Medical School Pharmocology Exam 4 Wsu

Front 1

bile acid-binding resins used in the management of hyperlipidemia

Back 1

cholestyramine, colestipol, colesevelam

(bind bile acids, preventing enterohepatic recycling, thus diverting hepatic efforts to renew bile acids, instead of producing plasma lipids)

Front 2

inhibits the rate-limiting enzyme of cholesterol synthesis, HMG-CoA reductase, resulting in dramatically decrased LDL levels

Back 2

Statins ( lovastatin, pravastatin, simvastatin, atorvastatin)

- may cause elevated liver enzymes, myositis, with increased creatin kinse from skeletal muscle and rarely rhabdomyolysis

Front 3

cholesterol absorption blocker

Back 3

ezetimibe

-dec LDL and has no effect on HDL or triglycerides

-rare se: inc in LFTs

Front 4

lipid-lowering agent that causes cutaneous flusing, which can be avoided by admistering concurrently with aspirin

Back 4

Nician

-directly reduces the secretion of VLDLs from liver and apolipoprotien synthesis by the liver, while increasing HDLs

Front 5

agents that decrease triglycerides dramatically by stimulating lipoprotien lipase

-inhibits formation of ApoC III which is an inhibitor of Lipoprotien lipase

Back 5

fibric acids

gemfibrozil
fenofibrate
clofibrate

-clofibrate has been associated with gallstones and hepatobiliary neoplasms

Front 6

reduction of hepatic triglyceride production and increase in triglyceride clearance

Back 6

omega-3 fish oils, omacor and other generics

-deep ocean fish are primary dietary source of omega-3 polyunsaturated fatty acids (PUFA)

SE: risk of hemorrhagic stroke inc

Front 7

se of fibric acids (gemfibrazil and fenofibrate)

Back 7

mild gi distress and myopathies

Front 8

drugs categories used to tx elevated LDL - cholestrol

Back 8

statins - primarily
bile acid-binding resins
niacin
ezetimbe - least used

Front 9

drugs used to tx elevated VLDL - triglycerides

Back 9

fibric acids: gemfibrozil or fenofibrate

moa: inhibit formation of ApoCIII which is an inhibitor of lipoprotien

Front 10

lipid lab values requiring tx with statins

Back 10

total cholestrol > 200
LDL-Chol > 130
HDL < 40
C-reative protien > 2.0

Front 11

dec production of leukotirenes and prostaglandins by inhibiting phospolipase A2 and expression of cox - 2

Back 11

glucocorticoids
-hydrocortisone, prednisone, triamcinolone, dexamethasone, beclomethasone

ae: introgenic cushings syndrome - buffalo hump, moon face, truncal obesity

Front 12

glucocorticoid used for the tx of leukemias and lymphomas, as well as for RA and asthma

Back 12

prednisone

-triggers apoptosis and can lead to hypercortisolism with cushing like symptoms. Drug must be tapered gradually to prevent life-threating adrenal insufficincy

Front 13

commonly used analygesic and antipyretic, but unlike NSAIDS, has no anti-inflammatory properties

Back 13

acetaminophen

-weaker inhibitor of COX, it inhibits prostaglandin synthesis in the cns, a related prodrug (phenacetin) is no longer available due to nephrotoxicity

Front 14

NSAID with analgesic, antipyretic, antiplatelet and anti inflammatory properties that irreversibly inhibit COX

Back 14

aspirin (acetylsalicylic acid)

-inhibits the formation of prostaglandin E (PGE)
-dec pain and fever
-dec syn of PGE in stomach, predisposing to acute gastritis

Front 15

reversible inhibitors of COX widely used as over the counter (OTC) pain relevers

Back 15

ibuprofen
naproxen
piroxicam

-these agents share many of the same effects as aspirin, but are more efficacious analgesics and anti-inflammatories

-they lack aspirin's long duration and antiplatelet effects

Front 16

high potency NSAID used in tx of gout and arthritis, and for closure of patent ductus arteriosus

Back 16

indomethacin

-conversely, prostaglandin E (PGE)can be used to maintain a patent ductus arteriosus in congenital cyanotic heart disease

Front 17

newly avaiable NSAID, used in tx of RA and other chronic conditions, with dec risk of ulcer and other GI bleeds

Back 17

celecoxib

-celecoxib and a similar drug, rofecoxib, selectively inhibit COX-2 present only in leukocytes

-these agents do not inhibit COX-1 that produces protective prostaglandins in the stomach, as sulfa drugs, they both can cause hypersensitivity in some patients

Front 18

eicosanoid preparation used to prevent peptic ulcers in patients taking high doses of NSAIDs for conditions such as RA

Back 18

misoprostol

moa: block histamine stimulated cAMP production

-this prostaglandin E (PGE) analog dec gastric acid production and inc mucus production, protecting the lining of the stomach

use: inflammatory GI disease esp when ulcer due to NSAID

Front 19

used in the tx of RA and IBD (inflammatory bowel disease), a recombinate protien product that inhibits the effects of tumor necrosis factor alpha (TNF - a)

Back 19

Etanercept

-adminstered iv, this drug is a fusion btwn the extracellular domain of TNF-a and the Fc portion of an antibody, a similar monoclonal antibody, infliximab, also binds and inhibits TNF-a

Front 20

standard of care for disease modifying anti-rheumatic drugs (DMARD) therapy

-inhibits dihydrofolate reductase and consequent thymidine deficiency

Back 20

Methotrexate

ae: gi, hematological and heptic effects, also teratogenic

Front 21

txmt of malaria and ameba infestation

partitions into acidic vacuole of these organisms

Back 21

hydroxychloroquine

-also reduces chemotaxis, phagocytosis and superoxide production in PMN, as a consequence of accumulation in lysosomes

Front 22

a sulfonamide used to tx inflamamatory bowel disease

Back 22

sulfazalazine

-drug is split into 5-aminosalicylic acid and sulfapyridine by enteric flora

-se: rash, dizziness, gi upset, photo senstivity

Front 23

the estrogen partial agonist used to prevent osteoporosis in postmenopausal women

Back 23

raloxifene

-in also inc serum high density lipoprotien (HDL), protecting against athrosclerosis and heart disease

-another selective estrogen receptor modulator (SERM), tamoxifen, it does not inc risk of endometrial cancer

Front 24

these compounds reduce bone resorption and formation, and are used in the txmt of osteoprosis (postmenopausal, senile, or glucocorticoid-induces) and Paget disease

Back 24

bisphosphonates
-alendronate, etidronate, pamidronate, risedronate

characterised by poor oral availability and can not bet taken with food, may cause esophageal ulcerations

-must be taken with large amounts of water and pts must be upright for at least 30 min afterward

Front 25

used for tx of osteoporosis, this hormone produces by thyroid decreases bone breakdown, and dec serum calcium and phosphate levels

Back 25

calcitonin

also used in txmt of acute hypercalcemia and paget disease

-salmon calcitonin is used because it is more potent and has longer half-life

adm intranasally or by injection

Front 26

this form of insulin is given in the morning and in the evening, to maintain basal levels of insulin for 12 to 24 hrs

Back 26

ultralente insulin

-supplemented throughout the day with insulin lispro, a moidifed version of human insulin, insulin glargine, has a even longer duration of action

Front 27

oral hypoglycemic agents used to stimulate the release of endogenous insulin from B cells

Back 27

sulfonylureas - glyburide and glipizide

-stimulate the closure of potassium channels, resulting in depolarization of B cells and the release of preformed insulin vessicles

Front 28

oral hypoglycemic agent that does not require functional pancreatic islet cells and dec postprandial glucose levels with out resultant hypoglycemia or weight gain

Back 28

metformin

-biguanide compound that functions by increasing peripheral glycolysis and therefore, hepatic gluconeogensis, resuling in dec in serum glucose levels

Front 29

this ultra-rapid-acting human insulin is admistered immediately before meals

Back 29

insulin lispro

-an altered form of insulin that enters the circulation more rapidly than crystalline zinc (regular) insulin

Front 30

this insulin secretagogue has a rapid onset, but shorter duration of action than sulfonyluraeas

Back 30

repaglinide

-belongs to a class of drugs known as meglitinides, which facilitate insulin relsease from pancreatic B cells by binding to potassium channels

Front 31

these agents inc cell sensitivity to insulin, by stimulating the peroxisomal proliferator gamma (PPAR g) nuclear receptor

Back 31

Thiazolidinediones (TZD) or "Glitazones" - rosiglitazone and pioglitazone

-PPARg regulates a number of genes involved in carbohydrate metabolism. The first member of this class, troglitazone, was removed from the market bc it caused hepatotoxicity

Front 32

oral hypoglycemic agent that functions within the intestinal lumen, dec postprandial hyperglycemia, although there are not effects on fasting sugar

Back 32

Acarbose and miglitol

-inhibits alpha-galactosidase, an enzyme required for rapid absorption of most dietary sugars

Front 33

what reaction occurs between warfarin (anti-coag) and cimetidine (H2 blocker)?

Back 33

bother are lipid soluble and metabolized by liver enzymes cyp P450

cimetidine must be dosed in large dose bc of low potency, inhibiting warfarin metabolism and inc prothrombin time

-use instead ranitidine bc cleared renally or proton pump inhibitor that dec stomach acid in pt on warfarin

Front 34

what risk does a diabetic have when taking metoprolol?

Back 34

Metoprolol is a B1 blocker and some B2 blocker, which blocks epi driven tachycardia, symptom which occurs when one is hypoglycemic, which is masked by B blockers. Best to give diabetics calcium channel blockers such as amlodipine to tx HTN

Front 35

How does warfarin and St John wart interact with each other?

Back 35

St John wart is a p450 inducer, since warfarin is metabolized by p450, there is low conc of warfarin and inc coagulation.

Front 36

how does alendronate bisphosphonate, levofloxacin and Ca fortified orange juice interact with each other?

Back 36

levofloxacin binds to calcium which causes it to not be absorbed. So dont drink the oj or any other calcium with the levofloxacin.

Front 37

How does warfarin and acetaminophin react with each other?

Back 37

both are metabolized by p450 enzyme in the liver. Acetaminophin is metabolized to a toxic metabolite NAPQI that inhibit Vit K carboxylase adn reductase accentuating warfarin effect and inc bleeding.

-best if pt on warfarin takes other analgesic like NSAID

Front 38

what interaction occurs btwn methotrexate, cyclosporine and ketoconazole?

Back 38

methotrexate
-inhibits dihydrofolate reductase and excreted renally

cyclosporine
-inhibit T cell activity and prevents nuclear localization of NFAT, excreted by liver p450 enzymes

Ketoconazole
-antifungal, inhibits fungal p450 involved in sterol synthesis

ketoconazole inhibits cyclosporin elimination leading to accumulation and renal toxicity with sx of pitting edma in ankles, azotemia , hyperuricema and hyperkalemia.

Front 39

how does amiodarone, erythromycin and midazolam interact

Back 39

the three together cause excessive sedation for days.

amiodarone is a a antiarrythmic and cyp3A4 inhibitor and p-glycoprotien pump inhibitor

erythromycin is a macrolide antibiotic and has the same actions as amiodarone.

midazolam is a iv sedative/anesthetic benzodiapine which is eliminated by cyp3A4

Midazalam along with amiodarone and erythomycin, inhibits midazalam elimination and inc conc of drug causing inc action of sedation

Front 40

how does statins and grapefruit interact?

Back 40

grapefruit consist of a compound called furanocoumarins which inhibits cyp3A4 lasting >24 hr. Pt should not EAT grapefruit when on statin because will cause inc conc of statin leading to rhabdomyolysis

Front 41

drug with moa which inhibit efferent limb of immune system

Back 41

anti-inflammatory effects of glucocorticoids such as cortisol

Front 42

drug with following ae:

a. Cataracts (an early sign of intoxication)
b. Hyperglycemia and diabetes
c. Thinning of the skin
d. Edema
e. Peptic ulcer
f. Osteoporosis
g. Athersclerosis
h. Psychosis
i. Impaired wound healing
j. Susceptibility to infection
k. Iatrogenic Cushingoid state
l. Atrophy of the adrenal gland

Back 42

adverse effects of glucocoritcoids

Front 43

what COX? is found in the stomach, platelets and many other tissues?

Back 43

COX1

Front 44

What COX? is involved in inflammation (e.g. macrophages), the vascular
endothelium and the renal juxaglomerular apparatus

Back 44

COX 2

Front 45

What NSAID is NOT a good choice to tx gout and why?

Back 45

Aspirin bc inc levels of uric acid

Front 46

what drug has the following se?

central effects including tinnitus, vertigo and hyperventilation leading to respiratory alkalosis

Back 46

Aspirin

Front 47

Extensively metabolized in the liver, and in overdose, metabolites can cause irreversible and fatal hepatotoxicity and renal toxicity.

Prompt treatment with acetylcysteine reduces hepatotoxicity.

Back 47

Acetaminophen (Tylenol)

Front 48

drugs which have serious hematological (rarely agranulocytosis, aplastic anemia) and renal (more commonly acute renal failure, intersitial nephritis, nephrotic syndrome).

Back 48

Ibuprofen (Advil), naproxen (Aleve), fenprofen, ketoprofen and others are
phenylpropionic acid derivatives

Front 49

significantly lower incidence of gastric irritation than the non-selective drugs

Back 49

celecoxcib

Front 50

decrease the effectiveness of diuretics, beta-blockers and
ACE inhibitors and may increase the toxicity of methotrexate and lithium

Back 50

NSAIDS

Front 51

converted to 6-mercaptopurine, an inhibitor of several steps in purine interconversions that inhibits DNA synthesis

Back 51

Azathioprine (Imuran)

Front 52

anti-estrogen agent that undergoes hepatic metabolism to an active compound that inhibits dihydroorotate dehydrogenase

Diarrhea, hair loss and hepatic damage can occur

Back 52

Leflunomide (Arava)

Front 53

a fusion protein consisting of human TNF receptors and the Fc fragment of IgG.

effective forms of therapy against RA

Back 53

Etanercept (Enbrel)

Front 54

chimeric human-mouse monoclonal anti-TNF that
also reduces symptoms by inactivating TNF after intravenous injection

effective forms of therapy against RA

Back 54

Imfliximab (Remicade)

Front 55

effective therapy against RA

-used against a variety of other diseases ranging from anklosing spondylitis to psoriasis to ulcerative colitis.

Back 55

Tumor Necrosis Factor alpha (TNF) Inhibitors

Etanercept (Enbrel)
Imfliximab (Remicade)
Adalimumab (Humira)

Front 56

Opportunistic infections including tuberculosis may occur

Back 56

Tumor Necrosis Factor alpha (TNF) Inhibitors

Etanercept (Enbrel)
Imfliximab (Remicade)
Adalimumab (Humira)

Front 57

drug used in patients that have failed to respond to anti-TNF drugs in tx of RA

Back 57

Abatacept (Orencia)

Front 58

a chimeric monoclonal antibody that targets CD20 B-cell antigen.

approved for use with methotrexate against a variety of autoimmune diseases including rheumatoid arthritis that is resistant to anti-TNF agents

Back 58

Rituximab (Rituxan)

Front 59

an inhibitor of xanthine oxidase. It inhibits both steps in the synthesis
of urate.

-given chronically to prevent attacks and is of no value in relieving acute gouty attacks

Back 59

Allopurinol

Front 60

binds to tubulin in leukocytes and reduces both their mobility and ability to
undergo phagocytosis

->only used for short periods to control acute attacks

Back 60

Colchicine

Front 61

may precipitate acute gout when it is first administered (dissolution and reformation of urate crystals).

Back 61

Allopurinol

Front 62

inhibits both actively excreted and reaccumulated urate which results in a net loss of urate

Back 62

Probenicid

Front 63

can cause an increase in BMD - bone mass density

-associated with bloating, bleeding and breast tenderness as well as an increased risk for thromboembolism

Back 63

Estrogen

Front 64

None of these drugs is well absorbed by mouth, and their absorption is hindered by calcium supplements.

About half of the absorbed dose is bound to bone, and the remainder is lost unchanged in the urine.

Back 64

Bisphosphonates

alendronate (Fosamax), ibandronate and risedronate

Front 65

used against iatrogenic osteoporosis caused by glucocorticoids, male osteoporosis and in higher doses, against Paget’s disease

Back 65

Alendronate

Front 66

most frequent untoward effects are heartburn, esophageal irritation, diarrhea and GI effects.

Back 66

orally administered bisphosphonates

To reduce damage to the esophagus, patients must take the drug with water in an upright position and maintain this position for an hour

Front 67

the N-terminal 34 amino acids of PTH.

Like PTH it stimulates bone formation, and it has been approved for treatment of severe osteoporosis in both men and women

Back 67

Teriparatide

Front 68

insulin type?

solution of monomeric insulin -- rapid absorption.

Back 68

Soluble or regular insulin

Front 69

insulin type?

intermediate-acting – insulin mixed with protamine to slow
absorption.

Back 69

NPH insulin

Front 70

insulin type?

slow absorption – amorphous insulin zinc suspension

Back 70

Lente insulin

Front 71

insulin type?

very slow absorption -- insulin zinc suspension

Back 71

Ultralente insulin

Front 72

insulin type?

most soluble and most rapid-acting form -- mutations introduced into the human insulin B chain diminish insulin selfassociation.

Back 72

Lispro and aspart insulin

Front 73

finely powdered regular insulin self administered using bong-like inhaler device

Avoids insulin injections. Rapid onset, similar to sub-cutaneous injections of rapid-acting lis-pro insulin. Since there are no slow-acting forms of inhaled insulin, night-time injections of lente insulin are still required.

Back 73

Inhaled insulin – EXUBERA (Pfizer)

Front 74

traditional oral anti-diabetic – insulin secretagogues

Back 74

Sulfonylureas

the first drugs used therapeutically include tolbutamide and
chlopropamide. Examples of the second generation which are approximately 100-fold more potent include glyburide (DIABETA) and glipizide (GLUCOTROL).

Front 75

a biguanide – first-line drug of choice – lowers insulin resistance, particularly in the liver –reduces appetite.

Back 75

Metformin

Front 76

used for advanced T2DM patients with diminished β cell function

Back 76

Insulin

Front 77

lower insulin-resistance, potentiation of insulin action on peripheral tissue

primary site of action is agonistic binding to peroxisomal proliferator activator receptoer (PPAR)

Back 77

Thiazolinediones – 'glitazones': rosiglitazone and pioglitazone

Front 78

insulin secretagogues, act like sulfonylureas by inducing insulin secretion through closure of ATP-sensitive K channel, but have very rapid action and short duration

Back 78

'Glitinides' - repaglinide and nateglinide

Front 79

gila monster GLP-1 – insulin secretagogue – induces beneficial weight-loss.

Back 79

Exenatide

Front 80

agents bind to the ATP-sensitive K+ channel reducing its conductance. As a result, the β cell depolarizes and consequently induces all the
downstream events involved in the normal regulation of insulin secretion

Back 80

Sulfonylureas

glyburide (DIABETA) and glipizide (GLUCOTROL).

Front 81

T2DM drug with ae of anorexia, nausea, vomiting, abdominal discomfort, diarrhea, and lactic acidosis and contrindicated for pt with renal disorders

Back 81

metformin (GLUCOPHAGE®),a BIGUANIDES

Front 82

T2DM drug with Benefits of:
1. No hyploglycemia risk.
2. Associated anorexia may lead to weight loss.

Back 82

metformin (GLUCOPHAGE®),a BIGUANIDES

Front 83

insulin secretogogues, the risk of induced hypoglycemia is low
since, unlike the sulfonylureas, the GLP-1-induced insulin release also requires the presence of high blood glucose levels

Back 83

Incretins

Front 84

drug for T2DM

Actions:
1. Induces insulin releases
2. Depresses glucagon releases
Together, these first two actions blunt the post-prandial (following meals) glucose surge.
3. Delays gastric emptying – blunts appetite – associated with significant weight loss.

Back 84

Exenatide (BYETTA)

Front 85

adverse effects: Cancers & Cardiovascular diseases

Back 85

Postmenopausal Hormone Replacement Therapy

Front 86

Alternative therapies for managing menopausal symptoms

Back 86

1. Phytoestrogens (e.g. isoflavones) in the natural products
2. Lifestyle Modifications:
Lower core body temperature, relaxation techniques, stop smoking, weight loss

Front 87

increase the risk of endometrial and cervical cancer, this risk is reduced with the combination preparation.

Back 87

Estrogen only contraceptive

Front 88

Adverse reactions: cardiovascular and tumor

Cardiovascular effects: less than 35 years old, non-smoking women

Back 88

Hormonal Contraception
(1) Combinations of Estrogens and Progestins (Oral)

(2) Progestin alone (oral or implanted)

Front 89

These agents can induce the metabolism of oral contraceptives and
decrease their effectiveness

Back 89

1. Antibiotics such as rifampin, penicillin, and tetracycline
2. Anti-HIV agents
3. Anti-epileptic drugs
4. Saint John’s Wort

Front 90

Competitive Inhibitor, competing for Progestin receptors

Terminate early pregnancy when combine with prostaglandin

Back 90

Mifepristone (RU486)

a Progesterone antagonist

Front 91

a partial agonist Competitive inhibitor, Estrogen receptors, Breast cancer (palliative treatment)

Back 91

Tamoxifen

a Estrogen antagonist

Front 92

a partial agonist Competitive inhibitor, Stimulate ovulation (Infertility)

Back 92

Clomiphene

a Estrogen antagonist

Front 93

the gold standard of care for patients with estrogen-receptor-positive cancers (majority of breast cancer patients)

Back 93

Tamoxifen

Front 94

estrogen synthesis inhibitors that have recently been demonstrated for their effectiveness for replacing the clinical use of Tamoxifen in postmenopausal patients

Back 94

anastrozole, letrozole, and exemestane

Aromatase inhibitors

Front 95

Reverse protein loss after Trauma, Surgery, or Prolonged Immobilization (negative nitrogen balance was observed in these patients, anabolic activity of androgens can improve the nitrogen balance)

Back 95

protein Anabolic Agents

Front 96

used in the palliative treatment of prostate cancer since its action on the hypothalamus, can inhibit androgen secretion

Back 96

Diethylstibestrol

Front 97

In Women: masculinization, menstrual irregularity due to LH & FSH suppression, male pattern baldness during pregnancy, masculinization of female fetus

Back 97

Adverse effects of Androgens

Front 98

In Children: disturbances in growth and bone development

Back 98

Adverse effects of Androgens

Front 99

In Men: azoospermia due to the inhibition of gonadotropin secretion and the conversion of excess androgens to estrogens

Back 99

Adverse effects of Androgens

Front 100

a GnRH analog, as effective in the tx of prostate cancer and has fewer side effects (used in conjunction with antiandrogen).

Back 100

leuprolide

Front 101

These processes result in reduced transcription of the early cytokine gene Il-2 as well as Il-3, Il-4, TNF-a, interferon gamma, and GM-CSF.

These effects lead to a dose dependent inhibition of lymphokine production after the TcR-CD3 complex and other cell surface receptors are engaged.

These drugs are not effective in halting the amplification of the immune response after activation.

Back 101

cyclosporin A (Neoral®, Sandimmune) is a lipophilic cyclic decapeptide

tacrolimus (Prograf) is a macrolide antibiotic

Both drugs are fungal derived and bind with high affinity to a family of cytoplasmic proteins present in most mammalian cells.

Cyclosporine binds cyclophilins

tacrolimus binds FKBPs (FK binding proteins).

Front 102

drugs are potent inhibitors of the prolactin gene that can act as an immunoactivator.

Back 102

Cyclosporine and tacrolimus

CALCINEURIN-INHIBITING AGENTS

Front 103

preferred in liver transplantation as cyclosporine is partially dependent on bile salts for absorption

Back 103

Tacrolimus

Front 104

HMG CoA reductase inhibitors can have elevated levels when used with ____?____ (a calcineruin - inhibiting agent) thus predisposing the user to rhabdomyolysis.

Back 104

cyclosporine

Front 105

most significant and common side effect limiting the
widespread use of cyclosporine and tacrolimus, both calcinurin - inhibiting agents

Back 105

NEPHROTOXICITY

Front 106

occurs within the first few weeks of cyclophilins and tacrolimus use and is mediated by the sodium retention and vasoconstriction caused by these agents.

Back 106

HYPERTENSION

Front 107

interferes with signal transduction of the second signals during the G1 phase delivered by Il-2, Il-4 or Il-6.

Back 107

sirolimus

a non-calcinurin-inhibiting agent

Front 108

major side effects of a non - calcinurine inhibiting agents are dyslipidemia and thrombocytopenia.

Back 108

sirolimus

Front 109

some concerns regarding a synergistic nephrotoxicity with cyclosporine or tacrolimus.

Back 109

sirolimus

Front 110

immunosuppressive agents which are eliminated by cyp3A4

Back 110

sirolimus, cyclosporine and tacrolimus

Front 111

decreasing intracellular purine synthesis, RNA production is decreased. This results in a decrease in B and T lymphocyte numbers, decreased immunoglobulin production and decreased Il-2 secretion.

Back 111

azathioprine (Imuran®)

Front 112

used as a maintenance immunosuppressive agent in organ transplantation and can be used in therapy of autoimmune disorders after a response has been established by more toxic agents (such as cyclophosphamide).

Back 112

azathioprine (Imuran®)

Front 113

immunosuppressive agent with major complications of myelosuppression, anemia, and alopecia

Back 113

azathioprine (Imuran®)

Front 114

potentially lethal interaction with allopurinol can lead to bone
marrow aplasia as allopurinol blocks the metabolism of ____?____ by xanthine oxidase

Back 114

azathioprine (Imuran®)

Front 115

structural analogue of folic acid that can competitively and irreversibly binds to the enzyme dihyfofolate reductase (DHFR) that reduces dihydrofolic acid (FH2) to the active intracellular
metabolite folinic acid (FH4).

Back 115

Methotrexate

Front 116

The common side effects of a immuosuppressive agent include gastrointestinal
upset, stomatitis, alopecia, macrocytosis, and CNS problems such as fatigue, headaches and loss of concentration.

Back 116

methotrexate

Front 117

immuosuppressive agent toxicity can be severe and even fatal

Back 117

methotrexate

Front 118

an antimetabolite derived from nitrogen mustard

widely used in the treatment of severe, life threatening autoimmune diseases and inflammatory diseases such as systemic lupus erythematosus, Wegener’s granulomatosis, vasculitis, and refractory rheumatoid arthritis.

Back 118

Cyclophosphamide

Front 119

Barbiturates, alcohol, phenytoin, and rifampin may accelerate metabolism to the active forms and increase toxicity.

While drugs that inhibit microsomal enzymes such as corticosteroids, antimalarials, tricyclic antidepressants, and allopurinol may decrease metabolism and decrease toxicity or immunosuppressive

Back 119

Cyclophosphamide

Front 120

what drug interacts with succinylcholine possibly causing prolonged neuromuscular blockade?

Back 120

Cyclophosphamide

Front 121

Side effects include alopecia, nausea and vomiting, anaorexia, diarrhea, stomatitis and mucositis. It may cause sterility and gonadal suppression.

Congestive heart failure and pulmonary toxicity (pneumonitis and fibrosis) are potentially fatal complications associated with high-dose, prolonged therapy.

Back 121

cyclophosphamide

Front 122

Lymphocyte proliferation and response to antigenic or mutagenic stimulation is thus depressed in the presence of
______?________.

Back 122

Mycophenolate mofetil
(CellCept®)

Front 123

Prodrug inhibitor of pyrimidine synthesis – rather than purine synthesis.
Drug is orally active. Currently approved for rheumatoid arthritis.

Back 123

LEFLUNOMIDE

Front 124

least likely to activate TB?

A. Abatacept (Orencia)
B. Etanercept (Enbrel)
C. Infliximab (Remicade)
D. Adalimumab (Humira)
E. Hydroxychloroquine

Back 124

E. Hydroxychloroquine

Front 125

Less gastric irritation is an advantage this drug has over nonselective NSAIDs

Back 125

Celecoxib (Celebrex) is a selective COX 2 inhibitor

Front 126

the best choice to reduce the level of urate in blood during first attack of
gouty arthritis

Back 126

Probenicid

Front 127

drugs causes human B-lymphocytes to die

Back 127

Rutuximab (Rutuxin)

Front 128

drug used to tx osteoporosis in man due to chronic use of corticosteriod

Back 128

Alendronate (Fosamax)

Front 129

used as the adjuvant treatment for male patients with estrogen receptor-positive breast cancer because inhibits the synthesis of estrogen in the patients.

Back 129

Aromatase inhibitor (AI) such as anastrozole, letrozole, or exemestane

Front 130

drug used for high risk estrogen receptor-positive breast cancer because of competitive antagonist acting at estrogen receptor

Back 130

Tamoxifen

Front 131

drug used along with methimazole to treat the cardiovascular effects of hyperthyroid patient

Back 131

Propranolol

Front 132

what drug combination in hyperthyroid pt would cause hypertensive crisis

Back 132

Epinephrine and Propranolol

Front 133

what drug combination would result in muscle aches along with the grossly elevated muscle enzyme levels in the serum and the dark urine are indicative of rhabdomyolysis

Back 133

Simvastatin – amiodarone

bc both are metabolized by cyp3A4

Front 134

- Time, amount, emesis, scenario
- Others ill?
- What other meds/products are possible?
- Reason for ingestion?
- Acute-on-chronic?
- Product identification
- Friends, family, EMS, police
- Search patient, retrieve containers
- PMH, social, medications, allergies

Back 134

key historical points to be obtained from poisoned pt or witness

Front 135

- ↑ pulse
- ↑ blood pressure
- ↑ respirations
- ↑ temperature
- ↓ bowel sounds
- Altered mental status (picking, Lilliputian speech)
- ↑ pupils
- Dry, hot, flushed skin
- Other: Urinary retention

Back 135

Anticholinergic Toxidrome

Front 136

- ↑ pulse
- ↑ blood pressure
- ↑ respirations
- ↑ temperature
- ↔ bowel sounds
- Altered mental status
- ↑ pupils
- Diaphoresis
- Other: bruxism

Back 136

Sympathomimetic Toxidrome

Front 137

- ↓ pulse
- ↔ blood pressure
- ↔ respirations
- ↓ temperature
- ↑ bowel sounds
- ↔ mental status
- ↓ pupils
- Diaphoresis
- Other: fasciculations, weakness, odors
- (diarrhea, urination, miosis, bronchorrhea, bronchospasm, emesis, lacrimation, salivation)

Back 137

Cholinergic Toxidrome

Front 138

- ↓ blood pressure
- ↓ pulse
- ↓ respirations
- ↓ temperature
- ↓ bowel sounds
- ↓ mental status
- ↓ pupils
- Diaphoresis
- Other: track marks

Back 138

Opioid Toxidrome

Front 139

- EKG
- Urinalysis
- Bedside tests:
- Methemoglobinemia
- Urine ferric chloride
- Wood’s lamp

Back 139

Diagnostic Laboratory studies important in dx various poisoning

Front 140

- Methanol / metformin
- Uremia
- Diabetic ketoacidosis / AKA
- Paraldehyde / phenformin / propylene glycol
- Isoniazid / iron
- Lactate
- Ethylene glycol
- Salicylates

Back 140

these agents cause an inc in anion gap

Anion Gap = Na – (HCO3 + Cl)

Front 141

- Salicylates
- Phenobarbital
- Toxic alcohols
- Lithium

Back 141

compounds that can be removed with hemodialysis

Front 142

- Ion trapping
- Hemodialysis
- Hemoperfusion
- Multi-dose charcoal
- Hyperbaric oxygen
- Antidotes

Back 142

ways to enhance toxic elimination

Front 143

antidote for digoxin

Back 143

digibind

Front 144

antidote for carbon monoxide

Back 144

oxygen

Front 145

antidote for cyanide

Back 145

CAK

The Cyanide Antidote Package (also known as the Cyanide Antidote Kit (CAK), the Lilly Kit, the Pasadena Kit, and the Taylor Kit) is the only antidote currently available in the United States.

The CAK can be associated with
toxicities including Hypotension, which can Exacerbate shock, and methemoglobinemia, which reduces the oxygen-carrying capacity of the blood and can be particularly dangerous in oxygen-deprived victims of smoke-halation.

Front 146

antidote for heroin

Back 146

naloxone

Front 147

antidote for Methemoglobinemia

Back 147

Methylene Blue

Front 148

- Skin / Eye decontamination
- Gut decontamination
- Activated Charcoal
- Cathartics
- Whole bowel irrigation

Back 148

ways to reduce absorption of toxin

-reduce toxin load

Front 149

- Binds material
- Interrupts enterohepatic recirculation
- Gut dialysis
- Initial dose 1 gram/kg
- Not all substances adsorb

Back 149

actions of activated charcoal

Front 150

- Corrosive injury to esophagus or GI tract
- Intestinal obstruction
- Ileus

Back 150

activated charcoal contraindications

Front 151

- Massive amount of toxin
- Metals
- Sustained release products
- Concretions
- Body packers

Back 151

indications for whole bowel irrigations

Front 152

- Inadequate airway protection
- Obstruction
- Ileus
- Perforation

Back 152

whole bowel irrigation contraindications

Front 153

- Unprotected airway
- Ingestion of corrosive substance

Back 153

gastric lavage contraindications

Front 154

- Life-threatening amount of toxic substance within 60-90 minutes of ingestion

- Altered mental status or critically ill patient within 60-120 minutes of ingestion

- Later, if concretions, delayed gastric emptying, or sustained-release

Back 154

Gastric Lavage Indications

Front 155

- Primary role is decontamination in home setting

- Max effectiveness only when within 60 minutes

- Only given upon advice of PCC or HCP

Back 155

Ipecac Indications

Front 156

- Age less than one year
- Absence of a gag reflex
- CNS depression
- Ingestion of CNS acting agent
- Corrosive agent
- Ingestion of cardiac depressant

Back 156

Ipecac Contraindications

Front 157

Increases the time to administration of charcoal once the patient is in the emergency department

Back 157

Ipecac

Front 158

- Aspiration
- Esophageal perforation/ spasm
- Hypothermia / electrolyte imbalance
- Epistaxis / GI bleeding
- Instillation of charcoal into the lungs

Back 158

Gastric Lavage Complications

Front 159

ae of rosiglitazone and pioglitazone, both thiazolidinediones

Back 159

edema and potentially hepatotoxicity

Front 160

ae seen in 79 yr old women with CAD present with nausea, vomitting and abd pain 3 days ago. Pt on warfarin, furosemide, digoxin, captopril, vit E and multivit.

what happened?

Back 160

furoseminde is a loop dieurtic with ae of hypokalemia.

Hypokalemia produces digoxin toxicity manifested by gi sx

Front 161

88 yr old male pt during last 1 mo deteriorating ability to perform daily activity and develop urinary incontinence

drugs:
terazosin, timolol eye drops, temazepan, tylenol, lisinopril and sleep aid (diphenhydramine) - otc

pe: mild bladder distention and MMSE = 20/30

Back 161

diphenhydramine anti-chol causes
1. perpherally, causes urinary retention and incontinence

2. centrally causes acute confusional state

Front 162

102 yr old women with osteoarthritis started taking ibuprofen instead of tylenol and developed inc in BUN and creat

Back 162

nsaids inc renal toxicity from reduction of renal prostaglandin formation

-> with inc age inc risk

drug-organ toxicity

Front 163

88 yr old male pt during last 1 mo deteriorating ability to perform daily activity and develop urinary incontinence

drugs:
terazosin, timolol eye drops, temazepan, tylenol, lisinopril and sleep aid (diphenhydramine) - otc

pe: mild bladder distention and MMSE = 20/30

Back 163

diphenhydramine anti-chol causes
1. perpherally, causes urinary retention and incontinence

2. centrally causes acute confusional state

Front 164

85 year old man with hx of demential and seizures disorder presents w/ inc confusion and inc fall

med: donepezil and phenytoin

pe: muscle wasting, MMSE = 17/30, ataxic gait

lab: low alb and normal phenytoin levels

Back 164

total phytoin is both free and bound but the look at the free alone there is an increase in free phenytoin due dec albumin

Front 165

86 yr old femail DM pt with also HTN, CAD, depression, OA, GERD, and glaucoma

hx & pe: CHF

med: insulin, enalapril, furoseminde, metoprolol, aldactone, digoxin, ranitidine, clecoxib, sertaline, asa, & various eye drops

Back 165

pt cant afford her meds so her disease is beginning to be exacerbated, esp in this case CHF

Front 166

Explain why celecoxib causes less gastric irritation than
aspirin. Why is aspirin a better thrombolytic agent?

Back 166

less inhibition of Cox-1 with celecoxib(cox-2 inhibitor), asa accumulate in mucosa and does inhibit cox-1 and cox-2

Front 167

What are imfliximab and rituximab, and what are their
mechanisms of action in chronic inflammatory diseases
like rheumatoid arthritis?

Back 167

moa: scavenger of TNF-a

action by help regress disease

tx:
1. nsaids or celecoxib
2. methotrexate
3. remicade or entercept

if these dont work then use rituximab is an Antibody against CD 20

containdicated for latent TB

Front 168

How do allopurinol and probenecid lower blood urate?

Back 168

allopurinol acts by inhibit xanthine oxidase so less urate formed

probenecid acts by preventing the secretion of and reuptake of uric acid, at high doses

asa - acts like probenicid but only prevents secretion but at very high does inhibit reuptake, so that is why pt with gout should not take asa, does not block both actions at normal doses

Front 169

A serious adverse effect that may occur with a single
therapeutic dose of one aspirin tablet is
(A) infertility
(B) hepatotoxicity
(C) nephrotoxicity
(D) bronchial asthma
(E) hemolytic anemia

Back 169

A serious adverse effect that may occur with a single
therapeutic dose of one aspirin tablet is
(A) infertility
(B) hepatotoxicity
(C) nephrotoxicity
(D) bronchial asthma
(E) hemolytic anemia

D rare genetic condition in which inhibition of COX
shunts arachidonic acid through lipoxygenase to form
leukotrienes that provoke severe asthma

Front 170

Which of the following agents used to prevent organ transplant rejection is
most likely to cause significant bone marrow suppression?
A. anti-lymphocyte globulin
B. cyclosporine (Sandimmune®)
C. prednisone
D. sirolimus (Rapamune®)
E. tacrolimus (Prograf®)

Back 170

Which of the following agents used to prevent organ transplant rejection is
most likely to cause significant bone marrow suppression?
A. anti-lymphocyte globulin
B. cyclosporine (Sandimmune®)
C. prednisone
D. sirolimus (Rapamune®)
E. tacrolimus (Prograf®)

Answer:
D. sirolimus

Front 171

Which of the following correctly matches an
immunosuppressant agent with its mechanism of action?
A. tacrolimus – inhibition of activation of T cell
transcription factors for cytokine expression
B. cyclosporine – prevention of clonal expansion of T and
B lymphocytes
C. cyclophosphamide - inhibition of antigen presentation
D. azathioprine – negative regulation of T cell expression of lymphokines
E. prednisone – inhibition of IMP dehydrogenase

Back 171

Which of the following correctly matches an
immunosuppressant agent with its mechanism of action?
A. tacrolimus – inhibition of activation of T cell
transcription factors for cytokine expression
B. cyclosporine – prevention of clonal expansion of T and
B lymphocytes
C. cyclophosphamide - inhibition of antigen presentation
D. azathioprine – negative regulation of T cell expression
of lymphokines
E. prednisone – inhibition of IMP dehydrogenase

Answer:
A tacrolimus inhibits nuclear translocation of NFAT

Front 172

Which of the following associates the correct mechanism of action with a
drug used in type 2 (non-insulin dependent) diabetes?
A. acarbose - reduction of insulin resistance
B. glipizide - inhibition of intestinal alpha-glucosidase
C. metaformin - inhibition of ATP-sensitive potassium channels
D. repaglinide - modulation of pancreatic insulin release
E. rosiglitazone - reduction in circulating glucagon levels

Back 172

Which of the following associates the correct mechanism of action with a
drug used in type 2 (non-insulin dependent) diabetes?
A. acarbose - reduction of insulin resistance
B. glipizide - inhibition of intestinal alpha-glucosidase
C. metaformin - inhibition of ATP-sensitive potassium channels
D. repaglinide - modulation of pancreatic insulin release
E. rosiglitazone - reduction in circulating glucagon levels

Answer:
D . repaglinide modulates pancreatic insulin release, binds like sulfonylureas but has a second binding site that may do other
functions.
correct answer for other choices:
a. acarbose - reduce intestial absorption of glucose
b. glipizide - stimulate insulin release from pancreas
c. metformin - lowers insulin resistance and reduces appetite
e. rosiglitazone - agonist binding to PPAR-gamma, reduce insulin resistance

Front 173

Which of the following insulin regimens most closely mimics insulin
release from a normally functioning pancreas when used in a type 1
diabetic patient?
A. prebreakfast and predinner injections of lente insulin plus an injection
of regular insulin if blood glucose exceeds 150 mg/dl.
B. premeal injections of insulin lispro plus morning and evening
injections of lente insulin
C. premeal injections of neutral protamine hagedorn (NPH) insulin plus
an injection of insulin lispro at bedtime
D. postmeal injection of lente insulin plus a prebreakfast injection of
regular insulin
E. postmeal injections of insulin glargine

Back 173

Which of the following insulin regimens most closely mimics insulin
release from a normally functioning pancreas when used in a type 1
diabetic patient?
A. prebreakfast and predinner injections of lente insulin plus an injection
of regular insulin if blood glucose exceeds 150 mg/dl.
B. premeal injections of insulin lispro plus morning and evening
injections of lente insulin
C. premeal injections of neutral protamine hagedorn (NPH) insulin plus
an injection of insulin lispro at bedtime
D. postmeal injection of lente insulin plus a prebreakfast injection of
regular insulin
E. postmeal injections of insulin glargine

Answer:
B. The lente injections provide a baseline level of insulin and the premeal
injections of quick-acting lispro provide the insulin peaks needed to deal
with dietary intake of carbohydrates

Front 174

inhibition of intestinal alpha-glucosidase

Back 174

acarbose

Front 175

Which of the following drugs reduces LDL-cholesterol by
reducing secretion of VLDL from the liver and also
reduces triglycerides?
A. atorvastatin
B. cholestyramine
C. ezetimibe
D. gemfibrozil
E. niacin

Back 175

Which of the following drugs reduces LDL-cholesterol by
reducing secretion of VLDL from the liver and also
reduces triglycerides?
A. atorvastatin
B. cholestyramine
C. ezetimibe
D. gemfibrozil
E. niacin

Answer:
E. niacin reduces VLDL and LDL

Front 176

Which of the following descriptions best describes the molecular
mechanism of action for the statins?
A. binding to PPAR-gamma receptor to activate lipoprotein lipase
B. increasing fecal excretion of bile acids to increase conversion of
cholesterol to bile acid
C. inhibition of hepatic cholesterol biosynthesis to increase LDL
receptor activity
D. inhibition of cholesterol uptake from the intestinal lumen
E. inhibition of cholesteryl ester transfer protein (CETP)

Back 176

Which of the following descriptions best describes the molecular mechanism of action for the statins?

A. binding to PPAR-gamma receptor to activate lipoprotein lipase
B. increasing fecal excretion of bile acids to increase conversion of cholesterol to bile acid
C. inhibition of hepatic cholesterol biosynthesis to increase LDL receptor activity
D. inhibition of cholesterol uptake from the intestinal lumen
E. inhibition of cholesteryl ester transfer protein (CETP)

Answer:
C. Statins inhibit HMG-CoA reductase to block biosynthesis of
cholesterol in hepatocytes. Lowered intracellular cholesterol activates
transcription of the LDL receptor gene. After translation, the
increased LDL receptor activity allows greater uptake of LDL from the
circulation.

Front 177

A 45-year-old woman who is being treated for hypertension
and hypercholesterolemia develops diffuse
muscle pain and weakness. Serum creatine kinase
activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?
(A) Captopril
(B) Hydrochlorothiazide
(C) Lovastatin
(D) Nicotinic acid
(E) Propranolol

Back 177

A 45-year-old woman who is being treated for hypertension
and hypercholesterolemia develops diffuse
muscle pain and weakness. Serum creatine kinase
activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?
(A) Captopril
(B) Hydrochlorothiazide
(C) Lovastatin
(D) Nicotinic acid
(E) Propranolol

Answer:
C

Front 178

For lipid-soluble drugs, which of the following apply to
elderly patients as contrasted to younger adults? More
than one may be correct.
A. volume of distribution is larger
B. half-life is longer
C. % body fat is greater
D. liver is smaller
E. liver blood flow is lower
F. Phase I metabolism activity is lower
G. Phase II metabolism is unchanged
f(D/T) = Css * Vd * (0.693/t1/2)

Back 178

For lipid-soluble drugs, which of the following apply to elderly patients as contrasted to younger adults? More than one may be correct.
A. volume of distribution is larger - true
B. half-life is longer - yes for lipid soluble drug
C. % body fat is greater - true, reason why vol of dist inc
D. liver is smaller - true, less capacity to metabolize drug in inc half life
E. liver blood flow is lower - not always true, can be imp if dec CO with CHF, esp for lipid soluble drug bc dec delivery drug to liver
F. Phase I metabolism activity is lower - (oxidation, conjugaion) yes
G. Phase II metabolism (glucoronidation, sulfonazation) is unchanged - true
f(D/T) = Css * Vd * (0.693/t1/2) -> as half life inc more likely to more effect and inc effect so steady state conc are going to be higher in elderly pt compared to younger pt

Front 179

A 72-year old male is being treated for prostate cancer with leuprolide. Which of the following is the correct mechanism of action for leuprolide?

A. inhibitor of 5 alpha -reductase
B. competitive antagonist at androgen receptors
C. competitive inhibitor of LH
D. synthetic analog of GnRH
E. agonist at estrogen receptors

Back 179

A 72-year old male is being treated for prostate cancer with leuprolide. Which of the following is the correct mechanism of action for leuprolide?

A. inhibitor of 5 alpha -reductase
B. competitive antagonist at androgen receptors
C. competitive inhibitor of LH
D. synthetic analog of GnRH
E. agonist at estrogen receptors

Answer:
D. analog of GnRH - chronic treatment inhibits FSH and LH
release which shuts down testosterone synthesis

Front 180

metabolism is saturated and elimination is zero order in overdose

Back 180

aspirin

Front 181

NSAID that causes severe gastric effect

Back 181

indomethacin

Front 182

inhibits both steps in SYNTHESIS of urate

Back 182

allopurinol

Front 183

partial agonist, COMPETITIVE INHIBITOR of estrogen receptors, stimulates ovulation

Back 183

clomiphene

Front 184

sediative drug which takes long to be metabolized in older pts due to inc lipid solubility of the drug and the inc in percent body fat in older pt

Back 184

diazepam