Pharmacology

[#4] Family #4: which members belong to the “Autonomic drugs (adrenergic and cholinergic)” family?

Members: β-blockers · β2-agonists · α1-blockers (prazosin) · α1-agonists (phenylephrine) · atropine · bethanechol · physostigmine · pralidoxime.

[#4] A patient develops wheezing after starting new glaucoma eyedrops. Which drug was most likely given?

β-blockers (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] An overdose causes bradycardia and hypotension. Which drug was most likely given?

β-blockers (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] A β-blocker overdose needs a drug that raises cAMP independently of β receptors. Which is more likely: Glucagon or Phenylephrine?

Glucagon. phenylephrine for β-blocker overdose → glucagon raises cAMP independently of β receptors; phenylephrine acts via Gq

[#4] An older man has BPH and hypertension. Which drug is most appropriate?

α1-blockers (prazosin) (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] Drug curves are shown before and after an antagonist, showing epinephrine reversal. Which drug was most likely given?

α1-blockers (prazosin) (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] A nasal decongestant spray causes rebound congestion and raised BP. Which drug was most likely given?

α1-agonists (phenylephrine) (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] A patient has vagal bradycardia (inferior MI), or heart rate must be raised without inotropy. Which drug is most appropriate?

atropine (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] A patient has postoperative urinary retention. Which drug is most appropriate?

bethanechol (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] A patient is hot, dry, flushed, and confused after jimsonweed or an OTC sleep aid. Which drug is most appropriate?

physostigmine (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] Anticholinergic toxicity with CNS signs needs a tertiary amine that enters the CNS. Which is more likely: Physostigmine or Neostigmine?

Physostigmine. neostigmine → anticholinergic toxicity with CNS signs needs physostigmine (tertiary amine enters CNS)

[#4] Salivation, sweating, wheezing, and fasciculations follow insecticide exposure. Which drug is most appropriate?

pralidoxime (#4 Autonomic drugs (adrenergic and cholinergic))

[#4] Organophosphate poisoning leaves persistent nicotinic effects despite muscarinic-only treatment. Which is more likely: More atropine or Pralidoxime?

Pralidoxime. more atropine for organophosphate weakness → atropine is muscarinic only; persistent nicotinic effects need pralidoxime

[#9] Family #9: which members belong to the “Dyslipidemias and lipid-lowering drugs” family?

Members: familial hypercholesterolemia · lipoprotein lipase / apoC-II deficiency · abetalipoproteinemia · statins · fibrates (gemfibrozil, fenofibrate) · niacin · ezetimibe · bile acid sequestrants (cholestyramine).

[#9] A patient has tendon xanthomas and very high LDL; the father died of an MI young. What is the most likely diagnosis?

familial hypercholesterolemia (#9 Dyslipidemias and lipid-lowering drugs)

[#9] A patient has tendon xanthomas and early CAD. Which is more likely: LDL receptor defect or LPL/apoC-II deficiency?

LDL receptor defect. LDL receptor defect (type IIa) → tendon xanthomas and early CAD = LDL receptor; eruptive xanthomas and pancreatitis = LPL/apoC-II (chylomicrons)

[#9] A child has pancreatitis, eruptive xanthomas, milky plasma, and very high triglycerides. What is the most likely diagnosis?

lipoprotein lipase / apoC-II deficiency (#9 Dyslipidemias and lipid-lowering drugs)

[#9] Post-heparin LPL activity is normal. Which is more likely: ApoC-II deficiency or LPL deficiency?

ApoC-II deficiency. LPL deficiency → normal post-heparin LPL activity points to apoC-II deficiency

[#9] Siblings have ataxia, retinitis pigmentosa, spiny RBCs, and very low cholesterol. What is the most likely diagnosis?

abetalipoproteinemia (#9 Dyslipidemias and lipid-lowering drugs)

[#9] A patient's cholesterol fell after starting a drug that inhibits the rate-limiting enzyme of cholesterol synthesis. Which drug was most likely given?

statins (#9 Dyslipidemias and lipid-lowering drugs)

[#9] The drug works by increasing hepatocyte LDL-receptor synthesis. Which is more likely: Ezetimibe or Statin?

Statin. decreased absorption of dietary cholesterol (ezetimibe) → statins (and resins) work by increasing hepatocyte LDL-receptor synthesis

[#9] A patient has triglycerides of 550–2000 with recurrent pancreatitis. Which drug is most appropriate?

fibrates (gemfibrozil, fenofibrate) (#9 Dyslipidemias and lipid-lowering drugs)

[#9] Muscle pain, high CK, and myoglobinuria follow adding another drug to a statin. Which drug was most likely given?

fibrates (gemfibrozil, fenofibrate) (#9 Dyslipidemias and lipid-lowering drugs)

[#9] A patient has flushing after starting a new drug. Which drug was most likely given?

niacin (#9 Dyslipidemias and lipid-lowering drugs)

[#11] Family #11: which members belong to the “Pharmacokinetics and drug interactions” family?

Members: Pharmacokinetics and drug interactions.

[#11] An IV dose and the resulting plasma concentration are given. Which topic does this scenario test?

11 Pharmacokinetics and drug interactions

[#11] A target plasma level and the volume of distribution are given. Which dose do these two values let you calculate?

Loading dose (#11 Pharmacokinetics and drug interactions)

[#11] An infusion rate and the steady-state plasma level are given. Which relationship is used to solve this?

Rate = CL × Css (#11 Pharmacokinetics and drug interactions)

[#11] Serial plasma levels or a drug's half-life are given. How long until steady state (or near-complete elimination) is reached?

~4–5 half-lives (90% ≈ 3.3 t½) (#11 Pharmacokinetics and drug interactions)

[#11] New diazepam or phenytoin toxicity appears after starting OTC cimetidine. Which pharmacokinetic change is most likely?

↑Levels of warfarin, phenytoin, benzodiazepines, statins (#11 Pharmacokinetics and drug interactions)

[#11] Contraceptive or valproate failure follows carbamazepine or St. John's wort. Which pharmacokinetic change is most likely?

↓Levels: OCP failure, ↓valproate, accelerated vitamin D catabolism (#11 Pharmacokinetics and drug interactions)

[#11] Ciprofloxacin or levothyroxine fails when taken with calcium, iron, or a PPI. Which mechanism explains the treatment failure?

Decreased absorption (itraconazole needs acid) (#11 Pharmacokinetics and drug interactions)

[#11] A patient has bimodal isoniazid levels, low TPMT, or CYP2D6 amplification. Which mechanism best explains these findings?

Pharmacogenetic polymorphism (reduce 6-MP dose with low TPMT) (#11 Pharmacokinetics and drug interactions)

[#11] A loading dose is being calculated. Which is more likely: Volume of distribution or Clearance?

Volume of distribution. using clearance for the loading dose → loading dose depends on Vd only; maintenance dose depends on clearance

[#11] The drug loses a constant fraction per half-life and reaches steady state in about 4–5 half-lives regardless of dose. Which is more likely: Zero-order kinetics or First-order kinetics?

First-order kinetics. linear (zero-order) extrapolation → first-order drugs lose a constant fraction per half-life; ~4–5 half-lives to steady state regardless of dose

[#11] A drug fails when taken with antacids, calcium, iron, or a PPI. Which is more likely: Cytochrome P450 interaction or Decreased absorption?

Decreased absorption. a cytochrome P450 interaction → with antacids, calcium, iron, or PPIs the problem is decreased absorption

[#16] Family #16: which members belong to the “Anticancer drugs and toxicities” family?

Members: vincristine / vinblastine · paclitaxel · bleomycin · doxorubicin · cyclophosphamide / ifosfamide · cisplatin · methotrexate · 5-fluorouracil.

[#16] Tingling hands and feet with absent ankle reflexes develop on chemotherapy. Which drug was most likely given?

vincristine / vinblastine (#16 Anticancer drugs and toxicities)

[#16] The M-phase drug blocks microtubule assembly. Which is more likely: Taxanes or Vinca alkaloids?

Vinca alkaloids. vincas vs taxanes → vincas block microtubule assembly; taxanes block disassembly; both M phase

[#16] A breast or ovarian cancer is treated with a chemotherapy drug. Which drug was most likely given?

paclitaxel (#16 Anticancer drugs and toxicities)

[#16] Pulmonary fibrosis with restrictive PFTs follows chemotherapy for testicular cancer. Which drug was most likely given?

bleomycin (#16 Anticancer drugs and toxicities)

[#16] Heart failure with an S3 develops months after breast cancer chemotherapy. Which drug was most likely given?

doxorubicin (#16 Anticancer drugs and toxicities)

[#16] Hematuria follows a high-dose drug given before a stem cell transplant. Which drug was most likely given?

cyclophosphamide / ifosfamide (#16 Anticancer drugs and toxicities)

[#16] A patient develops nephrotoxicity and ototoxicity. Which drug was most likely given?

cisplatin (#16 Anticancer drugs and toxicities)

[#16] A patient with renal impairment receives an intrathecal drug. Which drug was most likely given?

methotrexate (#16 Anticancer drugs and toxicities)

[#16] Rescue requires a folate that bypasses DHFR. Which is more likely: Leucovorin or Folic acid?

Leucovorin. folic acid for methotrexate toxicity → leucovorin bypasses DHFR; folic acid needs DHFR

[#16] AML develops years after treatment for Hodgkin lymphoma. Which condition is this?

16 Anticancer drugs and toxicities

[#16] Relapsed leukemia shows the drugs undetectable inside the blasts. Which condition is this?

16 Anticancer drugs and toxicities

[#16] Circulating blasts appear years after alkylating agents. Which is more likely: Recurrent Hodgkin disease or Therapy-related AML?

Therapy-related AML. recurrence of Hodgkin disease → circulating blasts years after alkylators = therapy-related AML

[#19] Family #19: which members belong to the “Antibiotics: mechanisms, resistance, side effects” family?

Members: β-lactams (penicillins, cephalosporins) · Vancomycin · Aminoglycosides (gentamicin) · Tetracyclines (doxycycline) · Macrolides (azithromycin, erythromycin) · Linezolid · Fluoroquinolones (ciprofloxacin, levofloxacin) · TMP-SMX.

[#19] Cellulitis does not respond to nafcillin; blood cultures grow MRSA. Which antibiotic class does this resistance pattern involve?

β-lactams (penicillins, cephalosporins) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] An E. coli isolate is ampicillin-resistant but ceftriaxone-sensitive. Which antibiotic class does this resistance pattern involve?

β-lactams (penicillins, cephalosporins) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] The enzyme hydrolyzes 3rd-generation cephalosporins while carbapenems stay active. Which is more likely: TEM-1 β-lactamase or ESBL?

ESBL. TEM-1 β-lactamase vs ESBL → TEM-1 spares 3rd-generation cephalosporins; ESBLs hydrolyze them (carbapenems stay active)

[#19] A patient has a resistant enterococcal infection. Which antibiotic does this resistance most likely involve?

Vancomycin (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] Endocarditis on penicillin has a synergistic drug added to shorten therapy. Which drug was most likely added?

Aminoglycosides (gentamicin) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] Hearing loss or rising creatinine develops during treatment of pyelonephritis or pneumonia. Which drug was most likely given?

Aminoglycosides (gentamicin) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] A teenager on an acne antibiotic gets a sunburn or loses effect when taking it with milk. Which drug was most likely given?

Tetracyclines (doxycycline) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] The drug binds the 30S ribosomal subunit. Which is more likely: Tetracyclines or Macrolides?

Tetracyclines. 50S inhibitors (macrolides) → aminoglycosides and tetracyclines bind 30S, not 50S

[#19] A community MRSA abscess is not responding to treatment. Which drug is most appropriate?

Linezolid (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] An infection keeps progressing on the current antibiotic. Which drug was most likely given?

Fluoroquinolones (ciprofloxacin, levofloxacin) (#19 Antibiotics: mechanisms, resistance, side effects)

[#19] TB therapy causes dim vision, color loss, or numb feet. Which condition is this?

19 Antibiotics: mechanisms, resistance, side effects

[#19] TB therapy causes vision and color loss. Which is more likely: Isoniazid or Ethambutol?

Ethambutol. Isoniazid vs ethambutol toxicity → ethambutol causes vision and color loss; isoniazid causes peripheral neuropathy (B6)

[#22] Family #22: which members belong to the “Antiviral drugs (herpes, influenza, HIV)” family?

Members: Acyclovir/valacyclovir · Ganciclovir · Foscarnet · Oseltamivir/zanamivir · NRTIs (zidovudine, didanosine) · NNRTIs (efavirenz, nevirapine) · Protease inhibitors (-navir, ritonavir) · Enfuvirtide.

[#22] Genital vesicles or HSV encephalitis are treated with an antiviral. Which drug is most appropriate?

Acyclovir/valacyclovir (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] CMV retinitis is treated with an antiviral. Which drug is most appropriate?

Ganciclovir (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] An AIDS patient has HSV/VZV lesions that don't respond to high-dose acyclovir. Which drug is most appropriate?

Foscarnet (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] HSV becomes resistant to acyclovir in the usual way. Which is more likely: Viral DNA polymerase mutation or Loss of viral thymidine kinase?

Loss of viral thymidine kinase. Viral DNA polymerase mutation → the usual acyclovir resistance is loss of viral thymidine kinase; foscarnet still works

[#22] Influenza within 48 hours, or a nursing-home outbreak, is treated with an antiviral. Which drug is most appropriate?

Oseltamivir/zanamivir (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] Epigastric pain to the back, high amylase, or lactic acidosis develops on antiretrovirals. Which drug was most likely given?

NRTIs (zidovudine, didanosine) (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] Anemia and neutropenia develop weeks into HIV post-exposure prophylaxis. Which drug was most likely given?

NRTIs (zidovudine, didanosine) (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] How might a question stem present NRTIs (zidovudine, didanosine)?

rising viral load and resistance after years of zidovudine (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] HIV becomes resistant to zidovudine. Which is more likely: Thymidine kinase loss or Reverse transcriptase mutation?

Reverse transcriptase mutation. Thymidine kinase (acyclovir resistance) in HIV → zidovudine resistance is mutation of reverse transcriptase

[#22] Viral load and resistance rise after years of an antiretroviral. Which drug was most likely given?

NNRTIs (efavirenz, nevirapine) (#22 Antiviral drugs (herpes, influenza, HIV))

[#22] The drug acts at maturation after budding. Which is more likely: Entry/uncoating block or Protease inhibitor?

Protease inhibitor. Entry/uncoating block → protease inhibitors act at maturation after budding; neuraminidase inhibitors block virion release

[#38] Family #38: which members belong to the “Eicosanoids, NSAIDs, and aspirin” family?

Members: Aspirin · NSAIDs (ibuprofen, naproxen, ketorolac, indomethacin) · Celecoxib (COX-2) · Misoprostol · Leukotrienes · Reye syndrome · Aspirin-exacerbated respiratory disease.

[#38] A patient with possible ACS receives initial treatment. Which drug is most appropriate?

Aspirin (#38 Eicosanoids, NSAIDs, and aspirin)

[#38] A patient develops tinnitus and vertigo after starting a new medication. Which drug was most likely given?

Aspirin (#38 Eicosanoids, NSAIDs, and aspirin)

[#38] A drug's antiplatelet effect persists because platelets have no nucleus. Which is more likely: Irreversible platelet COX inhibition or Dose-selective COX-1 inhibition?

Irreversible platelet COX inhibition. Dose-selective COX-1 inhibition by low-dose aspirin → antiplatelet because platelet COX inhibition is irreversible (no nucleus)

[#38] An elderly patient on an ACE inhibitor and a diuretic has a rising creatinine after starting a new medication. Which drug was most likely given?

NSAIDs (ibuprofen, naproxen, ketorolac, indomethacin) (#38 Eicosanoids, NSAIDs, and aspirin)

[#38] In aspirin-induced asthma, leukotriene levels rise. Which is more likely: Lipoxygenase inhibition or COX block shunting to 5-LOX?

COX block shunting to 5-LOX. Lipoxygenase inhibition in aspirin asthma → the drug blocks COX; arachidonate shunts to 5-LOX, raising leukotrienes

[#38] A child given aspirin for flu develops vomiting, stupor, hepatomegaly, and high ammonia. What is the most likely diagnosis?

Reye syndrome (#38 Eicosanoids, NSAIDs, and aspirin)

[#38] A patient with asthma and nasal polyps develops bronchospasm after taking ibuprofen. What is the most likely diagnosis?

Aspirin-exacerbated respiratory disease (#38 Eicosanoids, NSAIDs, and aspirin)

[#38] A patient with aspirin sensitivity needs an alternative pain reliever. Which is more likely: Ibuprofen or naproxen or Acetaminophen?

Acetaminophen. Ibuprofen or naproxen as an alternative in aspirin sensitivity → all NSAIDs cross-react; acetaminophen is safer

[#38] An arachidonic acid pathway diagram is shown. Which condition is this?

38 Eicosanoids, NSAIDs, and aspirin

[#47] Family #47: which members belong to the “Diuretics” family?

Members: loop diuretics (furosemide) · thiazides (hydrochlorothiazide) · spironolactone · amiloride/triamterene · acetazolamide.

[#47] A patient has volume overload with pulmonary edema and a GFR under 20. Which drug is most appropriate?

loop diuretics (furosemide) (#47 Diuretics)

[#47] A patient started a new antihypertensive weeks ago and now has low potassium and metabolic alkalosis. Which drug was most likely given?

thiazides (hydrochlorothiazide) (#47 Diuretics)

[#47] A patient has recurrent calcium stones with high urine calcium. Which drug is most appropriate?

thiazides (hydrochlorothiazide) (#47 Diuretics)

[#47] A nephron diagram is shown and a diuretic is given. Which drug was most likely given?

thiazides (hydrochlorothiazide) (#47 Diuretics)

[#47] A patient with calcium stones needs a diuretic that lowers urinary calcium. Which is more likely: Thiazide or Loop diuretic?

Thiazide. loop diuretic for calcium stones → thiazides lower urinary calcium; loops raise it

[#47] A man with cirrhotic ascites develops breast enlargement on his diuretic. Which drug was most likely given?

spironolactone (#47 Diuretics)

[#47] A diuretic is antiandrogenic. Which is more likely: Amiloride or triamterene or Spironolactone?

Spironolactone. amiloride/triamterene for gynecomastia → only spironolactone is antiandrogenic

[#47] A patient on an ACE inhibitor plus a combination pill containing HCTZ has a potassium of 6.4. Which drug was most likely given?

amiloride/triamterene (#47 Diuretics)

[#47] A climber takes prophylaxis before a high-altitude ascent. Which drug is most appropriate?

acetazolamide (#47 Diuretics)

[#47] An obese patient has papilledema, a normal MRI, and a high opening pressure. Which drug is most appropriate?

acetazolamide (#47 Diuretics)

[#47] A diuretic causes metabolic acidosis. Which is more likely: Acetazolamide or Loop or thiazide diuretic?

Acetazolamide. metabolic acidosis from loops/thiazides → loops and thiazides cause contraction alkalosis; acetazolamide (and K-sparing drugs) cause acidosis

[#48] Family #48: which members belong to the “Antihypertensive drugs and hypertensive damage” family?

Members: ACE inhibitors · ARBs · sacubitril–valsartan · dihydropyridine calcium channel blockers · labetalol · nitroprusside / nitrates · hyperplastic arteriolosclerosis · hypertensive retinopathy.

[#48] A patient develops a new dry cough or lip and tongue angioedema without hives after starting a BP drug. Which drug was most likely given?

ACE inhibitors (#48 Antihypertensive drugs and hypertensive damage)

[#48] A hypertensive diabetic has albuminuria. Which drug is most appropriate?

ACE inhibitors (#48 Antihypertensive drugs and hypertensive damage)

[#48] Labs show ↑Ang I, ↓Ang II, and ↑bradykinin. Which is more likely: ARB or ACE inhibitor?

ACE inhibitor. ACE inhibitor vs ARB lab pattern → ACE inhibitor: ↑Ang I, ↓Ang II, ↑bradykinin (cough, angioedema); ARB: ↑renin and ↑Ang II, bradykinin unchanged