Pharmacy rotation

73. Which of the following is a potential adverse effect associated with unfractionated heparin (UFH)? (A) hyperglycemia (B) hypothyroidism (C) thrombocytopenia (D) excessive cough (E) muscle cramps

73. (C) Heparin-induced thrombocytopenia (HIT) is a potentially serious complication of unfractionated heparin therapy, usually occurring within 4 to 10 days after heparin treatment has started. Fortunately, current estimates show that it is infrequent, occurring in approximately 0.3% to 3.0% of patients receiving UFH for more than 4 days. HIT should immediately be suspected in a patient who develops deep vein thrombosis or pulmonary embolism while receiving UFH.

74. A 31-week-pregnant woman is diagnosed with an uncomplicated urinary tract infection (UTI). Which of the following would be most appropriate in this situation? (A) doxycycline (B) trimethoprim-sulfamethoxazole (C) metronidazole (D) nitrofurantoin (E) levofloxacin

74. (D) Nitrofurantoin has been shown to be a safe and effective drug during pregnancy for treating UTIs. Tetracyclines, fluoroquinolones, and sulfonamides are not recommended for use in pregnancy because of the various risks they pose on the fetus.

83. A 50-year-old man with asymptomatic hyperuricemia is to begin therapy for newly diagnosed hypertension. Which of the following is most likely to increase his serum uric acid levels further and possibly precipitate a gout attack? (A) amlodipine (B) candesartan (C) hydrochlorothiazide (D) metoprolol (E) ramipril

83. (C) Thiazide diuretics can raise plasma levels of uric acid, which can be problematic in patients who already have hyperuricemia or a previous history of gout. Calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, and β-blockers have not been shown to raise plasma levels of uric acid.

84. In addition to insulin and fluid replacement with 0.9% saline, which electrolyte is commonly infused in the type 2 diabetic patient who arrives in the emergency department in a hyperglycemic, hyperosmolar, nonketotic state? (A) bicarbonate (B) potassium (C) calcium (D) magnesium (E) sulfate

84. (B) Insulin not only causes cellular uptake of glucose but also of potassium. Hypokalemia may develop when insulin is infused to correct either a hyperglycemic hyperosmolar state or a diabetic ketoacidosis. Hence, in order to avoid hypokalemia, potassium chloride can be added to a saline solution, as long as the serum potassium is not elevated.

1. A history of which of the following warrants special consideration when initially prescribing levothyroxine? (A) peptic ulcer disease (B) chronic stable angina (C) obesity (D) rheumatoid arthritis (E) parkinsonism

1. (B) Multiple factors influence the initial dose of levothyroxine when used for thyroid replacement therapy, including age, the duration and severity of hypothyroidism, and the presence of certain underlying conditions. Thyroid hormones are known to elevate heart rate and increase cardiac contractility, both of which demand more oxygen utilization by the heart. In hypothyroid patients with a history of chronic stable angina, initial levothyroxine doses are typically smaller and then titrated upward. This regimen prevents a more immediate increase on the heart's workload that could occur with usual doses and minimizes the chances of an exacerbation of angina.

10. Which of the following medications is most appropriate for the treatment of an initial case of acute uncomplicated cystitis in a 23-year-old woman? (A) amoxicillin (B) ciprofloxacin (C) doxycycline (D) azithromycin (E) gentamicin

10. (B) Acute uncomplicated cystitis is predominately caused by E coli. While trimethoprimsulfamethoxazole has been used to treat uncomplicated cystitis in numerous cases, it is becoming more ineffective due to the emergence of resistant strains of E coli. As a result, fluoroquinolones such as ciprofloxacin are now considered the drugs of choice over all other antibiotics. Three-day courses of fluoroquinolones have been shown to be more effective than single-dose therapies.

100. A 24-year-old man is on a 2-injection regimen for his type 1 diabetes mellitus that includes NPH and regular insulin taken before breakfast and then again before dinner. One evening, he has an abnormally light dinner and in the middle of the night, he awakens in a cold sweat with his heart pounding. He obtains a glucometer reading and discovers that his blood glucose is 44 mg/dL. He eats some candy and then goes back to sleep. Immediately after awakening the next morning, his blood glucose is 277 mg/dL. What would be the most appropriate course of action at this time? (A) take the usual morning insulin regimen after breakfast instead of before breakfast (B) decrease the morning NPH dose and leave the morning regular insulin dose unchanged (C) increase the morning NPH dose and leave the morning regular insulin dose unchanged (D) leave the morning NPH dose unchanged and increase the morning regular insulin dose (E) increase both the morning NPH and regular doses

100. (D) Regular insulin is a short-acting insulin that starts working 30 to 60 minutes after administration. Increasing the dose by a few units can help quickly restore a normoglycemic state. NPH is an intermediate-acting insulin, which has an onset of action of 2 to 4 hours. Therefore, adjusting the NPH dose at breakfast time will not correct the morning hyper-glycemia. If the NPH dose was increased, it could cause him to experience hypoglycemia in the middle of the day once it starts to work.

11. Assuming no contraindications, which of the following class of medications is considered the preferred long-term control therapy for persistent asthma? (A) inhaled corticosteroids (B) leukotriene antagonists (C) long-acting B2 agonists (D) methylxanthines (E) muscarinic antagonists

11. (A) Inhaled corticosteroids (eg, beclomethasone, fluticasone, triamcinolone, etc) are the preferred long-term control therapy for persistent asthma in all patients because of their potency and consistent effectiveness. Low- to medium-dose inhaled corticosteroids offer several advantages over other medications, including the ability to reduce bronchial hyperresponsiveness, improve overall lung function, and reduce severe exacerbations that often lead to emergency department visits and hospitalizations.

12. Which of the following type 2 diabetes mellitus medications is correctly paired with its mechanism of action? (A) glimepiride; enhancement of insulin secretion (B) metformin; reduction of postprandial glucagon secretion (C) miglitol; enhancement of insulin sensitivity at skeletal muscle (D) rosiglitazone; inhibition of intestinal sucrase and glucoamylase (E) sitagliptin; enhancement of hepatic insulin sensitivity

12. (A) Glimepiride is an example of a sulfonylurea, which, as a class of medications, enhances the secretion of insulin from pancreatic β-cells. Hence, sulfonylureas are sometimes known as insulin secretagogues. Metformin, a biguanide, enhances insulin sensitivity of both hepatocytes and skeletal muscle cells, by decreasing gluconeogenesis. Miglitol, an α-glucosidase inhibitor, inhibits intestinal enzymes that degrade carbohydrates. Thiazolidinediones (TZDs) or glitazones, such as rosiglitazone, also enhance insulin sensitivity in hepatic and skeletal muscle tissues. Sitagliptin belongs to a relatively new class of type 2 diabetes medications known as DPP-IV (dipeptidyl peptidase 4) inhibitors, which stabilize blood levels of an incretin called glucagon-like peptide-1 (GLP-1). During hyper-glycemia, incretins stimulate insulin secretion and inhibit glucagon secretion. DPP-IV metabolizes incretins. Hence, DPP-IV inhibitors block this enzyme, thereby increasing the level of incretins.

13. Along with diuretic therapy, which of the following agents is considered first-line therapy in a 52-year-old man with hypertension who develops systolic heart failure with an ejection fraction of 30% following a myocardial infarction? (A) diazoxide (B) lisinopril (C) prazosin (D) reserpine (E) verapamil

13. (B) The use of an ACE inhibitor with diuretic therapy is the regimen of choice in hypertensive patients with systolic heart failure and reduced cardiac output. This is based on the fact that ACE inhibitors have demonstrated reduced cardiovascular morbidity and mortality in several studies. ACE inhibitors have also been shown to slow cardiac remodeling, improve cardiac function, and reduce cardiovascular events following a myocardial infarction.

14. A 61-year-old man arrives at the emergency department (ED) suffering an acute myocardial infarction as a result of coronary artery thrombosis. One of the agents administered to the patient is a thrombolytic agent. From the choices below, which drug is a thrombolytic agent? (A) abciximab (B) alteplase (C) warfarin (D) heparin (E) clopidogrel

14. (B) Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both abciximab and clopidogrel are considered antiplatelet agents. Abciximab inhibits the activation of glycoprotein IIb/IIIa receptors on platelets, which helps to reduce platelet aggregation. Clopidogrel blocks adenosine diphosphate (ADP) receptors on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus.

15. A patient on a 16 mg daily dose of hydromorphone is being switched to morphine sulfate for pain control. If 7.5 mg of hydromorphone is equianalgesic with 30 mg of morphine sulfate, what dose of morphine sulfate should be prescribed if you account for 25% cross-tolerance? (A) 30 mg (B) 36 mg (C) 48 mg (D) 64 mg (E) 80 mg

15. (C) Opioid rotation is a common practice of switching a patient from one opioid to another. This typically occurs when patients are not getting sufficient pain relief with one opioid (despite increasing its dose) or are complaining of its side effects. Opioid rotation requires the provider to determine approximate equianalgesic dosing conversions, as different opioids usually have different potencies. In this particular problem, 7.5 mg of hydromorphone is equianalgesic with 30 mg of morphine sulfate. Using this ratio of relative potencies, the first step is to determine how many milligrams of morphine sulfate is equianalgesic with 16 mg of morphine sulfate: Solving for x, the calculation is 64 mg. Solving for x, the calculation is 64 mg. Because of wide ranges in individual responses to the various opioids and also because of potential cross-tolerance between opioids, the calculated dose of the new opioid is typically reduced by at least 25% to ensure safety: 64 mg −16 mg (25% of 64) = 48 mg

16. A 37-year-old woman under your care is diagnosed with bipolar I disorder. As part of her drug regimen, you prescribe lithium carbonate as long-term maintenance therapy. Which of the following would be most appropriate to perform or order prior to the initiation of lithium carbonate? (A) electrocardiogram (B) fasting plasma glucose (C) liver function tests (D) serum creatinine (E) urine culture

16. (D) Patients on chronic lithium carbonate therapy have an approximate 10% to 20% risk of developing renal problems such as glomerulosclerosis, tubular atrophy, or interstitial nephritis. Each of these conditions can lead to filtration problems and a subsequent rise in serum creatinine. Hence, it is advised to obtain a baseline serum creatinine prior to administering lithium carbonate to follow any changes that may occur in renal function during therapy. It is also advised that lithium carbonate be avoided in patients with pre-existing renal disease.

17. One of the most common adverse effects with spasmolytics such as carisoprodol and cyclobenzaprine is their tendency to cause which of the following? (A) rash (B) drowsiness (C) hypertension (D) myalgia (E) hyperglycemia

17. (B) Spasmolytics like carisoprodol and cyclobenzaprine are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute and painful musculoskeletal conditions. Some of the more common adverse effects include drowsiness, dizziness, and dry mouth. These effects appear to be related to the drug's antimuscarinic properties. Patients should be advised not to use these drugs with alcohol or other central nervous system (CNS) depressants, as these combinations can cause significant sedation. Operating machinery or driving a motor vehicle should be avoided while taking carisoprodol or cyclobenzaprine.

18. A 68-year-old man is recently diagnosed with depression associated with the loss of his close sister to an automobile accident. He is currently taking oxybutynin for overactive bladder disease and lisinopril for hypertension. He has no known drug allergies. Which of the following medications would be most appropriate to prescribe for this patient? (A) alprazolam (B) amitriptyline (C) buspirone (D) desipramine (E) fluoxetine

18. (E) Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are usually considered first-line antidepressants due to their relative safeness in overdose and their minimal affinity for muscarinic, α-adrenergic, and hista-mine receptors, thereby causing fewer side effects. Tricyclic antidepressants such as amitriptyline and desipramine produce several adverse effects associated with their antimuscarinic properties (eg, dry mouth, constipation, blurred vision, urinary retention, etc). The patient is already taking the antimuscarinic agent oxybutynin, so a tricyclic antidepressant could attenuate these adverse effects. Orthostatic hypotension is also common with tricyclic anti-depressants, and because the patient is taking lisinopril for hypertension, the risk for a significant drop in blood pressure is high. Buspirone and alprazolam are not indicated for depression.

19. One of the common tendencies associated with antiarrhythmic drugs is their ability to produce "proarrhythmic" effects, which means they ________________ (A) suppress the arrhythmia that they are being used for without any serious adverse effects (B) selectively block certain ion channels in the heart that are responsible for triggering the arrhythmia (C) create a new and often worse arrhythmia in the heart (D) increase the resistance of cardiac cells to premature activation by prolonging the refractory period (E) decrease conduction velocity through the sinoatrial (SA) and atrioventricular (AV) nodes

19. (C) Many antiarrhythmic drugs have the potential for causing new arrhythmias or even worsening arrhythmias for which the drug is indicated. This phenomenon is referred to as a "proarrhythmic" effect. For example, treatment with the class 1A agent quinidine for supraventricular arrhythmias can precipitate torsade de pointes (a form of ventricular tachycardia) in 4% to 8% of patients using the drug because of its ability to prolong the QT interval. Long QT interval syndrome (LQTS) can often lead to an abrupt loss of consciousness and death. It is characterized by QT prolongation accompanied by tachycardia. In patients with LQTS who develop torsade de pointes, the symptoms can range from syncope (where the torsade de pointes stops suddenly) to cardiac arrest (when it results in ventricular fibrillation). Hence, torsade de pointes can have a particularly poor prognosis.

2. Which of the following medications is capable of causing agranulocytosis? (A) insulin (B) metformin (C) methimazole (D) prednisone (E) desmopressin

2. (C) Methimazole is an antithyroid agent known as a thionamide or thiourea drug. It decreases the synthesis of thyroid hormone by inhibiting the oxidation of iodide and the coupling of iodotyrosines. Minor adverse reactions include skin rash, nausea, vomiting, and drowsiness. The main risk of thionamides, however, is agranulocytosis, with the incidence varying between 0.5% to 6.0%. Patients who receive methimazole should be closely supervised and cautioned to report immediately any evidence of illness, including sore throat, skin eruptions, fever, headache, or general malaise. In such cases, methimazole should be discontinued and white blood cell and differential counts should be made to determine whether agranulocytosis has developed. Because the onset is sudden, routine monitoring is not required. It is particularly important for the patient to carefully monitor for signs and symptoms during the early stages of methimazole therapy, because methimazole-induced agranulocytosis usually occurs within the first 3 months of therapy.

20. Taking aspirin or ibuprofen 30 to 45 minutes prior to taking ____________ often helps to blunt intense flushing and may increase patient compliance. (A) atorvastatin (B) warfarin (C) niacin (D) ezetimibe (E) metformin

20. (C) Of all the therapeutic agents currently on the market, niacin has the greatest potential to raise high-density lipoproteins (HDL-C), often by as much as 25% to 35%. The amount of niacin needed to achieve this therapeutic effect is very high compared to the recommended daily allowance (RDA) for niacin (3.0 to 4.5 g/day vs 20 mg/day). Unfortunately, compliance with niacin therapy is low because of intense (yet harmless) flushing of the skin that is quite similar to hot flashes experienced in many post-menopausal women. Aspirin and other NSAIDs can often blunt this prostaglandin-mediated response to high doses of niacin, as their mechanism of action is to decrease prostaglandin synthesis.

21. A 24-year-old man presenting to the clinic 1 week ago was diagnosed with depression and subsequently prescribed 10 mg/day of fluoxetine. He unexpectedly shows up today and states that he is not experiencing any improvement since starting the medication. What is the best treatment option at this time? (A) double the dose of fluoxetine to 20 mg/day (B) maintain the current dose of fluoxetine and comfort the patient that the medication may still take at least 1 to 2 more weeks to work (C) discontinue the fluoxetine and start sertraline (D) discontinue the fluoxetine and start amitriptyline (E) maintain the current dose of fluoxetine and add phenelzine to the medication regimen

21. (B) Alleviation of symptoms associated with depression is typically slow in onset following initiation with SSRIs. Fluoxetine, for instance, can take anywhere between 2 to 6 weeks to achieve substantial benefit when used for depression. After just 1 week of therapy, there is little justification to increase the current dose or switch to another SSRI such as sertraline. Switching the patient to a TCA such as amitriptyline at this point would further delay symptom relief, as TCAs can take several weeks to produce improvement. Compared to SSRIs, TCAs are also more likely to create unwanted side effects such as weight gain, orthostatic hypotension, and constipation. Combining an SSRI with a monoamine oxidase inhibitor (MAOI) such as phenelzine can cause serotonin syndrome that can be lethal. In order to avoid interaction between SSRIs and MAOIs, it is recommended that at least 4 to 5 weeks pass after discontinuing one and starting the other.

22. Assuming no contraindications to their use, which of following are the antihypertensives of first choice for treating hypertension in the type 2 diabetic patient? (A) angiotensin converting enzyme inhibitors (B) Ca+2 channel blockers (C) β-blockers (D) thiazide diuretics (E) α-receptor blockers

22. (A) Aggressive treatment of hypertension in diabetic patients is essential in preventing many comorbidities, including nephropathy, myocardial infarction, and stroke. The American Diabetes Association (ADA) currently recommends the use of ACE inhibitors as first-line agents for the treatment of hypertension in diabetic patients. This recommendation is based on a number of studies that have demonstrated a clinically significant decrease in the development and progression of diabetic nephropathy, a so-called "protective renal effect." The majority of diabetic patients will actually require the use of multiple antihypertensive agents to reach their goal blood pressure, as one medication alone is often ineffective. Whatever combination regimen is selected, it should include an ACE inhibitor. Angiotensin receptor blockers (ARBs) have also recently been shown to have similar "nephroprotective" properties and could be selected in lieu of ACE inhibitor.

41. Drug X is an antiepileptic medication that is labeled as a "CYP2D6 inducer." CYP2D6 enzymes do not metabolize drug X. Drug Y is an antihypertensive medication that is typically metabolized to inactive products by CYP2D6 enzymes. If drugs X and Y are taken simultaneously, a patient will: (A) be at greater risk for having a seizure (B) be at lesser risk for having a seizure (C) likely experience hypertension (D) likely experience hypotension (E) likely experience hypotension and be at greater risk for having a seizure

41. (C) As a CYP2D6 inducer, the antiepileptic medication will stimulate or increase the activity of the enzymes responsible for metabolizing the antihypertensive medication into harmless byproducts. As a result, the patient is more susceptible to having his/her blood pressure elevate, because the dose of the antihypertensive drug is being cleared from the body more quickly.

23. Which of the following medications would be most appropriate for an otherwise healthy 57year-old man seeking relatively quick relief from urinary obstructive symptoms with slight prostatic enlargement due to benign prostatic hyperplasia (BPH)? (A) finasteride (B) doxazosin (C) testosterone (D) desmopressin (E) atropine

23. (B) α1-adrenergic antagonists (blockers) such as doxazosin cause relaxation of the internal urethral sphincter and also decrease prostatic smooth muscle tone. As a result, urinary outflow from the bladder is enhanced and the patient is less likely to experience obstructive symptoms such as weak urine flow, straining to initiate urine flow, dribbling after urination, and the constant feeling of a full bladder. 5α-reductase inhibitors such as finasteride and dutasteride decrease the production of intrapro-static dihydrotestosterone (DHT) by inhibiting the enzyme type II 5α-reductase. Within the prostate, this enzyme converts testosterone into DHT, which causes prostatic enlargement and growth. As a result, 5α-reductase inhibitors shrink the prostate, which subsequently can provide relief of obstructive symptoms. α1-adrenergic antagonists are faster acting in providing symptom relief compared to the 5α-reductase inhibitors, which often take up to 6 months to maximally shrink an enlarged prostate gland. Hence, patients with troublesome symptoms seeking quick relief generally do not prefer 5α-reductase inhibitors. The use of testosterone would not be indicated as this could raise DHT levels and cause further prostatic enlargement. Desmopressin is a synthetic analog of antidiuretic hormone (ADH) and would cause urinary retention, thus exacerbating symptoms. Atropine is a muscarinic antagonist and would also worsen symptoms.

24. Chronic therapy with which of the following medications can potentially lead to abrupt, unpredictable, and transient motor fluctuations (from mobility to immobility) often referred to as the "on-off phenomenon"? (A) cyclobenzaprine (B) diazepam (C) methotrexate (D) levodopa/carbidopa (E) carbamazepine

24. (D) One of the drug therapies used to manage the symptoms of Parkinson disease is the combination of levodopa (L-DOPA) and carbidopa. Levodopa is the precursor to dopamine, which is the neurotransmitter whose decreased concentrations in the substantia nigra lead to symptoms of tremor, rigidity, bradykinesia, and postural instability. Levodopa is converted into dopamine by dopa decarboxylase, an enzyme found within the nervous tissue and also the peripheral circulation. Levodopa is used instead of dopamine because it can cross the blood- brain barrier. While levodopa can improve symptoms, it does not halt progression of the disease. Carbidopa inhibits peripheral dopa decarboxylase, which allows more levodopa to cross the blood-brain barrier instead of being converted into dopamine within the circulation. Carbidopa itself does not cross the blood-brain barrier. A complication that can potentially develop over time with this therapy is the "on-off phenomenon," which is characterized by abrupt, unpredictable, and transient fluctuations in motor symptoms. The patient experiences a good response to therapy during the "on" phase, but then encounters symptoms of their underlying parkinsonism during the "off" period. Dyskinesias can occur in the "on" periods, but overall, mobility is improved.

25. A 5-year-old child with no known drug allergies is diagnosed in your clinic with bilateral acute otitis media. Which of the following is the drug of choice? (A) levofloxacin (B) nitrofurantoin (C) amoxicillin (D) doxycycline

25. (C) First choice antibiotic treatment for acute otitis media includes a 10-day course of amoxicillin (80 to 90 mg/kg/day in two divided doses) or a combination of erythromycin (50 mg/kg/day) and a sulfonamide (150 mg/kg/day). Reasons for amoxicillin therapy include spectrum of activity including both susceptible and intermediate resistant S pneumoniae, safety, cost, and tolerability.

26. Which of the following drugs is indicated for the treatment of anemia associated with chronic renal failure? (A) deferoxamine (B) warfarin (C) protamine sulfate (D) erythropoietin (E) argatroban

26. (D) Erythropoietin (EPO) is a naturally occurring hormone synthesized and secreted by the kidneys. Synthetic forms of EPO include Epogen and Procrit. EPO works at the red bone marrow to stimulate erythropoiesis. In patients with chronic renal failure, EPO production is usually impaired, and this EPO deficiency leads to anemia. Deferoxamine is an ironchelating compound that can be given systemically in situations of iron overdose. Warfarin and argatroban are both anticoagulants and do not typically affect red cell count. Protamine sulfate is a heparin-chelating compound that can be given in cases of heparin overdose.

27. A 57-year-old woman with hypertension and a recent diagnosis of chronic stable angina presents for her quarterly check-up. She is currently treated with metoprolol tartrate 100 mg bid and her blood pressure is 148/88 mm Hg with a pulse of 54 bpm. She has not experienced anginal attacks since being started on metoprolol tartrate 4 months ago. Which of the following is the most rationale approach to managing the patient at this time? (A) add diltiazem to the current medication regimen (B) add ramipril to the current medication regimen (C) discontinue the metoprolol tartrate and start diltiazem (D) discontinue the metoprolol tartrate and start hydrochlorothiazide (E) double the current dose of metoprolol tartrate

27. (B) In combination with β-blocker therapy, evidence demonstrates that ACE inhibitors further reduce cardiovascular risk in patients with coronary disease. Generally, β-blockers are not used in combination with other cardiac depressant drugs such as calcium channel blockers (eg, amlodipine). Discontinuing the patient's β-blocker therapy would be harmful, as the drug is indicated and working well for her chronic stable angina. Abrupt discontinuation of a β-blocker (without tapering) could cause problematic rebound hypertension. Doubling the metoprolol dose would pose a risk of lowering her heart rate below the current 54 bpm. (Saseen and Maclaughlin,

28. Which of the following is considered an osmotic laxative? (A) senna (B) polyethylene glycol (C) docusate sodium (D) methylcellulose (E) loperamide

28. (B) Polyethylene glycol (PEG) is an example of an osmotic laxative that leads to water retention in the bowel. It is often used when complete colonic cleansing is required prior to gastrointestinal endoscopic procedures or colorectal surgeries, and is not recommended for routine treatment of constipation. Senna is a plant derivative found in preparations such as Senokot and Ex-Lax. While the exact mechanism is unknown, it is believed that senna induces peristalsis by directly stimulating the enteric nervous system of the bowel. Docusate is a typical ingredient found in stool softeners, whereas methylcellulose is a plant product used in bulkforming laxatives. Loperamide is not a laxative, but rather an antidiarrheal agent.

29. A 48-year-old man is brought to the emergency department by his sister after suffering from loss of consciousness, followed by muscle rigidity and rhythmic contractions, and then a return to a normal state. When asked about medication use, the patient states he is currently being treated with a drug for depression but cannot remember the name. He claims that he has never had a seizure or seizure-like activity prior to this event. Approximately 6 hours after the first episode, the patient suffers a second one while still in the ED. Which of the following medications is the patient most likely taking? (A) bupropion (B) duloxetine (C) fluoxetine (D) nortriptyline

29. (A) Bupropion has been shown in some patients to cause seizures in a dose-dependent fashion, particularly in those with a history of head trauma or electrolyte abnormalities. Tricyclic antidepressants (eg, nortriptyline), selective serotonin reuptake inhibitors (eg, fluoxetine), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), and monoamine oxidase inhibitors (eg, phenelzine) have not been associated with seizures.

3. A 56-year-old African American woman with moderate asthma and hypertension suffers a mild, ischemic stroke. Prior to this event, her hypertension was controlled with diet and exercise, but her recent blood pressure measurements have averaged 148/90 mm Hg. Which of the following is the most appropriate antihypertensive therapy for this patient considering her history and present medical conditions? (A) Atenolol & lisinopril (B) diltiazem & hydrochlorothiazide (C) diltiazem & hydralazine (D) hydralazine & atenolol (E) hydrochlorothiazide & lisinopril

3. (E) There are two evidence-based antihypertensive regimens for patients with a medical history of ischemic stroke or transient ischemic attack (TIA) to reduce the risk of a recurrent stroke. The first is a combination of an ACE inhibitor with a thiazide diuretic and the second is monotherapy with an angiotensin receptor blocker (ARB). Patients with a history of ischemic stroke should have a blood pressure goal of less than 130/80 mm Hg.

30. A 23-year-old man visits the clinic today for a pre-employment physical. He has a medical history of asthma that is currently being managed prn with a metered-dose inhaler of albuterol. The patient tells you he has been using it daily for the past month due to increased shortness of breath and that it does not seem to be working too well. Which of the following is the most rationale approach to managing the patient at this time? (A) add ipratropium bromide for use on a daily basis and continue albuterol prn (B) add fluticasone for use on a daily basis and continue albuterol prn (C) discontinue the albuterol and prescribe fluticasone for use on a daily basis (D) add methylprednisone for use on a daily basis and continue albuterol prn (E) increase the dose of albuterol and keep using prn

30. (B) The patient is in need of long-term control therapy due to his worsening symptoms. Whenever increased use of a quick-relief medication such as a β2-agonist (albuterol) occurs, it is usually indicative of needing to add a long-term control agent to the therapeutic regimen or to increase the dose of an already prescribed long-term control medication. Inhaled corticosteroids like fluticasone are considered first-line long-term control medications for patients with persistent asthma.

31. A progestin-only contraceptive, or "minipill," would be most appropriate for which of the following patients? (A) a 25-year-old woman in excellent overall health (B) a 28-year-old woman with a history of epilepsy (C) a 32-year-old woman with a history of pelvic inflammatory disease (D) a 37-year-old woman who smokes 2 packs per day and has a history of hypertension (E) a 38-year-old woman with a history of asthma and bronchitis

31. (D) In the majority of cases, a combined hormonal contraceptive (ie, one that contains both an estrogen and progestin) is the preferred method of oral contraception because of its efficacy when used perfectly (>99%). However, for women older than 35 years of age who are smokers or are obese, or who have a history of hypertension or vascular disease, progesterone-only contraceptives are recommended. Ethinyl estradiol (EE), the most common estrogen found in combined hormonal contraceptives, has been associated with an increased risk of myocardial infarction in women older than 35 years of age who are smokers. Additionally, EE has also been shown to cause increases in blood pressure in both normotensive and mildly hypertensive women. Progestin-only contraceptives, however, tend to be less effective than the combined hormonal contraceptives.

32. Which of the following should be used cautiously in patients with chronic pulmonary disease or elevated intracranial pressure (ICP)? (A) morphine sulfate (B) naloxone (C) carbamazepine (D) methylphenidate (E) verapamil

32. (A) Via its interaction with mu (µ) receptors throughout the CNS, morphine and other related opioids not only produce an analgesic effect, but they also can cause respiratory depression, particularly as doses are increased. Typically, morphine will reduce the respiratory rate, which then leads to an increase in the levels of carbon dioxide (CO2) in the blood and cerebrospinal fluid (CSF). In the patient with underlying pulmonary disease, whose ventilation and gas exchange efficiency may already be compromised, morphine has the potential to raise the CO2 level further and also limit how much oxygen (O2) can be breathed into the lungs. Excess CO2 also has the effect of causing pronounced vasodilation of cerebral blood vessels, which results in an increase in ICP. Elevations in ICP can also reduce ventilation further.

33. Which of the following is the drug of choice for treating herpes simplex virus (HSV) types 1 and 2? (A) amantadine (B) acyclovir (C) zidovudine (D) nystatin (E) zanamivir

33. (B) Acyclovir is the treatment of choice for HSV disease, typically in oral doses of 200 mg five times daily or 400 mg three times daily. In situations where oral acyclovir cannot be absorbed effectively by the GI tract or tolerated by the patient, intravenous acyclovir can be administered at a rate of 15 mg/kg/day.

34. Which of the following class of antihypertensives is associated with a first-dose phenomenon that is characterized by transient dizziness or faintness, palpitations, and possible syncope? (A) α1-blockers (B) angiotensin converting enzyme inhibitors (ACEIs) (C) angiotensin receptor blockers (ARBs) (D) thiazide diuretics (E) potassium-sparing diuretics

34. (A) α1-blockers (eg, doxazosin, terazosin, and prazosin) can cause a potentially severe orthostatic hypotension that is associated with the initial dose. This phenomenon can also occur with increases in dose. α1-Blockers are peripheral vasodilators and the drop in blood pressure produces the symptoms of dizziness, faintness (as blood flow to the brain decreases due to the decrease in blood pressure), and palpitations (which is indicative of the heart trying to elevate its rate to increase blood pressure). These episodes can be better tolerated by patients if the first dose or dose increases are taken at bedtime.

35. A 35-year-old man is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? (A) phenobarbital (B) valproate (C) phenytoin (D) lorazepam (E) donepezil

35. (D) In most patients suffering from generalized convulsive status epilepticus (GCSE), benzodiazepines such as lorazepam and diazepam are effective initial therapies due to their relatively high lipid solubility. As a result, they are able to cross the blood-brain barrier easily, which gives them the potential to stop seizures quickly. Lorazepam's lipid solubility is less compared to diazepam, and it also redistributes to fat more slowly. Hence, lorazepam tends to have a longer duration of action (12 to 24 hours) than diazepam (20 to 30 minutes). Phenytoin is often administered immediately after benzodiazepine administration for long-term seizure control, as it has a long half-life (20 to 36 hours) compared to diazepam. Phenytoin is not given first because its lipid solubility is less than the benzodiazepines and therefore cannot enter the brain quickly enough to terminate seizure activity.

36. Abrupt cessation of which of the following antihypertensives can produce significant rebound hypertension, tachycardia, and excessive sweating? (A) angiotensin converting enzyme inhibitors (ACEIs) (B) angiotensin receptor blockers (ARBs) (C) β-blockers (D) thiazide diuretics (E) potassium-sparing diuretics

36. (C) Gradual tapering of β-blockers over a period of 1 to 2 weeks is advised before discontinuation to avoid rebound hypertension, tachycardia, and sweating. Abrupt cessation of β blockers has also been shown to cause unstable angina, myocardial infarction, and even death in the hypertensive patient with coronary artery disease.

37. A 54-year-old man with chronic stable angina is being treated with daily doses of metoprolol and sublingual nitroglycerin prn to control occasional angina attacks. Approximately 45 minutes after taking sildenafil, the patient suffers a severe attack and takes several nitroglycerin tablets within a short time frame that ultimately leads to his death. Which of the following best explains what occurred? (A) the nitroglycerin/sildenafil combination led to a fatal arrhythmia (B) the nitroglycerin/sildenafil interaction triggered acute arterial thromboembolism (C) the nitroglycerin/sildenafil interaction led to severe hypotension (D) the metoprolol/sildenafil combination triggered a fatal coronary vasospasm (E) the metoprolol/sildenafil combination led to severe bronchospasm

37. (C) Sildenafil and other selective phosphodiesterase (PDE) inhibitors (eg, tadalafil, vardenafil) profoundly potentiate the vasodilatory effects (eg, a greater than 25 mm Hg decrease in systolic blood pressure) of organic nitrates and potentially life-threatening hypotension or hemodynamic collapse can result. Nitrates promote the formation of cyclic guanosine mono-phosphate (cGMP) by stimulating guanylate cyclase. Sildenafil acts to decrease the degradation of cGMP by inhibiting the enzyme that degrades it (PDE type 5). Together, these combined effects of the nitrate and PED-5 inhibitor result in increased accumulation of cGMP, which causes more pronounced smooth muscle relaxation and vasodilation than with either drug alone. In this scenario, the profound hypotension led to a significant decrease in coronary blood flow, thereby worsening the patient's ischemia that he was experiencing during his angina attack. Because of the serious risk of concomitant use of organic nitrates and selective PDE inhibitors, such combined use is contraindicated.

38. A patient with myasthenia gravis would likely experience symptomatic benefit with which of the following? (A) acetylcholinesterase inhibitors (B) muscarinic antagonists (C) α1-blockers (D) β-blockers (E) dopamine agonists

38. (A) Myasthenia gravis is characterized by autoantibodies directed against nicotinic cholinergic receptors at neuromuscular junctions. By inhibiting the enzyme responsible for metabolizing acetylcholine (acetylcholinesterase), the synaptic concentration of acetylcholine increases and can bind more frequently to functional nicotinic receptors yet to be affected by the disease. This can alleviate the symptoms such as limb weakness, difficulty swallowing, and difficulty chewing associated with the disease. Examples of acetylcholinesterase inhibitors include neostigmine and pyridostigmine.

39. From the choices given below, which medication is considered the safest for use during pregnancy? (A) warfarin (B) captopril (C) isotretinoin (D) esomeprazole (E) misoprostol

39. (D) Warfarin is contraindicated in all trimesters and is listed as category X by the FDA, because it has been shown to induce fetal bleeding and cause several teratogenic effects including CNS malformations, structural deformities of the nose, and bone dysplasias. ACEIs (eg, captopril) should not be used due to their increased risk of causing fetal hypotension, fetal renal damage, and major congenital malformations. Isotretinoin is also listed as category X and is a known teratogen that causes malformations of the CNS, face, and ears. Misoprostol is a synthetic prostaglandin analog indicated for reducing the risk of NSAID-induced gastric ulcers in patients at high risk of complications from gastric ulcer. It also has oxytocic properties, meaning that it can induce uterine contractions that may endanger pregnancy. The drug comes with a black box warning stating that administration to women who are pregnant can cause abortion, premature birth, or birth defects. Esomeprazole is category B and has not been shown to cause birth defects or threaten pregnancy.

4. A 4-year-old child swallows several tablets of a medication that he found in his parent's bathroom cabinet underneath the sink. Approximately 2 to 3 hours after ingesting the tablets, there were no symptoms other than nausea and vomiting. Thirty hours after ingesting the tablets, elevated aminotransferase levels were detected followed by jaundice, hepatic encephalopathy, renal failure, and death. What did the child most likely swallow? (A) diazepam (B) aspirin (C) oxycodone (D) acetaminophen (E) phenobarbital

4. (D) Acetaminophen toxicity may result from a single toxic dose, from repeated ingestion of large doses of acetaminophen (eg, 7.5 to 10 g daily for 1 to 2 days), or from chronic ingestion of the drug. Dose-dependent hepatic necrosis is the most serious acute toxic effect associated with overdose and is potentially fatal. Acetaminophen is the second most common cause of liver failure requiring transplantation in the United States.

40. The risk of extrapyramidal side effects (pseudoparkinsonism) and tardive dyskinesia is associated with which class of medications? (A) amphetamines (B) benzodiazepines (C) monoamine oxidase inhibitors (MAOIs) (D) tricyclic antidepressants (TCAs) (E) typical (first-generation) antipsychotics

40. (E) Typical antipsychotics (eg, haloperidol, chlorpromazine, fluphenazine) can produce pseudoparkinsonism via blockade of dopamine (D2) receptors in the nigrostriatum. Symptoms can include akinesia, bradykinesia, mask-like facial expression, tremor, cogwheel rigidity, and postural abnormalities. Tardive dyskinesia may also occur, as the reported incidence with first generation antipsychotics ranges from 0.5% to 62%.

42. A 50-year-old man presents to the emergency department with an episode of paroxysmal supraventricular tachycardia (PSVT). He is hypotensive (BP 88/58 mm Hg), does not feel faint, nor is complaining of any chest pain. His electrocardiogram (ECG) shows a regular arrhythmia with no P waves, narrow QRS complexes, and a heart rate of 172 bpm. Successive Valsalva maneuvers fail to terminate the PSVT. Which of the following intravenous treatments would be most appropriate for the patient at this time? (A) morphine (B) amiodarone (C) atenolol (D) adenosine (E) digoxin

42. (D) This patient only has mild symptoms resulting from his PSVT. In these situations, nonpharmacologic measures that increase vagal activity (eg, Valsalva maneuver) to the heart can be attempted to help restore a sinus rhythm. Because this failed in our patient, drug therapy is the best option. Adenosine is often the drug of first choice in patients with PSVT, as it slows conduction and interrupts the reentry pathways through the AV node. Adenosine is capable of producing hypotension and would need to be used cautiously. However, adenosine has a short duration of action (6 to 10 seconds). Intravenous verapamil and diltiazem are equally efficacious in terminating PSVT and could also be used in this situation.

43. Which of the following is the primary site of action for warfarin? (A) kidneys (B) liver (C) blood (D) small intestine (E) red bone marrow

43. (B) Warfarin interferes with the actions of vitamin K in the liver. Within hepatocytes, vitamin K is a cofactor required for the activation of clotting factors II (prothrombin), VII, IX, and X. By disrupting the actions of vitamin K, warfarin indirectly results in a slower rate of synthesis of these four clotting factors, thereby creating the anticoagulant effect.

44. Disulfiram increases the level of which of the following to produce flushing, throbbing headache, vomiting, and palpitations during alcohol intake? (A) acetic acid (B) acetylaldehyde (C) alcohol dehydrogenase (D) creatinine (E) glucuronic acid

44. (B) Disulfiram inhibits the hepatic enzyme alde-hyde dehydrogenase in the biochemical pathway for alcohol degradation. This effect causes acetylaldehyde to accumulate which produces severe facial flushing, throbbing headache, nausea and vomiting, palpitations, weakness, dizziness, blurred vision, and confusion. This reaction only occurs if the patient drinks alcohol while taking disulfiram. In the absence of alcohol, disulfiram has little or no effect.

45. Which of the following exerts its action by inhibiting cell wall synthesis? (A) amoxicillin (B) ciprofloxacin (C) doxycycline (D) erythromycin (E) gentamicin

45. (A) All β-lactam antibiotics, including the penicillins (eg, amoxicillin) and cephalosporins, prevent bacterial growth by inhibiting cell wall synthesis. Fluoroquinolones (eg, ciprofloxacin) block bacterial DNA synthesis. Erythromycin, doxycycline, and gentamicin all inhibit protein synthesis but via different mechanisms.

46. The use of triptans is contraindicated in patients with a history of which of the following? (A) kidney stones (B) gall bladder disease (C) cerebrovascular disease (D) peptic ulcer disease (E) schizophrenia

46. (C) Triptans (eg, sumitriptan, eletriptan, etc) are serotonin receptor agonists that are taken to help terminate and relieve pain associated with acute migraine attacks. During an attack, vasodilation of intracranial blood vessels occurs, leading to dural plasma extravasation, perivascular inflammation, and subsequent pain. Triptans help minimize these reactions by causing vasoconstriction of intracranial blood vessels. However, in the patient who has underlying cerebrovascular disease, vasoconstriction can further diminish blood flow, creating potentially dangerous hypoxic conditions in the brain.

47. Two 0.75-mg tablets of levonorgestrel taken 12 hours apart are effective as _________ (A) emergency contraception following unprotected intercourse (B) analgesia for pain associated with endometriosis (C) a method to increase the chances of becoming pregnant by inducing ovulation (D) a method for preventing hot flashes in postmenopausal women (E) a method of protection against HIV transmission

47. (A) There are a few products on the market that are FDA-approved specifically for emergency contraception, including Plan B (two 0.75-mg tablets of levonorgestrel taken 12 hours apart).

48. Which drug can potentially lead to oropharyngeal candidiasis, and which agent can be used to treat this type of infection? (A) albuterol; ketoconazole (B) triamcinolone; fluconazole (C) fluticasone; amantadine (D) cromolyn sodium; levofloxacin (E) flunisolide; metronidazole

48. (B) If they coat the mouth and throat, inhaled corticosteroids (eg, triamcinolone, fluticasone, flunisolide) can alter the local bacteria and fungal population, thereby enhancing fungal growth. In cases of oropharyngeal candidiasis (thrush), white spots on the tongue and hard palate can be visualized, and the patient usually has pain on swallowing. In the asthma patient, the utilization of a spacer with a metered dose inhaler (MDI) can help minimize the chances of oropharyngeal candidiasis, as can routine gargling and rinsing following each inhaled treatment. Fluconazole is an antifungal agent that is effective in treating oropharyngeal candidiasis.

49. A 19-year-old woman presents to the clinic with complaints of nausea, diarrhea, flatulence, stomach cramps, and bloating. A stool sample provided while at the clinic has frothy and greasy characteristics but is free of any visible blood. She explains that she just returned from a 2-week camping trip where she did a great deal of swimming in a couple of lakes. Which of the following medications would be most appropriate for this patient? (A) metronidazole (B) nystatin (C) trimethoprim-sulfamethoxazole (D) doxycycline (E) erythromycin

49. (A) The patient is most likely suffering from giardiasis that could have been contracted on her camping trip. While swimming, she may have inadvertently swallowed water contaminated with Giardia lamblia, whose incubation period is generally 1 to 3 weeks, after which symptoms develop. An effective treatment is metronidazole 250 mg taken three times daily for 5 to 7 days.

5. Which of the following requires drug-free periods to avoid tolerance when used as prophylaxis for chronic stable angina? (A) digoxin (B) diltiazem (C) metoprolol (D) isosorbide dinitrate (E) propranolol

5. (D) According to the American College of Cardiology/American Heart Association practice guidelines for chronic stable angina, β-blockers like metoprolol are generally considered among the initial antianginal drugs of choice in the long-term prophylactic management of chronic stable angina. Long-acting nitrates such as isosorbide dinitrate can be used alone or in combination as second-line therapy in patients previously treated with a β-blocker. However, the development of tolerance is a major limiting step in their efficacy when used longterm. The degree of tolerance can be limited by utilizing a regimen that includes a minimum 8- to 10-hour period per day without nitrates no matter the route of delivery (ointment, patch, or tablets).

50. A 34-year-old woman presents to the clinic with complaints of intermittent flushing and blushing that started 3 to 4 weeks ago. Since then, she has noticed several inflammatory papules on the cheeks, nose, and chin. Upon exam, you notice an overall rosy hue to the face and the absence of any comedones. Which of the following would be the best course of topical therapy at this time? (A) mupirocin ointment (B) permethrin cream (C) tretinoin gel (D) hydrocortisone 1% cream (E) metronidazole gel

50. (E) Metronidazole is the topical treatment of choice for rosacea, which is consistent with the clinical findings in this 34-year-old female patient. Mupirocin ointment is a treatment option for impetigo, whereas permethrin is indicated for scabies. Tretinoin is effective and is indicated for comedonal acne.

51. A 25-year-old woman complains of chest pain, shortness of breath, sweating and trembling. After an extensive negative work-up, the patient is diagnosed with panic disorder. Which of the following would be the most appropriate sustained treatment? (A) buspirone (B) clomipramine (C) clorazepate (D) paroxetine (E) ramelteon

51. (D) For sustained treatment of panic attacks, SSRIs are the initial drugs of choice. Sublingual benzodiazepines are often effective for urgent treatment.

52. A 52-year-old man recently underwent surgery for a hip replacement. Upon discharge, he is prescribed oxycodone 7.5 mg and acetaminophen 325 mg and told to take 1 to 2 tablets every 6 hours prn to help manage the pain he is expected to encounter as he recovers at home. Which of the following medications would you also recommend for the patient to help minimize potential side effects associated with his pain medication? (A) esomeprazole (B) diphenhydramine (C) guaifenesin (D) hydrocortisone 1% cream (E) senna & docusate

52. (E) Constipation is a common adverse effect of opioid therapy. In order to minimize or prevent constipation, the use of stool softeners (docusate) and a stimulant laxative (senna) can be initiated when opioid therapy is begun.

53. A 64-year-old woman with a medical history of rheumatoid arthritis and deteriorating vision presents to the clinic with complaints of painful bilateral swelling of her ankles and hands, morning stiffness, loss of appetite, and fatigue. She is currently taking naproxen sodium 500 mg twice per day. Which medication(s) would be most appropriate for this patient? (A) acetaminophen (B) azathioprine (C) cyclosporine (D) hydroxychloroquine (E) methotrexate

53. (E) Whereas NSAIDs such as naproxen provide some symptomatic relief in rheumatoid arthritis, they do not alter disease progression like DMARDs (disease-modifying antirheumatic drugs). NSAIDs are best used in conjunction with DMARDs. Methotrexate is usually the DMARD of choice because it is well tolerated by the majority of patients and can produce beneficial effects in 2 to 6 weeks. Hydroxychloroquine is another DMARD that can be used for rheumatoid arthritis but can produce ocular toxicity. Cyclosporine and azathioprine are used less frequently today due to toxicity and lack of long-term benefits. Similar to naproxen, acetaminophen would also fail to alter disease progression.

54. When used for advanced carcinoma of the prostate, chronic administration of leuprolide inhibits the synthesis of androgens by _____________________ (A) blocking gonadotropin-releasing hormone (GnRH) receptors at the anterior pituitary (B) blocking luteinizing hormone (LH) receptors on interstitial (Leydig) cells of the testes (C) increasing the secretion of GnRH from the hypothalamus (D) inhibiting pulsatile secretion of gonadotropins from the anterior pituitary (E) upregulation of the number of GnRH receptors at the anterior pituitary

54. (D) Leuprolide is a GnRH (LHRH) agonist that suppresses the pulsatile secretion of follicle stimulating hormone (FSH) and LH (gonadotropins) from the anterior pituitary when given chronically. Continuous administration of a GnRH agonist causes down-regulation of GnRH receptors on gonadotropes, which, in turn suppresses gonadotropin release and gonadal function. Decreased amounts of LH, in particular, lead to diminished production of androgens by the testes (especially DHT), which support prostate growth. It is believed that by interrupting the hormonal pathways that modulate prostatic growth, tumor development and metastasis is slowed.

55. Mitotic inhibitors such as vinblastine and vincristine are classified as chemotherapeutic agents because they __________ (A) block hormone receptors (B) cross-link or alkylate DNA (C) inhibit the function of microtubules (D) inhibit the synthesis of RNA (E) inhibit topoisomerase

55. (C) Vinca alkaloids (eg, vincristine, vinblastine) bind to tubulin, the structural protein that forms the microtubules, which comprise the mitotic spindle. Through this binding, the microtubules are unable to assemble to form the mitotic spindle, which results in a cell's (both normal and cancerous) inability to divide.

56. A 35-year-old woman diagnosed with depression 3 weeks ago has been taking a medication prescribed by her clinician. Recently, she reports complaints of dry mouth, constipation and visual sensitivity to bright light. Which of the following medications was the patient most likely prescribed? (A) bupropion (B) nortriptyline (C) phenelzine (D) sertraline (E) venlafaxine

56. (B) Tricyclic antidepressants (eg, nortriptyline) produce anticholinergic side effects not seen with other types of antidepressants such as SSRIs, SNRIs, and MAOIs. Anticholinergic side effects include dry mouth, constipation, photophobia, blurred vision, urinary retention, and tachycardia.

57. Which of the following is a common adverse effect associated with the use of stimulants such as methylphenidate for attention-deficit hyperactivity disorder (ADHD)? (A) diarrhea (B) hypoglycemia (C) hypotension (D) paresthesias (E) reduced appetite

57. (E) Stimulants (eg, amphetamines, methylphenidate) are considered first-line therapy in the majority of cases of ADHD. Both amphetamines and methylphenidate block dopamine and norepinephrine reuptake, while amphetamines also stimulate norepinephrine release. Elevated levels of CNS norepinephrine have been associated with an anorexigenic effect, leading to reduce caloric intake.

71. Which of the following therapeutic regimens is most appropriate for a 17-year-old girl diagnosed with gonococcal and chlamydial urethritis? (A) amoxicillin & clavulanate (B) trimethoprim-sulfamethoxazole (C) metronidazole (D) ceftriaxone & azithromycin (E) doxycycline & amoxicillin

71. (D) It is estimated that in females with gonorrhea, coexisting chlamydial infection occurs 50% of the time. For gonococcal urethritis, the treatment of choice is ceftriaxone. In cases of coexistent chlamydial infection, either doxycycline or azithromycin are recommended.

58. A 28-year-old woman in the emergency department is administered an intravenous paralytic agent prior to endotracheal intubation. The agent produces transient muscle fasciculations, particularly over the thorax and abdomen, prior to paralysis. Which of the following was the patient most likely administered? (A) tubocurarine (B) rocuronium (C) carbamazepine (D) succinylcholine (E) pyridostigmine

58. (D) Tubocurarine and rocuronium are classified as nondepolarizing neuromuscular blocking drugs, whereas succinylcholine is depolarizing. Nondepolarizing agents competitively block nicotinic receptors on skeletal muscle, which leads to flaccid muscle paralysis. Depolarizing agents, on the other hand, activate nicotinic receptors on skeletal muscle cells leading to membrane depolarization, initial fasciculations, and intense contractions. Succinylcholine is not metabolized efficiently at neuromuscular junctions; hence, the cells remain depolarized and are unable to repolarize or recover back to a resting state. This failure to repolarize then leads to a flaccid muscle paralysis. Pyridostigmine in an acetylcholinesterase inhibitor indicated for myasthenia gravis and causes an increase in skeletal muscle activity.

59. A 22-year-old man with pernicious anemia can be given which of the following to correct any hematologic and neurologic defects of his condition? (A) vitamin K (B) folic acid (C) ferrous sulfate (D) vitamin B12 (E) erythropoietin

59. (D) Pernicious anemia is a chronic illness caused by impaired absorption of vitamin B12 due to a lack of intrinsic factor (IF) production by the gastric mucosa. Replacement therapy with intramuscular injections of vitamin B12 is often used to treat this condition. An alternative is Nascobal, a synthetic form of vitamin B12 as a nasally administered gel.

6. Following chronic therapy for its listed indication, which of the following medications is typically tapered prior to discontinuation? (A) omeprazole for gastroesophageal reflux disease (GERD) (B) glipizide for type 2 diabetes mellitus (C) prednisone for systemic lupus erythematosus (D) metformin for type 2 diabetes mellitus (E) ezetimibe for hyperlipidemia

6. (C) Chronic therapy with systemic corticosteroids can induce atrophy of the adrenal glands, which significantly depresses the adrenal response to adrenocorticotropic hormone (ACTH). Stopping prednisone suddenly would leave the body without a source of glucocorticoids, because the hypothalamic-pituitary-adrenal axis needs time to re-establish its normal functioning. As a result, an acute adrenal crisis (Addisonian crisis) that is marked by dehydration with severe vomiting and diarrhea, hypotension, shock, and loss of consciousness can develop and potentially lead to a fatality.

60. Which of the following are common adverse effects associated with aminoglycosides? (A) diarrhea and bone marrow depression (B) ototoxicity and nephrotoxicity (C) blurred vision and hyperglycemia (D) headache and hypoglycemia (E) rash and dyspepsia

60. (B) All aminoglycosides are ototoxic and nephrotoxic. The likelihood of experiencing these toxicities occurs when treatment lasts beyond 5 days, at higher doses, in elderly patients, and those suffering from renal insufficiency. Other agents that produce either of these toxicities should not be used concurrently.

61. In the treatment of asthma, long-acting β2-agonists are _______________________ (A) an effective substitute for inhaled corticosteroids as monotherapy for long-term control of any form of asthma (B) commonly used as an adjunct to inhaled corticosteroid therapy for providing long-term control of more severe forms of asthma (C) of limited use due to their low therapeutic index, risk of life-threatening toxicity, and numerous drug interactions (D) the drugs of choice for providing prompt relief of bronchoconstriction and its accompanying acute symptoms such as cough, chest tightness, and wheezing (E) the most effective at reducing inflammation of bronchial airways

61. (B) Long-acting β2-agonists are the preferred adjunctive therapy to inhaled corticosteroids in the long-term treatment of more severe forms of asthma. A combination of an inhaled corticosteroid and long-acting β2-agonist provides greater asthma control than increasing the dose of the inhaled corticosteroid alone. Because they lack anti-inflammatory properties, long-acting β2-agonists should not be used as monotherapy for long-term control of asthma, because alone they increase the risk of asthma-related death.

62. A patient presents with signs and symptoms of moderate congestive heart failure that includes a modest degree of left ventricular dysfunction, shortness of breath, fatigue, reduced exercise tolerance, and ankle edema. Which of the following drug combinations would be the best choice for initial treatment? (A) digoxin and hydrochlorothiazide (B) metoprolol and triamterene (C) metoprolol and enalapril (D) enalapril and furosemide (E) isosorbide dinitrate and furosemide

62. (D) A combination of a loop diuretic and an ACE inhibitor is typically the initial treatment in most symptomatic patients with congestive heart failure. ACE inhibitors have been demonstrated to not only reduce symptoms but also mortality in patients with symptomatic heart failure. Loop diuretics offer the best option to reduce the congestive symptoms in the lungs and fluid retention in the ankles.

63. A 24-year-old woman presents with nausea that has fluctuated in severity for the last 3 weeks. The patient states that the nausea seems to have coincided with taking a prescription for birth control pills for the first time. Substitution of her current prescription with a combined hormonal contraceptive containing a lesser amount of which compound would most likely relieve the patient's nausea? (A) desogestrel (B) ethinyl estradiol (C) norethindrone (D) luteinizing hormone (E) testosterone

63. (B) The amount of steroid in a combined hormonal contraceptive accounts for many adverse effects than occur while taking the medication. Ethinyl estradiol excess can lead to nausea and bloating, whereas low-dose ethinyl estradiol can cause early or mid-cycle breakthrough bleeding and spotting. Low-dose progestin (eg, desogestrel, norethindrone) can lead to late-cycle breakthrough bleeding and spotting, whereas high dose progestin can cause weight gain, bloating, and constipation. Combined hormonal contraceptives do not contain luteinizing hormone or testosterone.

72. A patient is taking an antihypertensive medication for which the prescribing information says "do not use with other cardiac depressant drugs." To which combination of antihypertensive medications would this precaution or contraindication apply? (A) doxazosin & diltiazem (B) hydralazine & doxazosin (C) lisinopril & atenolol (D) lisinopril & verapamil (E) verapamil & atenolol

72. (E) Calcium channel blockers can cause cardiac conduction abnormalities such as brady-cardia or atrioventricular block. Similarly β-blockers are associated with bradycardia and atrioventicular conduction abnormalities, particularly second- and third-degree heart block. Their effects in producing these responses can be additive, and hence, they are not recommended for concomitant use.

64. Constipation, abdominal distention, bloating, and flatulence are common adverse effects associated with which class of drugs? (A) bile acid resins (B) fibrates (C) HMG-CoA reductase inhibitors (D) nonselective β-blockers (E) organic nitrates

64. (A) Bile acid resins (eg, cholestyramine, colestipol, colesevelam) are used for lowering LDL-C. They sequester bile acids in the intestinal lumen, thereby preventing them from carrying out their normal functions of emulsification and micelle formation. Emulsification is an important process for lipid digestion, while the formation of micelles is required for lipid absorption. These actions not only inhibit lipid digestion and absorption from the intestinal lumen, but they also deplete the hepatic pool of cholesterol as a result of increased bile acid synthesis. Normally, bile acids are recirculated (enterohepatic circulation) from the intestine and back to the liver for reincorporation into the bile. Resins cause the bile acids to be excreted with the feces, so the liver needs to continually synthesize new bile acids from endogenous cholesterol. Constipation, abdominal distention, bloating, and flatulence result from the increased lipid content of the stool, because lipids are not being absorbed across the intestinal wall. These adverse effects can often be managed by increasing fluid and fiber intake and also using stool softeners.

65. A 25-year-old man is hospitalized with symptoms of delusion, paranoia, rambling statements coupled with disorganized thought, and flattened affect. The companion who brings him to the hospital claims this is the first time she has ever witnessed any of these symptoms and is not aware of any medication he is currently taking. Which of the following medications is most appropriate for this patient? (A) sertraline (B) topiramate (C) olanzapine (D) clomipramine (E) thioridazine

65. (C) The patient is showing signs and symptoms of schizophrenia for which antipsychotic agents are the treatment of choice. Olanzapine is an atypical antipsychotic (eg, second-generation) that has less risk of causing extrapyramidal side effects (EPS) compared to typical antipsychotics (eg, first-generation) such as thioridazine. Because of the risk of EPS, typical or first-generation antipsychotics are not considered first-line treatments. Even though both typical and atypical antipsychotics appear to have similar efficacy, the atypical agents also tend to be better tolerated, which enhances compliance.

66. Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects? (A) acting as dopamine receptor agonists (B) acting as NMDA receptor antagonists (C) acting as serotonin receptor antagonists (D) decreasing reuptake of serotonin and norepinephrine (E) increasing GABAA receptor-mediated chloride conductance

66. (E) Benzodiazepines bind to GABAA receptors, which consist of many peripheral subunits that form chloride channels at their core. GABA is one of the major inhibitory neurotransmitters in the brain; hence, benzodiazepines enhance this inhibitory influence to produce sedation and calm.

67. Which of the following lists the common adverse effects caused by nitroglycerin when administered sublingually at high doses? (A) constipation, blurred vision, tinnitus (B) dyspepsia, abdominal distention, vomiting (C) elevated pulse, facial flushing, headache (D) photophobia, excessive salivation, excessive tearing (E) wheezing, cough, heartburn

67. (C) Sublingual nitroglycerin produces venodilation and vasodilation, which causes secondary responses of flushing and headache. The elevated pulse or tachycardia is reflexive in nature, and the heart tries to compensate for the drop in blood pressure by raising its rate.

68. Hyperkalemia is a contraindication to the use of which of the following medications? (A) metformin (B) cimetidine (C) triamterene (D) glipizide (E) verapamil

68. (C) Triamterene is a K+-sparing diuretic based on its mechanism of action. In the kidneys, it will lead to less K+ excretion in the urine and hence retention of plasma K+. In patients with elevated plasma K+, triamterene can cause further hyperkalemia, which can impact neuro-muscular and cardiac function.

69. Which of the following drugs block the actions of leukotrienes and can be used for long-term control of mild persistent asthma? (A) cromolyn sodium (B) omalizumab (C) zafirlukast (D) nedocromil sodium (E) ipratropium bromide

69. (C) Leukotrienes are inflammatory mediators that are generated within the lungs. When they bind to specific receptors, they induce a variety of responses, including bronchospasm and mucus production. Zafirlukast (and also montelukast) are leukotriene receptor antagonists that block these effects in the lungs and improve asthma symptoms. Zafirlukast is considered an alternative therapy for long-term control of asthma, as it has been shown to be less effective than inhaled corticosteroids. Both cromolyn and nedocromil are mast cell stabilizers and can also be used as an alternative treatment to inhaled corticosteroids. Omalizumab is an anti-IgE antibody, whereas ipratropium bromide is a muscarinic receptor antagonist.

7. Which of the following medications is often prescribed in combination with digoxin for managing moderate to severe congestive heart failure, but can also be a cause of digoxin toxicity? (A) nitroglycerin (B) furosemide (C) triamterene (D) verapamil (E) ramipril

7. (B) Digoxin binds to Na+/K+ ATPases on the sarcolemmal membranes of cardiac muscle cells and inhibits them from working. This raises intracellular Na+ levels, which facilitates Na+/Ca+2 exchange. The resulting increase in intracellular Ca+2 enhances contractile protein cross-bridge formation and cardiac contractility, resulting in a positive inotropic effect. One of the parameters often monitored in the heart failure patient taking digoxin is serum K+. Potassium and digoxin inhibit each others' binding to the Na+/K+ ATPases; therefore, hyperkalemia reduces the actions of digoxin, whereas hypokalemia increases its effect. As a result, hypokalemic patients are more susceptible to the many cardiac manifestations of digoxin toxicity, particularly ventricular arrhythmias. Rhythm disturbances are a major concern in heart failure patients, as they are already at an elevated risk for sudden cardiac death that can be linked to ventricular arrhythmias. Furosemide is a K+-wasting, loop diuretic that is often prescribed with digoxin to provide symptomatic relief due to fluid retention, particularly in patients with moderate to severe congestive heart failure. Hence, loop diuretics should be used cautiously as a result of their potential to cause hypokalemia and subsequently, an elevated risk of cardiac arrhythmias.

70. Which of the following has the potential for causing cyanide toxicity? (A) clonidine (B) diazoxide (C) hydralazine (D) reserpine (E) sodium nitroprusside

70. (E) Intravenous nitroprusside is a common medication used for hypertensive emergencies. It is metabolized to cyanide and then to thiocyanate, which is excreted in the urine. The level of thiocyanate should be monitored if nitroprusside infusion lasts longer than 72 hours. The risk of cyanide toxicity and thiocyanate accumulation is increased in patients with a history of impaired renal function.

75. A 43-year-old pilot is interested in quitting his 20-year habit of smoking. His medical history includes type 2 diabetes mellitus diagnosed 6 years ago for which he is currently taking metformin. Which of the following would be most appropriate to recommend to this patient? (A) alprazolam (B) clonidine (C) nicotine replacement therapy (D) nortriptyline (E) varenicline

75. (C) Nicotine replacement therapy is relatively safe in the majority of patients and comes in many forms (transdermal patches, gums, sprays, and inhalers). Both clonidine and nortriptyline are considered second-line smoking cessation agents because of their many side effects. Neither has been approved by the FDAfor smoking cessation. Alprazolam is also not indicated, and there is currently no evidence that it aids in smoking cessation. Varenicline is a relatively new agent for smoking cessation and is a partial agonist to α4-β2 nicotinic acetylcholine receptors. It has been approved by the FDA; however, varenicline is banned from use by pilots and air traffic controllers as per the Federal Aviation Administration

76. A 33-year-old woman treated with trifluoperazine for the past 3 months is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? (A) a delayed allergic reaction has occurred with trifluoperazine (B) tardive dyskinesia has begun to develop in the patient (C) the patient has developed neuroleptic malignant syndrome (D) the patient has developed serotonin syndrome (E) the patient has overdosed on trifluoperazine

76. (C) Neuroleptic malignant syndrome is an uncommon but serious complication with therapeutic doses of antipsychotic drug therapy, particularly the first-generation (typical) class. Cardinal signs and symptoms include a body temperature above 100.4°F, altered state of consciousness, autonomic dysfunction, and rigidity.

77. Which property accounts for why some β-blockers produce dizziness and drowsiness, whereas other β-blockers are not as likely to cause these problems? (A) selectivity for certain β-receptors (B) degree of lipophilicity (C) degree of intrinsic sympathomimetic activity (ISA) (D) serum half-life (E) margin of safety

77. (B) β-Blockers are capable of crossing the blood-brain barrier and, hence, can cause CNS side effects. In general, drugs that are more lipophilic can cross the blood-brain barrier more efficiently compared to drugs that are less lipophilic. Each β-blocker has a different degree of lipophilicity based on its chemical structure.

78. Which of the following antineoplastic medications is most likely to cause cardiac toxicity and precipitate heart failure? (A) doxorubicin (B) cisplatin (C) cyclophosphamide (D) tamoxifen (E) 6-mercaptopurine

78. (A) Doxorubicin is a common antineoplastic drug used for a variety of cancers, including breast, bladder, ovarian, and endometrial, among many others. Unfortunately, it has a well-established, dose-dependent adverse effect on the heart that is linked to free-radical formation. (

79. A type 1 diabetic patient who does not experience many of the normal warning signs of hypoglycemia when her blood glucose is 57 mg/dL is most likely receiving which of the following antihypertensive medications? (A) diltiazem (B) enalapril (C) hydrochlorothiazide (D) losartan (E) propranolol

79. (E) Nonselective β-blockers can mask many of the signs and symptoms of hypoglycemia in patients who tightly regulate their blood glucose levels. This is due to the fact that many of the symptoms are mediated through the sympathetic nervous system and β-receptors, including tachycardia, palpitations, and tremor. Sweating is another warning sign of hypoglycemia, but should still occur with β-blocker therapy, because it is mediated via cholinergic receptors.

8. Of the following choices, which regimen is considered first-line therapy for Helicobacter pylori-positive individuals with peptic ulcer disease? (A) omeprazole & clarithromycin & amoxicillin (B) omeprazole & ranitidine & clarithromycin (C) esomeprazole & clarithromycin & ampicillin (D) ranitidine & amoxicillin & bismuth subsalicylate (E) misoprostol & clarithromycin & metronidazole

8. (A) Triple-therapy regimens consisting of a proton pump inhibitor (PPI) and two antibiotics are considered first-line therapy for the eradication of Helicobacter pylori. PPI-based regimens that combine clarithromycin and amoxicillin or clarithromycin and metronidazole have been shown to have the most effective eradication rates. There are also 4-drug regimens that include bismuth subsalicylate that have been shown to be effective as well. Because of lower eradication rates, it is not recommended that histamine receptor antagonists like ranitidine be substituted for a PPI. Misoprostol is used for reducing the risk of nonsteroidal anti-inflammatory agent (NSAIA)induced gastric ulcer in patients at high risk of developing complications from these ulcers and in patients at high risk of developing gastric ulceration. It has no effect on H pylori eradication.

80. Which of the following is considered first-line therapy for a nonpregnant, 24-year-old woman suffering from cervicitis believed to be due to a Chlamydia trachomatis infection? (A) 7-day course of oral doxycycline or 1 oral dose of azithromycin (B) 7-day course of oral erythromycin or 1 oral dose of azithromycin (C) 7-day course of oral penicillin or 1 oral dose of trimethoprim-sulfamethoxazole (D) 7-day course of oral erythromycin or 1 oral dose of trimethoprim-sulfamethoxazole (E) 7-day course of oral penicillin or 1 oral dose of azithromycin

80. (A) Recommended drug regimens for Chlamydial cervicitis include a single oral 1-g dose of azithromycin, 100 mg of doxycycline orally for 7 days or 500 mg of levofloxacin orally for 7 days.

81. Which of the following agents is the treatment of choice to reverse an opioid overdose? (A) buprenorphine (B) butorphanol (C) nalbuphine (D) methadone (E) naloxone

81. (E) Naloxone is a specific opioid antagonist administered intravenously in cases of opioid overdose. It is a short-acting drug that may require repeated doses if the offending opioid has a long duration of action.

82. Which compound can be applied topically and acts as a keratolytic to remove corns, calluses, and common warts? (A) acetaminophen (B) salicylic acid (C) ibuprofen (D) hydroxychloroquine (E) colchicine

82. (B) Salicylic acid is a commonly used keratolytic that is typically applied as a lotion or gel (2% to 10% concentration) to corn pads. It is also indicated for the treatment of common warts, but is used in higher concentrations (17%).

85. Both rifampin and certain antiepileptics (AEDs) such as phenytoin and carbamazepine have been shown to reduce the effectiveness of which of the following? (A) nicotine replacement therapy (B) combined hormonal contraceptives (C) HMG-CoA reductase inhibitors (D) nonsteroidal anti-inflammatory drugs (E) proton pump inhibitors

85. (B) Certain medications have been implicated in decreasing the efficacy of oral contraceptives, including rifampin and some of the antiepileptics (AEDs). A back-up method of contraception is suggested for females taking rifampin and combined hormonal contraceptives concomitantly on a short-term basis. If they are taken for longer periods of time, the patient should consider an alternative method of contraception. Similarly, for those patients taking either phenytoin or carbamazepine for seizure disorder, an alternative method of contraception is highly recommended.

86. Which of the following provides the greatest fracture risk reductions and greatest increases in bone mineral density in postmenopausal females with osteoporosis? (A) alendronate (B) calcitonin (C) estrogen (D) raloxifene (E) vitamin D

86. (A) Bisphosphonates (eg, alendronate, rise-dronate, ibandronate) are the prescription drug of choice for osteoporosis over raloxifene, calcitonin, estrogen, and vitamin D due to their consistent ability to provide the greatest fracture risk reductions and bone mineral density increases. While some of these other medications can cause similar effects, they do so to a lesser extent. In particular, the risks of estrogen therapy outweigh the benefits on the bone as suggested by recent data from the Women's Health Initiative trials.

87. Drugs such as donepezil and rivastigmine that are used for Alzheimer disease exert their effect by which of the following mechanisms? (A) blocking muscarinic receptors (B) blocking serotonin receptors (C) inhibiting acetylcholinesterase (D) binding to muscarinic receptors (E) binding to serotonin receptors

87. (C) Acetylcholinesterase inhibitors for Alzheimer disease were designed around the "cholinergic hypothesis," which stated that the replenishment of acetylcholine could help restore memory and cognitive ability, both of which are lost as the disease progresses. While numerous cholinergic pathways are destroyed during Alzheimer disease, many others are also lost. Even though these acetylcholinesterase inhibitors are indicated for Alzheimer disease, they are not curative and do not restore function.

88. A 46-year-old man with a 2-year history of gouty arthritis presents to the clinic with a red, swollen joint at the base of the great toe. After resolution of the acute attack with indomethacin, a drug which inhibits the synthesis of uric acid was prescribed. Which of the following was the drug most likely prescribed? (A) allopurinol (B) colchicine (C) cyclosporine (D) probenecid (E) sulfasalazine

88. (A) Allopurinol is an inhibitor of xanthine oxidase, a key enzyme necessary for the production of uric acid. It is the most commonly prescribed drug for the long-term management of gout and is an effective prophylactic agent. Probenecid can also be prescribed as prophylactic therapy for gout. However, it is classified as a uricosuric drug, meaning it increases the renal clearance of uric acid rather than affecting uric acid synthesis. Colchicine is an antimitotic drug that can relieve acute attacks of gout, but also does not affect uric acid synthesis. Cyclosporine and sulfasalazine are not indicated for acute management of gout or for prophylactic therapy.

89. Which agent is most appropriate for the treatment of seasonal allergies in a 32-year-old male taxi driver? (A) diphenhydramine (B) clemastine (C) ergotamine tartrate (D) promethazine (E) loratadine

89. (E) The second-generation antihistamines such as loratadine, fexofenadine, and desloratadine are nonsedating when taken at recommended doses. Because the patient is employed as a taxi driver, remaining alert is of prime importance. First-generation antihistamines (eg, diphenhydramine, clemastine) have a much higher potential for causing sedation and should be avoided in this particular patient.

9. Following a gunshot wound to the lower abdomen, a 29-year-old man is hospitalized and treated with clindamycin for a potential anaerobic infection. After 3 days of clindamycin therapy, while recuperating in the hospital, he develops severe diarrhea, dehydration, and lower abdominal cramping. A stool culture is ordered and later discovered to contain Clostridium difficile. After discontinuing the clindamycin, which of the following would be the most appropriate treatment? (A) cefaclor (B) doxycycline (C) amoxicillin (D) metronidazole (E) cephalexin

9. (D) Clostridium difficile is a gram-positive, anaerobic, spore-forming bacillus that is responsible for the development of antibiotic-associated diarrhea and colitis. C difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization with C difficile, and release of toxins that cause mucosal inflammation and damage. Antibiotic therapy is the key factor that alters the colonic flora. Specific therapy aimed at eradicating C difficile is indicated if symptoms are persistent or severe. The drug of choice is metronidazole, 500 mg orally three times daily or 250 mg orally four times daily. Oral metronidazole and vancomycin are equally effective in treating diarrhea caused by C difficile. Despite the isolation of metronidazole-resistant strains of C difficile, metronidazole is the drug of first choice because of its lower cost and the fact that it can promote vancomycin-resistant nosocomial infections.

90. Which class of medications now includes a boxed warning and expanded warning statements about the increased risk of suicidality in children and adolescents being treated with these drugs? (A) benzodiazepines (B) typical antipsychotics (C) atypical antipsychotics (D) opiates (E) antidepressants

90. (E) In March 2004, the FDA instructed manufacturers of all antidepressants to include in their labeling a boxed warning and expanded warning statements about the increased risk of suicidal thinking and behavior in children and adolescents being treated with these drugs. This directive was based on a combined analysis of several studies that concluded the risk of suicidal behavior to be twice as high (4% vs 2%) in children and adolescents receiving antidepressants versus placebo.

91. In general, the bioavailability of a drug will be the greatest when it is administered by which of the following routes? (A) intramuscular (B) intravenous (C) oral (D) respiratory (E) subcutaneous

91. (B) Bioavailability represents the fraction of an administered drug that reaches the systemic circulation. Because the intravenous route represents direct administration of a drug into the circulation, the bioavailability would be 100%. All of the other routes listed as choices possess biologic barriers to a drug before it can be absorbed into the vasculature. These barriers can often impede a percentage of the drug dose from reaching the blood. Additionally, some drugs (particularly when given orally) can also be metabolized by enzymes or influenced by the firstpass effect through the liver before reaching the circulation.

92. Which of the following is the primary emergency treatment for anaphylaxis? (A) epinephrine (B) antihistamines (C) atropine (D) aminophylline (E) dopamine

92. (A) Intramuscular administration of epinephrine is the drug of choice to quickly reverse the considerable vasodilation (and subsequent drop in blood pressure) and bronchoconstriction that often occurs with anaphylaxis. Several adjunctive therapies (eg, intravenous fluids, antihistamines, corticosteroids) may also be necessary to help maintain blood pressure, reduce inflammation, and prevent bronchospasm. However, epinephrine should be the first drug administered.

93. A 12-year-old boy reaches under his friend's porch to retrieve a baseball and suffers a small puncture wound to his left hand as a result of a bite by the friend's cat. Within 24 hours, he becomes febrile and complains of chills, and the wound appears infected. Which drug(s) would be most appropriate to give this patient? (A) amoxicillin & clavulanate (B) erythromycin (C) trimethoprim-sulfamethoxazole (D) metronidazole (E) gentamicin

93. (A) Pasteurella multocida is the typical cause of an early infection (within 24 hours) due to a cat bite. Penicillins offer the best coverage for P multocida, compared to other antibiotics.

94. A 62-year-old man with a history of parkinsonism is recently diagnosed with colorectal cancer and is to begin chemotherapy. Which of the following regimens would be most appropriate in prophylactically treating acute nausea and vomiting associated with his moderately emetogenic chemotherapeutic regimen? (A) metoclopramide (B) metoclopramide & dexamethasone (C) ondansetron & dexamethasone (D) lorazepam (E) prochlorperazine

94. (C) Chemotherapy-induced nausea and vomiting (CINV) is a common problem for cancer patients that can often be avoided if treated prophylactically. Patients who receive chemotherapeutic regimens that are classified as being of moderate emetic risk should receive a selective serotonin receptor inhibitor (eg, SSRI; ondansetron, granisetron, dolasetron) and dexamethasone. The efficacy of the SSRI is enhanced when used concomitantly with dexamethasone. Antiemetics known as phenothiazines (eg, prochlorperazine) and metoclopramide can cause extrapyramidal side effects, and hence would not be advised for use in patients with parkinsonism.

95. A 52-year-old man is brought to the ED by his daughter because she recently notices that he gets extremely tired, has periodic tremors in his hands, and suffers from increasing memory lapses. Initial laboratory work shows a serum creatinine of 2.2 mg/dL. His medical history is significant for bipolar disorder, for which he has been taking the same drug for the past 32 months. Which of the following is most likely responsible for the patient's symptoms? (A) valproate (B) lithium carbonate (C) carbamazepine (D) olanzapine (E) risperidone

95. (B) The patient's symptoms are consistent with long-term lithium therapy, which can cause a variety of neuropsychiatric side effects (eg, tremor, ataxia, mental confusion, fatigue, poor concentration). Lithium is also known to produce adverse effects on the kidneys that can lead to nephrogenic diabetes insipidus and increased serum creatinine concentrations.

96. Angiotensin receptor blockers (ARBs) are not as likely to produce cough compared to angiotensin converting enzyme inhibitors (ACEIs) because they do not ___________ (A) cause hyperkalemia (B) cause hyponatremia (C) cross the blood-brain barrier (D) increase bradykinin levels (E) undergo a first-pass effect

96. (D) ACEIs not only inhibit the conversion of angiotensin I to angiotensin II, but they also block the metabolism of bradykinin, thus elevating bradykinin levels. Cough and other side effects of ACEIs are believed to be due to increased bradykinin. ARBs do not inhibit bradykinin metabolism; instead these block angiotensin receptors. Hence, they have limited, if any, potential in causing cough.

97. A 56-year-old woman is currently being treated with daily warfarin for thrombophlebitis. She has contracted a serious lower respiratory tract infection and is admitted to the hospital. The patient is started on ciprofloxacin upon admission, and after 3 days of treatment, her INR increases from 2.7 to 7.4. She also reports a nosebleed on the third night in the hospital. Her lower respiratory function has improved slightly, but the infection has still not resolved. Which of the following is the most likely explanation for the increase in the patient's INR? (A) decreased warfarin absorption in the small intestine (B) decreased warfarin metabolism by the liver (C) increased plasma protein binding of warfarin (D) increased warfarin absorption in the small intestine (E) increased warfarin metabolism by the liver

97. (B) There are several clinically important warfarin drug interactions, with most of them causing an increase in the drug's anticoagulant effect (ie, increasing the INR). Warfarin metabolism occurs via hepatic cytochrome P450 enzymes that can be inhibited by a large number of drugs, including the fluoroquinolones. When this inhibition occurs, plasma levels of warfarin rise, thereby enhancing the anticoagulant effect.

98. Which of the following medications increases the risk of developing Reye syndrome in the pediatric patient when used to treat influenza and other viral illnesses? (A) acetaminophen (B) aspirin (C) ibuprofen (D) oseltamivir (E) naproxen

98. (B) The pathogenesis of Reye syndrome is unknown, but there appears to be a potential association between aspirin use and the development of the disease. Reye syndrome is marked by hepatic failure and encephalopathy and has a poor prognosis.

99. Which of the following combination of drugs can be used effectively for prophylactic treatment of variant (Prinzmetal) angina? (A) diltiazem & atenolol (B) diltiazem & isosorbide dinitrate (C) isosorbide dinitrate & atenolol (D) lisinopril & atenolol (E) lisinopril & diltiazem

99. (B) Both organic nitrates and calcium channel blockers are effective prophylactically for spasm of coronary arteries. The use of β-blockers is not advised because the use of these drugs can cause unopposed α1-mediated vasoconstriction of coronary arteries, thereby worsening the ischemia. ACE inhibitors do not have a role in the treatment of variant angina.