Combo with Last but not least and 1 other

Glycylcylclines- Tigecycline

Structurally similar to tetracyclines USE against: • Broad-spectrum against multidrug-resistant Gram positive, some Gram-negative & anaerobic organisms Resistance is VERY low except d/t the efflux pumps [ Proteus and pseudomonas] MOA: Complicated skin infections soft tissue and intraabdominal infections **** increase risk of mortality****

Which of the following· best describes the mechanism of action of hydroxyurea?

Increases HbF synthesis An analog of urea • Inhibits the enzyme *ribonucleotide reductase* resulting in the depletion of deoxynucleoside triphosphate pools, thereby inhibiting DNA synthesis • S-phase specific agent Use: CML, Melanoma AE: Leukopenia, mild GI, dermatological changes w/ long term

AIDS patient is being treated with zidovudine, lamivudine, indinavir, fluconazole and co-trimoxazole. He *develops buffalo hump*, gynecomastia, hyperglycemia, hyperlipidemia, and nephrolithiasis. Assuming that these changes are a consequence of his drug treatment, the most likely cause is

Indinavir - high fat meals decrease bioavailability. A/E: • Parathesias, nausea, vomiting, diarrhea • Disturbances in lipid metabolism (diabetes, hypertriglyceridemia, hypercholesterolemia)

A 34-year-old diabetic female suffers from a complicated urinary tract infection. She is treated with ciprofloxacin. Which of the following statements describes the molecular mechanism of action of ciprofloxacin?

Inhibition of DNA gyrase (2 and 4)

14-year-old boy is hospitalized with headache, nausea and fever. A physical examination is significant for neck stiffness. Gram-negative cocci in pairs are revealed during CSF microscopy, strongly suggestive of Neisseria meningitidis. Which of the following is the best way to prevent infection in his family members and other close contacts?

Prophylaxis against mengitis = RIFAMPIN, CEFTRIAXONE, CIPROFLOXACIN DOC N.meningitidis = Ceftriaxone

S Phase specific

*All Antimetabolites* Cytarabine, Capecitabine, 5-Fluorouracil, 6-Mercaptopurine, 6-Thioguanine, Gemcitabine, Methotrexate *Hydroxyurea*

Isolates of M tuberculosis obtained from a 45-year-old HIV-positive male demonstrate resistance to a number of antibiotics. Which of the following is most likely to be the cause of resistance to streptomycin in these bacteria?

*Altered structure of bacterial ribosomal proteins* 3 principal mechanisms for AMINOGLYCOSIDE RESISTANCE 1) Plasmid-associated synthesis of enzymes that modify and inactivate drug (main) 2) Decreased accumulation of drug 3) Receptor protein on 30S ribosomal subunit may be deleted or altered due to mutation

A man with poor dentition is scheduled to have all his remaining teeth extracted for subsequent fitting of dentures. His medical history is remarkable for prosthetic valve replacement 5 years ago. He is not allergic to any drugs. His physician decides to *administer prophylactic therapy for infective endocarditis*. Which of the following drugs should be administered to this patient? A. Co-trimoxazole B. Aztreonam C. Gentamicin D. Penicillin G E. Amoxicillin

*Amoxicillin*

A 5-year-old boy presents to his family physician with a ear infection. Which of the following antibiotics is contraindicated in this child?

*CIPROFLOXACIN* *Fluoroquinolones* (preggers, nursing, under 18)- Connect tissue, Ciprofloxacin, Levofloxacin, *Tetracyclines* (preggers and children under 8) Doxycycline, Minocycline, Tetracycline *Tigecycline* (preggers and under 8) *Sulonamides* - preggers, neonates (under 2m) *CefaTRIAXONE* - preggers, neonates *Nitrofurantoin* - preggers at term 38-42 weeks or infants under 1 month (risk hemolytic anemia) *Fidaxomicin* safety + effectiveness not established in pts under 18 (GI disorders) *Albendazole* preggers and children under 2 (Mebend, Niclosamide under 2, Thiabendazole, Ivermectin) *Primaquine* - do not use during preggers bc fetus is G6PD relative deficient *Ribavirin* preg cat X *Metronidazole* preggers safety not established

A 34-year-old man receiving chemotherapy for testicular carcinoma develops signs of renal tubular damage. Which of the following drugs is most likely responsible for his nephrotoxicity? A. Vinblastine B. Cyclophosphamide C. Cisplatin -cissy the pissy (nephro problems) platin (braids) over her ears (ototoxicity) D. Paclitaxel E. Bleomycin

*Cisplatin* - Nephrotoxicity and Deafness *Paclitaxel*- Bald allergic pax the tax man who sits outside the breast and ovary cancer center in his new cremphor vechile (M phase microtubular arrest) *vinblastine* - BM supression, blast your balls (test cancer) *Cyclophosphamide* (hemorrhagic cystitis -also seen w/ Ifofamide) *L-Asparaginase* - Pancreatitis + bleeding *Vincristine* - peripheral neuropathy *Doxorubicin + Daunorubicin* - Dilated cardiomyopathy

78-year-old woman is diagnosed with metastatic breast cancer. She is treated with an opioid analgesic for bone pain. The opioid is very effective in controlling the pain during the first week of therapy but the analgesic effect wanes after a while. You explain to the patient that tolerance to the effect of the opioid has developed and a dose increase is necessary. Which of the following opioid effects is most resistant to tolerance development?

*Constipation * [u,S receptors] Tolerance to constipation may develop very slowly, if at all. • A laxative should be prescribed when an opioid is started. • Usually a stimulant laxative is prescribed. • A combination stimulant/softener can be useful (senna + docusate to tx or alviopan,methylnaltrexone which block mu-receptors but do not enter CNS) -Urticaria, pruritis can be managed with hydroxyzine or diphenhydramine -N+V tolerance in a few days tx with hydroxyzine, metoclopramide or prochlorperazine -Sedation disppears over a few days -Respiratory Deepression tolerance develops quickly - but can give naxloxone if necessary

A 56-year-old man has prostate cancer that will be treated with leuprolide. Which of the following drugs must be used adjunctively at the beginning of the chemotherapy?

*Flutamide* Given with GnRH agonists to prevent initial tumor flare-up -approved for Prostate cancer treatment *leuprolide + Goserelin* Use: Prostate cancer, fibriod uterus [Antiandrogens - Gonadotropin-Releasing Factor] -continuous dose will produce reversible medical castration, LH + FSH

A 50-year-old man has suffered third-degree burns over 80% of his body. He now suffers a Gram-negative infection acquired in the hospital. He is prescribed imipenem. Which of the following drugs must be co-administered with imipenem?

*Impienem + Cilastatin* • IV • Imipenem forms potentially nephrotoxic metabolite. Combining with enzyme inhibitor Cilastatin prevents metabolism thus prevents toxicity & increases availability. • Meropenem is not metabolized by same enzyme (no need for Cilastatin) AE: • GI distress (nausea, vomiting, diarrhea) • High levels of imipenem can provoke seizures • Allergic reactions (partial cross-reactivity with penicillin's)

Pancreatitis

*L-asparaginase* (also causes bleeding,hyperglycemia) - used in childhood leukemias *Didanosine* (hypertriglyceride, peripheral neuropathy

A 34-year-old man has a long history of heroin abuse and several addiction treatment failures. He is referred to a methadone detoxification program that turns out to be effective. Which of the following properties of methadone makes it an effective agent for heroin detoxification?

*Methadone long half life and less profound sedation + eupohoria* -abstinence syndrome prolonged by less severe than heroin -equal potency to morphine -less euphoria but longer duration of action - u receptor against, NMDA antagonist, and Sertonin and NE reuptake inhibitor Note: Levomethadyl acetate had an EVEN longer half-life (approved by FDA)s

QT prolong

*Methadone* torsades de pointes and death TCAs - avoid in patients with heart conduction problems *Macrolides* *Fluoroquinolones* QT prolongation (moxifloxacin, gemifloxacin,levofloxacin) *Quinine,Quinidine* (& hypotension,blackwater fever) *Artemisinin* (overall safe, hi dose neurotoxicity) *Lumefantrine* (minor antimalarial)

A tentative diagnosis of diabetic gastroparesis due to autonomic neuropathy is made. The physician prescribes a drug to increase gastrointestinal motility. The drug is

*Metoclopramide* Prokinetic (5-HT4 agonist) by accelerating gastric emptying and intestinal motility Anti-emetic (5-HT3 antagonist) USE: Treats Diabetic and Post-OP induced gastroparesis and as an Anti-emetic -reduces N + V from chemotherapy AE: via ANTI-DOPAMINERGIC - Sedation, Diarrhea, Parkinsonian effects Also diabetic neuropathic pain = *Amitriptyline + Imipramine* [TCAs] *Venlafaxine + duloxetine* [SNRIs] (AE:Nausea, sexual dysfunction, somnolence and SNRIs are better tolerated than TCAs) *Tramadol* *Gabapentin* *Pregabalin*

takes ibuprofen for osteoarthritis reports abdominal cramping after starting a drug prescribed to prevent NSAID-induced peptic ulcer. Which of the following drugs most likely caused this adverse effect?

*Misoprostol* is a synthetic prostaglandin E1 analog. Misoprostol has both acid inhibitory and mucosal protective properties. It stimulates production of *mucus and bicarbonate and enhances mucosal blood flow.* The use of misoprostol is limited because of its *potential to cause diarrhea (in up to 30% of patients) and abdominal cramping, nausea and flatulence.* NSAID ulcers should be treated with PPIs they support platelet aggregation and maintain clot integrity - used in hemorrhage ulcers

A 46-year-old man has severe diarrhea as a result of a carcinoid tumor. Which of the following would be an appropriate treatment for this patient

*Octreotide* USE: controls diarrhea associated with CARCINOID TUMORS, VIPomas, Acute Variceal bleeding, ACROMEGALY and alters portal blood flow also used in tx bleeding varices or high risk repeat bleeders (variceal hemorrhage via IV) AE: Abdominal Cramps, Nausea, Steatorrhea, Gallstones from reduced Pancreatic Exocrine activity but Endocrine activity is decreased as well

A woman has a syndrome characterized by severe gastric hyperacidity and gastrinomas. Which is the most effective drug for treating this syndrome in this patient?

*Omeprazole:* multiple endocrine neoplasia or Zollinger-‐Ellison syndrome.

A man develops anorexia, abdominal pain and diarrhea. Blood tests show eosinophilia, and a stool sample shows the presence of Taenia saginata. What drug is most appropriate to treat this helminthic infection in this patient?

*Praziquantel* or niclosamide! *MOA* • Increases permeability to calcium, paralysis of worm musculature. *A/E*: CYP 450 and YOU CANT give her in ocular cysticercosis = damage to the eye.

Drug of Choice for HSV keratoconjunctivitis and recurrent epithelial keratitis

*TRIFLURIDINE* Effective HSV-1,2, Vinca Transient irritation of eye & palpebral (eyelid) edema

A woman entering your cancer clinic is concerned about her chance of developing breast cancer. Her mother died of the disease and her sister has been diagnosed with the disease. A breast examination is negative. Which of the following might be used prophylactically in this woman

*Tamoxifen*: SERM w. antagonist effect on breast but agonist on endomet + bone. AE: hot flash, thrombosis, edema, endometrial cancer • Used as primary therapy for metastatic breast cancer in both men and postmenopausal women • *Decreases the incidence of breast cancer in women who are at high risk for developing the disease.*

After a week camping in the mountains a 35-year-old man develops watery diarrhea and abdominal cramps. The physician suspects he is showing symptoms of giardiasis and decides to institute empirical treatment with: A. Tinidazole B. Trimethoprim-Sulfamethoxazole C. Nifurtimox D. Pentamidine E. lvermectin

*Tinidazole*: Similar to metronidazole but better tolerated and has shorter treatment course MOA: *non-enzymatically reduced* by reacting with reduced *ferredoxin*=> causes the production of cytotoxic compounds

A 45-year-old man receives treatment with the F-CL regimen (5-fluorouracil plus leucovorin) after curative resection of a stage Ill colon cancer. Why is leucovorin added to the regimen?

*To potentiate the inhibition of thymidylate synthase by 5-FU* - 5-FU is also incorporated into RNA. - A/e *Skin exfoliation on palm and feet "hand-foot syndrome"*

potential renal adverse effects of NSAIDs?

*decrease renal blood flow* *acute interstitial nephritis* *analgesic nephropathy*

Meperidine has a half-life of 3 h. What are the side effects?

*tremulousness, dysphoria, myoclonus, and seizures, dilated pupils, muscle twitches, convulsions* Its principal metabolite, normeperidine, has no analgesic properties, has a half-life of 15-20 h, and produces significant adverse effects when it accumulates

Inhibits peptidyl transferase

...

Inhibits thymidylate synthase

...

A sexually active harris has recurring herpes genital is. Which of the following drugs would be most appropriate for treatment of recurrent herpes ?

Acyclovir: Commonly used for *genital herpes infections & prophylactically* in immunocompromised and transplant patients.

45-year-old man returns from a long trip to South America and is diagnosed with lung cysts due to infection with Echinococcus granulosus. The cysts are deemed inoperable. Which of the following is the drug of choice to treat this patient's conditio

Albendazole

29-year-old man being treated for leukemia develops a fever. His physician administers several agents that will cover bacterial, viral and fungal infections. Two days later he develops acute renal failure. Which of the following drugs was most likely responsible?

Amphotericin B

Preferred treatment for deep fungal infections during pregnancy

Amphotericin B by slow IV infusion

A woman has breast cancer that is metastatic to the axillary lymph nodes. The primary tumor is excised and chemotherapy, including cyclophosphamide and tamoxifen, is started. Which of the following mechanisms best explains the likely beneficial effect of tamoxifen in this patient?

Antagonism at estrogen receptors: • Selective Estrogen Receptors Modulators: They exhibit agonistic action in some tissue and antagonists in other tissues. •*Tamoxifen*: *Antagonist* effect on breast tissue but *agonistic* effect on endometrium & bone. •*Raloxifene*: *Antagonist* at breast & endometrium but *agonist* at bone

A man visits country where chloroquine-resistant P. falciparum is endemic. His blood tests positive for malarial parasites. He is treated with antimalarial drugs and develops megaloblastic anemia. Which of the following antimalarial drugs may have cause this adverse effect?

Antimalarials that are folate synthesis inhbitors • Sulfadoxine: More specific for hematological side effects. • Pyrimethamine + proguanil = inhibit plasmodial dihydrofolate reductase • Sulfonamides = inhibit dihydropteroate synthase

P. Aeruginosa

Antipseudomonal B-lactam + ciprofloxacin -Carbenicillin, Ticarcillin, Piperacillin

A pregnant woman with a known history of *penicillin allergy* presents with an upper respiratory infection due to *Streptococcus pneumoniae*. Which of the following drugs is most likely to be appropriate in terms of both effectiveness and safety?

Azithromycin: Increase tissue penetration and *no effect on CYP 450* improved oral absorption, longer 1/2 increased bioavailability to erythromycin. • *Common substitute for patients with penicillin allergy*

If allergic reaction only presents with respiratory symptoms give what txt:

B2 receptors agonists

Mupirocin

Binds isoleucyl transfer-RNA synthetase resulting in the inhibition of protein synthesis; • Eradication of nasal colonization with MRSA in adult patients and healthcare workers • Treatment of impetigo or secondary infected traumatic skin lesions due to S.aureus or S.pyogenes

A man complains of severe headaches that do not respond to conventional analgesics. A CT scan shows a tumor located on the left side of the brain. The tumor is removed and biopsy shows a highly malignant glioblastoma. Which of the following drugs, when given systemically, is most likely to slow the regrowth of the tumor?

Carmustine Lomustine and Semustine *All nitrosoureas cross the blood brain barrier* A/E: The *chloroethyl moiety of nitrosoureas* is capable of alkylating nucleic acids and proteins, producing single-strand breaks and inter strand cross-linkage of DNA

A 59-year-old male patient with multiple medical problems is taking several drugs, including warfarin, quinidine and phenytoin. Dosages of each drug are adjusted carefully to prevent harmful drug interactions. However, the patient suffers some gastrointestinal distress and begins consuming an over-the-counter remedy for heartburn. He presents with toxic effects from all his medications. He almost certainly took which over-the-counter drug?

Cimetidine

Travelers diarrhea (E.coli) treat with which antibiotic

Ciprofloxacin

A primigravida patient is administered indomethacin in order to delay preterm labor. Which of the following is a potential adverse effect of the use of indomethacin?

Closure of the fetal ductus arteriosus Indomethacin: DOC in gouty arthritis

DOCs for Opportunistic Infections in HIV from lab

Cytomegalovirus retinitis: Ganciclovir Herpes simplex virus disease: Acyclovir Bacterial respiratory diseases: High-dose amoxicillin or amoxicillin/clavulanate + azithromycin or clarithromycin) Disseminated Mycobacterium avium complex (MAC) disease: Clarithromycin + ethambutol; addition of rifabutin may also be considered: Candidiasis (mucosal): Fluconazole Aspergillosis, invasive: Voriconazole Chagas disease (American trypanosomiasis): Benznidazole (not commercially available in the U.S., contact the CDC Drug Service); Alternative therapy: Nifurtimox

A baby girl presents with fever and earache. The pediatrician notes meningeal irritation. The girl is hospitalized and diagnosed with *meningitis caused by a beta-lactamase-positive strain of Haemophilus influenzae*. Which of the following drugs is most likely to provide effective treatment for this patient? *** DOUBLE CHECK THIS ONE****

DOC for meningitis due to ampicillin-resistant H.influenzae

Toxoplasmosis

DOC: Pyrimethamine + clindamycin or sulfadiazine or folinic acid Lab says DOC: Pyrimethamine + sulfadiazine + leucovorin

A 62-year-old black man with a history of glucose-6-phosphate dehydrogenase deficiency presents with fever, irritative voiding symptoms, and perineal pain. Rectal examination is remarkable for a tender prostate. A urine Gram's stain is positive for gram-negative rods. He is diagnosed with acute prostatitis. The risk for development of hemolytic anemia is highest if he receives high-dose therapy with

DONT use : · co-trimoxazole **** *Can use Fosfomycin* : • Inhibits cytoplasmic enzyme *enolpyruvate transferase* in early stage of cell wall synthesis • Active against G+ and G- • Used for treatment of uncomplicated lower UTI's NALODIXIN ACID *Nitrofurantoin*: *MOA* Reduction by bacteria in the urine leads to formation of reactive intermediates that subsequently damage bacterial DNA *Use* LTI *Nalidixic acid* Uncomplicated UTI's *COMPLICATED UTI *= Aminoglycoside

Cat C pregger drugs

Delaviridine

Stimulates appetite

Dexamethasone Progestins (also helps with endometrial cancer) -Hydroxyprogesterone + Megesterol Androgens -Fluoxymesterone + testosterone

Following surgery for breast cancer, a patient is to undergo chemotherapy with a regimen that consists of cyclophosphamide, 5-fluorouracil and doxorubicin. Which of the following drugs is most likely to be protective against the toxicity of doxorubicin?

Dexrazoxane, an Iron chelating agent is used reduce free radical induced damage.

Which of the following antiamebic drugs acts exclusively or predominantly in the lumen of the bowel?

Diloxanide furoate: converted in the gut to the active form AN alternative to diloxanide furoate for mild to severe infections *IDOQUINOL * *Paromomycin*= only against luminal forms of e. histolytica and tapeworm

A 60-year-old woman is receiving the CHOP-BLEO regimen (cyclophosphamide, doxorubicin, vincristine, prednisone and bleomycin) for treatment of a non-Hodgkin's lymphoma. Which drug in the CHOP-BLEO regimen may cause irreversible cardiomyopathy?

Doxorubicin (Adriamycin) or daunorubicin and give *Dexrazoxane* to chelate the iron. *Cell cycle non specific* *MOA*: inhibit topo 2 *A/E*: Erythema at sites of prior radiation "Radiation recall reaction"

62-year-old woman is diagnosed with metastatic non-small-cell lung cancer. Her tumor does not respond to a combination regimen of cisplatin and paclitaxel. Treatment with the EGFR inhibitor erlotinib is initiated. By which molecular mechanism does erlotinib inhibit the activity of the epidermal growth factor receptor

Erlotinib is an inhibitor of the EGFR tyrosine kinase.

A male is undergoing treatment for active tuberculosis. - He complains of inability to discriminate between *green and red*. Which one of the following drugs may be causing this problem?

Ethambutol: • Inhibits arabinosyl transferases • Dose-dependent visual disturbances (eg, red/green color blindness) - cannot be used in children too young to receive sight tests • Resistance is generated by mutation in *emb gene*.

A male with suspected bacterial pneumonia is admitted to the hospital and given ceftriaxone and azithromycin for treatment. Soon after the first dose of ceftriaxone, he complains of difficulty breathing, abdominal cramps and lightheadedness. His blood pressure drops to 70/50 mmHg, while his heart rate is 125/min. Physical examination reveals a diffuse maculopapular rash. Which of the following drugs should be administered to this patient?

Epinephrine (i.m), Hydrocortisone (i.v), Anti-histaminics (i.v) were administered immediately.

57 -year-old woman is being treated for metastatic ovarian cancer with cisplatin and cyclophosphamide. To prevent nausea and vomiting, she is given a selective antagonist of 5-HT 3 receptors. Which antiemetic is this patient most likely taking?

Metoclopramide

If allopurinol is administered to a patient receiving chemotherapy to reduce hyperuricemia, it is important to decrease the dose of this drug.

Mercaptopurine(purine antagonist): • 6-MP is metabolised to thiouric acid by xanthine oxidase. • Dose of 6-MP must be reduced if coadministered with allopurinol

A 45-year-old man diagnosed with AIDS presents with cryptococcal meningitis. He refuses to be administered any drugs by the IV route. Which of the following antifungal agents can be given orally and is effective in treating the fungal infection?

Fluconazole: • *Good CSF penetration*. • High oral bioavailability. • Available in oral and IV formulations.

24-year-old patient with AIDS is being treated with zidovudine, lamivudine, nevirapine, cotrimoxazole, acyclovir,clarithromycin and fluconazole. The drug most likely to provide prophylaxis against cryptococcal meningitis is

Flucoazole

IF allergic reaction only presents as a rash give what drug

For rash only: anti histaminics and observation

The combination of opioid and nonopioid analgesics often results in analgesia superior to that produced by either agent alone. What happens when giving opioid + mixed opioid?

Further, agonist-antagonists are not recommended as routine analgesics, as their dosing is limited by a ceiling effect. • Additionally, *pentazocine* and *butorphanol* cause psychotomimetic adverse effects in patients who are already fearful and anxious. (mixed = pentazocine, butorphanol, nalbuphine do not use in patient on pure agonist opioid - causes withdrawl)

33-year-old female patient with a history of IV drug use and AIDS complains of difficulty reading and says she "sees spots". A diagnosis of CMV retinitis is made. Which of the following drugs would be most appropriate for the treatment of CMV retinitis in this patient?

Ganciclovir Analog of acyclovir (8-20 x activity against CMV) • Drug of choice for CMV retinitis & CMV prophylaxis in immunocompromised MOA • Phosphorylated by viral (UL97) and cell kinases • DNA chain terminator & DNA polymerase inhibitor • Reduced intracellular phosphorylation •Mutations in phosphotranferase (UL97), or viral DNA polymerase PK Ganciclovir (IV), Valganciclovir (oral) undergoes rapid hydrolysis in intestine & liver to ganciclovir • Excretion via urine AE = myelosuppression, dose-d neutropenia CI = Preggers class C

A woman living in a nursing home develops a sore throat, cough, fever and dizziness. Her symptoms worsen, and she is hospitalized. Approximately 12 hours later she is transferred to the intensive care unit and placed on mechanical ventilation. *Influenza A virus* is isolated from a tracheal aspirate. What drug should be given to this patient? A. Ganciclovir B. lndinavir C. Amantadine D. Zidovudine E. Zanamivir

Ion channel blockers= Amantadine, Rimantadine *EXCLUSIVELY ACTIVE ON INFLUENZA A VIRUS* Equally effective in prophylaxis and treatment (70- 90%)

Which of the following is the mechanism of action of omeprazole?

Irreversible inhibition of H+K+- ATPase.

Ampicillin and amoxicillin are in the same group of penicillins. Which of the following statements best characterizes a distinguishing feature of amoxicillin?

It has a higher oral bioavailability than ampicillin.

Your cousin is planning a three-week trip overseas and asks your advice regarding medications for traveller's diarrhea. Which of the following drugs would be effective? A. Loperamide B. Docusate C. Aluminum Hydroxide D. Omeprazole E. Metoclopramide

LOPERAMIDE • Widely used in the treatment of diarrhea. • They act by through either *μ or δ* receptors on enteric nerves, epithelial cells, and muscle. • At usual doses, diphenoxylate and loperamide *lack analgesic effects*

35-year-old male with advanced HIV infection is hospitalized with a vesicular skin rash suggestive of `varicella zoster virus (VZV) infection. Viral strains isolated from this patient lack phosphorylating enzymes. Which of the following drugs is most likely to be effective in treating this patient's infection?

Major use is treatment of CMV-induced retinitis in HIV/AIDS • Not phosphorylated by viral kinases • Requires activation by host cell kinases • Effective against HSV & ganciclovir resistant HSV MOA • DNA chain terminator & DNA polymerase inhibitor

A malnourished 11-year-old girl from a rural area presents to the local clinic with weakness, fever, cough, abdominal pain and eosinophilia. *Ascaris lumbricoides, Necator americanus and Trichuris trichiuria*. Which of the following is the drug preferred in the treatment of this child?

Mebendazole & Albendaxole: *MOA*: • Inhibits microtubule synthesis & glucose uptake • *ATP production is decreased* resulting in worm immobilization and death

A 76-year-old man develops an intra-abdominal infection caused by a beta-lactamase-producing gram-negative organism. The patient has a history of renal problems and is allergic to penicillin. What drug is the most appropriate for treating the infection in this patient? A. Nitrofurantoin B. Aztreonam C. Cefepime D. Ceftazidime E. Metronidazole

Metronidazole (azeotreonam is acceptable but it does renal metabolism) HEPATIC METABOLISM Chloramphenicol, clindamycin, erythromycin, clindamycin, erythromycin, clarithromycin, nafcillin, Metronidazole, Ceftriaxone, Cefoperazone, doxycycline Metro is Hepatic metabolism Oral, IV, rectal or topical USE: C.difficile infections (drug of choice) • Anaerobic or mixed intra-abdominal infections • Vaginitis (trichomonas & bacterial vaginosis, G.vaginalis) • Brain abscesses • H.pylori eradication

A 35-year-old male patient presents with lower abdominal discomfort, flatulence and diarrhea. Entamoeba histolytica is identified in his stools. A diagnosis of intestinal amebiasis is made. His symptoms are indicative of severe disease. Which of the following would be the preferred treatment for this patient

Metronidazole plus diloxanide furoate (asym) (metro is also used for giardia lamblia, trichomonas vaginalis)

Treatment for C. Diff

Metronidazole, if doesnt work - Vancomyocin

45-year-old male with advanced HIV infection is treated with high-dose ganciclovir for hemorrhagic colitis. Antiretroviral therapy is also begun. Giving zidovudine to this patient is most likely to precipitate which of the following conditions?

Neutropenia *Zidovudine* - Thymidine analogue that is oral - crosses BBB most common AE = BM suppression (neutropenia, anemia) -GI, headaches, insomnia Toxicity potentiated by coadmin. of probenecid, acetaminophen, lorazepam, indomethacin & cimetidine. • Stavudine & ribavirin activated by same pathways (might reduce active levels of zidovudine)

A new drug is being investigated. It is found to significantly inhibit gastric HCI secretion *stimulated by muscarine, histamine and gastrin*. This drug is most similar to which of the following drugs?

Omeprazole

The physician identifies the lesion as a chancre of primary syphilis. What is the most appropriate treatment for this patient?

Penicillin G

67-year-old man with atrial fibrillation has been treated with warfarin and atenolol for one year. Two weeks after starting a new drug he experiences sudden onset hemiplegia. Transesophageal echocardiography reveals a small thrombus in the left atrium. The recently added drug was most likely A. Fluconazole B. Clarithromycin C. Ciprofloxacin D. Phenobarbital E. Cimetidine

Phenobarbital

A patient being treated for tuberculosis develops ~right orange-red urine and calls his physician because he is afraid this is a sign of hematuria. Which of the following medications is most likely to be producing this effect?

Rifampin

U.S. teacher is travelling to Malawi, where chloroquine-resistant P. falciparum is endemic. She is going to be there for 1 month, participating in an educational exchange program. She is 20 weeks pregnant. Which drug should she take for malaria chemoprophylaxis?

See table!

premature infant is born with elevated free bilirubin. The mother received an antibiotic combination containing sulfamethoxazole for a urinary tract infection near to delivery. You suspect that the high bilirubin is caused by the sulfonamide, because of the following mechanism:

Sulfonamides compete with bilirubin for binding sites on albumin

Burning on urination - She has no fever and no history of urinary tract infections. She is diagnosed with an uncomplicated acute UTI. What is the recommended therapy for this patient?

TMP-SMX

A man presents with a fungal infection of the fingernails. The physician prescribes an oral antifungal agent that acts by *inhibiting squalene epoxidase*. Which antifungal did he prescribe?

Terbinafine it is Allylamine. • Inhibition of squalene epoxidase prevents synthesis of ergosterol. • It also causes accumulation of toxic levels of squalene in the fungal cell. it *accumulates in keratin but is much more effective in onychomycosis.*

You see a 12-year-old boy from Haiti with brownish discoloured and deformed anterior teeth. He has been on drug treatment for severe pneumonia 8 years earlier. Which antibiotic drug could be responsible for his abnormal dentition?

Tetracycline

An woman presents to her physician because of severe cutaneous erythema, blistering and desquamation on the face and other sun-exposed areas. She was recently seen in the clinic for acne. The most likely cause of her current condition is: A. Metronidazole B. Tetracycline C. Erythromycin D. Ampicillin E. Clindamycin

Tetracycline • Most common use = severe acne & rosacea Also for the treatment of syphilis in penicillin allergic patients *A/E*= • Photosensitization & Dizziness, vertigo

A male patient presents to his primary care physician complaining of a rash on his trunk. The patient states that he went hiking with friends in Maine about two weeks earlier and that a few days after the hike he developed a fever and headache. Shortly thereafter he developed a rash on his palms and soles which slowly migrated to his wrists, ankles and now his trunk. The physician recognizes the symptoms of Rocky Mountain spotted fever and prescribes

Tetracyclines- Clinical applications • Rickettsia (Rocky Mountain Spotted Fever, typhus)

Treatment for Cryptococcal Mengingitis

The recommended initial standard treatment for cryptococcal meningitis is amphotericin B IV, plus oral flucytosine, as induction therapy for 2 weeks -After at least a 2-week period of successful induction therapy, defined as substantial clinical improvement and a negative CSF culture after repeat lumbar puncture, amphotericin B and flucytosine may be discontinued and consolidation therapy initiated with fluconazole. This therapy should continue for 8 weeks. -After consolidation therapy, daily maintenance (suppressive) therapy with fluconazole should be continued indefinitely unless immune reconstitution occurs as a consequence of ART. -Patients treated with amphotericin B should be monitored for dose-dependent nephrotoxicity and electrolyte disturbances. Preinfusion administration of normal saline appears to reduce the risk for nephrotoxicity during treatment. -Amphotericin B infusion-related adverse reactions may be ameliorated by pretreatment with acetaminophen and diphenhydramine. -Patients receiving flucytosine should have flucytosine blood levels monitored to prevent bone marrow suppression and gastrointestinal toxicity. -Persons treated with fluconazole should be monitored for hepatotoxicity

The sedative effect of benzodiazepines results from the following

They decrease the EC50 of GABA with respect to GABAA receptor-mediated chloride influx Notes: Antiemetic potency of *lorazepam, alprazolam, and diazepam is low* but their beneficial effects for vomiting are based on sedative, anxiolytic, amnesic properties *useful in anticipatory vomiting*

A female is taking medication for a recently diagnosed medical problem. While at a party she develops facial flushing, headache, nausea, vomiting and abdominal cramps .immediately after having an alcoholic drink. This patient is most likely being treated for which of the following conditions?

Trichomonas vaginitis= metro

Pneumocystis jiroveci. He is not allergic to any drugs. Which of the following is the first choice for the treatment of Pneumocystis infection

Trimethoprim/sulfamethoxazole -Clindamycin + primaquine. -Dapsone + TMP (mild-to-moderate PCP only). -Atovaquone (mild-to-moderate PCP only). -Pentamidine (high rate of side effects: acute renal failure, hypotension, pancreatitis, hypo- and hyperglycemia, and electrolyte abnormalities).

A 23-year-old man is brought to the ER in a deep coma. He is cyanotic and unresponsive to painful stimuli. His blood pressure is 100/60 mmHg and his pulse is 1 00/min. His respiratory rate is 4/min and his temperature is 36.7 C (98 F). His pupils are constricted and poorly responsive to light. He is administered a drug IV and several minutes later the patient regained consciousness. The drug used in this patient's resuscitation procedure displays the greatest affinity for which of the following receptors?

U receptors Miosis • Due to excitatory action on the parasympathetic nerve innervating the pupil. • Following toxic doses of U agonists pinpoint pupils are pathognomonic. The majority of opioid analgesics act primarily at the U receptor. • Analgesia, euphoria, respiratory depression, and physiological dependence result mainly from activation of U receptors. • S and K receptors also contribute to analgesia, particularly at the spinal level. All opoid receptors are Gi

Physical examination reveals a heart murmur and petechial skin lesions. The signs and symptoms are strongly suggestive of infective endocarditis. The attending physician decides to institute empirical antimicrobial therapy. Which of the following is the recommended empirical therapy for this patient?

Vancomycin plus gentamicin: In combination with an aminoglycoside: •empirical treatment of infective endocarditis •enterococcal endocarditis or PRSP

A man presents with fever and chills. Blood cultures reveal MRSA. He is begun on an IV antibiotic. About 15 minutes after the initiation of the infusion the patient develops severe flushing of the skin. Which of the following drugs may have caused this adverse effect?

Vancomycin: Requires slow IV infusion (60-90 min) because of • 'Red man' or 'red neck' syndrome (infusion-related flushing over face and upper torso) ALSO A/E • Ototoxicity (drug accumulation) • Nephrotoxicity (drug accumulation)

M Phase specific

Vincristine - all Vinca Alkaloids (vincristine, vinblastine, vinrelbine) -all Taxanes (docetaxel, paclitaxel)

nurse taking a routine blood draw from an HlV patient sustains an accidental deep puncture with the contaminated hypodermic needle. Which of the following is the appropriate course of treatment for the nurse?

Zidovudine plus lamivudine plus efavirenz

On average, people of East Asian origin respond more favorably to treatment of non-small cell lung cancer with gefitinib than Caucasians because of a higher proportion of

a mutation in the tyrosine kinase domain of the epidermal growth factor receptor

Leukovorin

enhances 5-FU -leads to incorption of more 5-FU into RNA metabolite

A 14-year-old boy with severe asthma is on various antiasthmatic drugs, including albuterol, salmeterol, budesonide, and theophylline. He has a history of allergy to beta-lactam antibiotics. When infections with Bordetella pertussis are reported from his neighbourhood, his physician puts him on a macrolide for preventive treatment. The physician prescribes azithromycin, because compared to other macrolides

it does not inhibit the hepatic cytochrome P450 system. DOC B. Pertussis = Erythromyocin but not in this case Alt is TMP-SMX

He is severely ill and has responded poorly to several antipsychotics, including haloperidol. Plasma levels of his antispychotic drugs are measured after supervised oral administration and show abnormally low values. This patient is most likely to be an ultrarapid metabolizer due to

multiple copies of the CYP2D6 gene

A man comes to the physician because of a fever, headache, malaise, cough and sore throat. The causative virus is established, and the patient is given zanamivir. Which of the following is the mechanism of action of zanamivir?

oseltamivir and zanamivir: Neuraminidase Inhibitors-> Effective against BOTH *Type A and Type B* Influenza. • Oseltamivir: *orally active* prodrug (hydrolyzed in liver); Gi discomfort & nausea • Zanamivir: *NOT orally active* (inhaled, intranasal); Airway irritation

male is diagnosed with active pulmonary tuberculosis. He is started on the recommended typical first line antituberculous drugs. Pyridoxine is also prescribed in order to

reduce the hematological toxicity associated with isoniazid AE: NHLc (neuritis, hepatoxic, cyp inhib, lupus-like syndrome) Safe in preggers but hepatitis risk increased - pyridoxine supplementation is recommended

After surgery why is the bioavailability of PI reduced

α1-acid glycoprotein can increase in response to trauma & surgery

Action of opioids

• The opioids have two well-established actions on neurons: • They close voltage-gated Ca2+ channels on presynaptic nerve terminals. • They open K+ channels on postsynaptic neurons. • Both actions reduce neurotrasmitter release -Inhibit ascending pain transmission. -Activate descending pain-inhibitory circuits (supraspinal analgesia) by inhibition of inhibitory neurons by opioids