO raises haemoglobin levels and aerobic performance. Adverse effects associated with its use are: A. Flu-like symptoms B. Hypersensitvity reactions C. Hypertension D. All of the above ANS: D Erythropoietin (EPO) is a natural haematinic hormone indicated in the treatment of renal failure and anaemias. Prolonged administration of EPO raises haemoglobin levels and aerobic performance, so has been widely abused in endurance sports. Raised levels of RBCs combined with dehydration cause hypertension, flu-like symptoms and hypersensitivity reactions.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 43: Pharmacotherapy of Obesity Test Bank MULTIPLE CHOICE 1. The mechanism of action of phentermine that leads to weight loss is: A. Inhibits cannabinoid-1 (CB1) receptors B. Promotes release of dopamine centrally C. Inhibits reuptake mechanisms selective for serotonin D. Inhibits reuptake mechanisms for 5-HT, noradrenaline and dopamine ANS: B Phentermine is a noradrenergic amphetamine-like drug. The drug promotes release of noradrenaline in the hypothalamus, which enhances sympathetic neurotransmission, resulting in appetite suppression and increased energy expenditure. It is the only drug of its type available in Australia but its role in the treatment of obesity is questionable.

2. The only anti-obesity drug available for long-term management of obesity is: A. Salbutamol B. Rimonabant C. Orlistat D. Dexenfluramine ANS: C Orlistat is the only drug available for long-term management of obesity but a new drug called cetilistat is under development.

3. The mechanism by which orlistat promotes a reduction in body weight and plasma cholesterol is: A. Stimulation of gastric and pancreatic lipase B. Inhibition of gastric and pancreatic lipase C. Chelation of dietary triglycerides D. Increased circulating noradrenaline levels ANS: B Orlistat inhibits gastric and pancreatic lipase through the formation of a covalent bond with a serine residue in the active site of the enzyme. Inhibition of the action of the lipase Copyright © 2019 Elsevier Australia

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prevents the breakdown of dietary triglycerides (fat) and inhibits the absorption of cholesterol and lipid-soluble vitamins.

4. The clinical manifestation of the interaction between orlistat and warfarin is: A. Increased risk of bleeding B. Increased risk of thromboembolic event C. Synergism D. No effect ANS: A As vitamin K absorption may be decreased, people taking warfarin or phenindione should be monitored for changes in coagulation parameters.

5. The most common adverse reaction observed with orlistat is: A. Hepatic failure B. Renal failure C. Increased risk of stroke D. GIT upset ANS: D The most commonly observed adverse drug reaction involves the gastrointestinal tract and includes fatty or oily stools, oily spotting, flatulence, liquid stools, abdominal pain and faecal incontinence and urgency.

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Bryant: Pharmacology for Health Professionals, 5th Edition Chapter 44: Envenomation and Antivenoms Test Bank MULTIPLE CHOICE 1. The adverse reaction of greatest concern with snake antivenom administration is: A. Transmission of equine viruses to humans B. Chest pain C. Coagulopathies D. Anaphylaxis ANS: D Anaphylaxis is the greatest concern and the risk is greater in individuals allergic to horses, horse-based products (equine proteins) or antivenoms.

2. With respect to monovalent antivenoms, which of the following statements is TRUE: A. They are raised against venom from a single species B. Smaller dose of antivenom is used C. It is essential to identify the species of snake involved D. All of the above ANS: D These antivenoms are raised against the venom from a single species of snake. Usually, smaller doses are required, which decreases the risk of adverse effects, but snake identification with snake identification kits is essential to avoid administration of the wrong type of antivenom, which could be dangerous.

3. With respect to polyvalent antivenoms, which of the following statements is TRUE: A. They are raised against venom from a single species B. Smaller dose of antivenom is used C. Essential to identify the species of snake involved D. None of the above ANS: D These antivenoms are produced using venom from a number of species, which broadens usefulness of the antivenom and makes identification of the snake less important.

However, larger doses of the agent are required to provide the desired effect.

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4. Children may suffer a snake bite and, because of their lower body mass and the likelihood they have run around after a bite to find a parent, are at greater risk of severe envenomation. The dosage of antivenom for a child is: A. The same as that for an adult B. Lower than that for an adult C. Higher than that for an adult D. Children should not be given antivenom ANS: A The dosage of antivenom for a child is the same as that for an adult, as the basis of antivenom therapy is neutralising the venom, which is snake-dependent and independent of the body weight of the victim.

5. The antivenom for the funnel-web spider is: A. Derived from horse IgG B. Associated with hypersensitivity reactions such as anaphylaxis C. Given as a once only dose D. Given without delay ANS: D The antivenom for the funnel-web spider is derived from rabbit IgG. Hypersensitivity reactions are uncommon but caution is advised in victims allergic to rabbits or rabbit-based products. As envenomation can result in death within 30 minutes, administration of the antivenom is not delayed. If the victim does not respond, further antivenin treatment may be necessary (>8 ampoules).

6. Immediate first aid management of a box jellyfish sting includes: A. Soaking the attached tentacles with vinegar B. Maintaining respiratory and cardiovascular support C. Getting help immediately D. All of the above ANS: D The antivenom for the box jelly fish consists of sheep IgG. Initial first aid treatment involves soaking any attached tentacles with vinegar in order to inactivate the remaining stinging cells. Death can occur from respiratory failure or cardiotoxicity, and victims may also be unconscious before they leave the water. Seek help immediately since deaths have been recorded despite antivenom administration.

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