MCQ 5 - Pharm

Lithium as an inorganic ion can freely cross the placenta. Because lithium is highly effective for some conditions its use may be determined to be necessary for relapse prevention in the mother. Maternal exposure to lithium during human pregnancy carries a significant risk of adverse pregnancy outcomes many of which are evident at the time of labor and delivery. Please describe the major adverse outcomes:

-significantly but small increased risk of congenital cardiac malformations, particularly Ebstein's anomaly, during lithium administration in the first trimester -neural tube defects before 20 weeks of gestation and higher rates of central nervous system and neuromuscular complications. -maternal pre-eclampsia, as well as polyhydramnios -floppy infant syndrome -preterm birth -lower Apgar scores

1. What is the risk of taking warfarin and duloxetine concurrently? 2. When do you predict to see the peak effect of adding duloxetine to warfarin? 3. Discuss your plan. Are you going to continue warfarin? If yes why? If not why, and what are your going to do about her thrombotic problem?

1. Considered a major interaction. As duloxetine depletes platelet serotonin.The risk of bleeding complications is elevated. PT/INR and aPTT may or may not be effected by this interaction. Patient should be advised. 2. The half life of warfarin and of many of the clotting factors influenced by warfarin is lengthy. The half life of duloxetine is also fairly lengthy (half a day to a full day). One to two weeks to see the full effect of the interaction, however the intensity can continue to increase over time. 3. She is doing very well on warfarin, and has difficulty with NPP. Can continue both medications if your patient is reliable about her appointments, has a good health literacy and is willing to continue on this option. Do check to see how she responds to duloxetine before committing to a long term regimen.

The half life of Lithium is approximately:

20 hours

Rasagiline

A clinical trial found neuroprotective effects in the low dose arm, but the high dose arm failed to demonstrate protective effect

Pramipexole

A mechanistic neuroprotective is possible due to its ability to scavenge hydrogen peroxide

Cowage

A supplement that contains levodopa

When delivering antibiotics to a patient with reduced renal clearance the antibiotic is often dosed less frequently. When compared to patients having normal renal function- for a given dose- increasing the dose interval often results in: A. A greater range between peak and trough and longer time interval between peak and trough effects. B. The patient with reduced renal function gets to steady state much faster. C. Antibiotics are unnecessary as the build up of metabolic products in renal dysfunction is bactericidal. D. Makes no difference

A. A greater range between peak and trough and longer time interval between peak and trough effects

Which of the following is NOT an example of when migraine prophylaxis is indicated? A. A patient who experiences mild migraines two times a month that respond well to NSAIDs B. A patient who experiences moderate migraines (once a month) and has uncontrolled hypertension and a history of GI bleed excluding her from treatment with triptans and NSAIDs C. A patient who experiences severe migraines several times per week requiring treatment with a triptan D. A patient who experiences a moderate migraine every month during her menstrual cycle that causes her to miss several days of work

A. A patient who experiences mild migraines two times a month that respond well to NSAIDs

Which of the following is accurate regarding immunomodulatory therapy for relapsing-remitting MS (RRMS)? A. Alemtuzumab is reserved for patients with RRMS who have an inadequate response to two or more other drugs for MS B. Natalizumab is indicated as part of combination therapy in patients with RRMS as part of a first-line DMT C. Glatiramer acetate is approved by the US Food and Drug Administration (FDA) to slow disability progression in patients with RRMS D. Fingolimod is primarily indicated for patients with RRMS who have other preexisting conditions, such as recent myocardial infarction or unstable angina

A. Alemtuzumab is reserved for patients with RRMS who have an inadequate response to two or more other drugs for MS [Alemtuzumab due to its toxicity is reserved for use in patients who have an inadequate response to two or more other drugs for MS. Glatiramer does improve the relapse rate, but it is unclear if Glatiramer improves progession of disease Natalizumab is indicated as monotherapy for the treatment of patients with relapsing forms of MS, to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations. It is generally used in patients who have not responded to a first-line DMT or who have very active disease Fingolimod is contraindicated in patients with recent myocardial infarction, UA etc.]

Which statement is NOT correct? A. Anticholinergic adverse effects of cholinesterase inhibitors are best managed with a scopolamine patch. B. Anticholinergic adverse effects of cholinesterase inhibitors can be managed by changing from oral therapy to topical therapy. C. Symptomatic bradycardia and syncope caused by cholinesterase inhibitors can precipitate fall-related injuries. D. Agitation when seen in conjunction with AD should be conservatively managed using neuroleptics only when other measures fail and using low dose neuroleptics for short periods of time.

A. Anticholinergic adverse effects of cholinesterase inhibitors are best managed with a scopolamine patch. [Scopolamine is anticholinergic]

Which statement best describes the properties of centralling acting medications: A. Can be taken orally; poorly soluble in water; complex metabolism and low extraction; large distribution volumes and lengthy half lives. Narrow Therapeutic Index (TI) B. Must be injected, eliminated by the kidney, short half lives; high therapeutic index. C. Can be taken orally; poorly soluble in water; high hepatic extraction; large distribution volumes and lengthy half lives. Narrow TI D. Can be taken orally; highly soluble in water; complex metabolism and low extraction; large distribution volumes and lengthy half lives. Wide TI

A. Can be taken orally; poorly soluble in water; complex metabolism and low extraction; large distribution volumes and lengthy half lives. Narrow Therapeutic Index (TI)

Which statement is correct? A. Differences between various benzodiazepines on various stages of sleep are of theoretical rather than clinical importance. B. Non pharmacologic treatments of insomnia such as observation of proper sleep hygeine, healthy diet and proper excercise should be recommended only to patients after prescribing a long term and high dose benzodiazepine regimen. C. Primary insomnia is the most common type of sleep disorder. D. Most medical conditions when left untreated result in a state of fatigue and help to restore proper sleep patterns.

A. Differences between various benzodiazepines on various stages of sleep are of theoretical rather than clinical importance.

Which agent should not be used for treatment or prevention of recurrence of Bipolar Disorder? A. Gabapentin B. Lithium C. Valproic Acid D. Carbamazepine

A. Gabapentin

Certain pharmacologic properties are common to substances of abuse. Identify the property that is not one of the common properties. A. Lengthy elimination half life B. Rapid drug delivery to central nervous system C. Enhance central action of dopamine D. Tolerance or sensitization in vulnerable host

A. Lengthy elimination half life

Identify the preferred medication for the pharmacologic treatment of chronic generalized anxiety disorder, also associated with MDD. A. Mirtazapine B. Gabapentin C. Lorazepam D. Melatonin

A. Mirtazapine [alpha 2 antagonist]

Identify the correct statement. A. Reverse tolerance is seen with cocaine B. Alkaloidal Cocaine is more water soluble than cocaine HCL C. Water soluble drugs always provide an intense high after inhalation D. Cocaine has a large therapeutic window

A. Reverse tolerance is seen with cocaine [-Cocaine HCl is water soluble/readily dissolves in water, Alkaloidal cocaine is lipid soluble. -Alkaloidal cocaine melts at body temp and therefore is readily absorbed after inhalation. -Cocaine has a very low TI]

Identify the incorrect statement. A. SSRI and SNRI medications act to reduce the build-up of brain-derived neurotrophic factor and thereby promote neurotransmitter activity. B. SNRIs are used to treat major depression and chronic pain disorders. Since SSRIs do not improve symptoms of chronic pain disorders the mechanism is likely due to inhibition of norepinephrine reuptake. C. Bupropion is used to treat major depression and as an aid in smoking sensation. Bupropion is not useful for generalized anxiety disorders most likely due to its mechanism of action. D. TCAs have uses that are similar to SNRIs.

A. SSRI and SNRI medications act to reduce the build-up of brain-derived neurotrophic factor and thereby promote neurotransmitter activity. [TCAs and SNRIs are used for MDD and chronic pain]

Although the dopamine hypothesis cannot explain all aspects of schizophrenia, especially cognitive impairment it is still relevant to understanding the mechanism of action of almost all the available medications. Which statement does NOT support the dopamine hypothesis? A. Several atypical antipsychotic medications have minimal activity at the D/2 receptor yet are at least equally effective if not more effective in schizophrenia. B. Many antipsychotic medications are strong antagonists to the D/2 receptors found in the central nervous system. C. Medications that increase dopaminergic activity such as levodopa and amphetamines aggravate or induce schizophrenic psychosis in some patients. D. Post-Mortem findings indicate that Dopamine receptor density is increased in the brains of untreated schizophrenic patients.

A. Several atypical antipsychotic medications have minimal activity at the D/2 receptor yet are at least equally effective if not more effective in schizophrenia.

Buprenorphine is similar to methadone in: A. efficacy B. safety C. Legal restrictions D. cost

A. efficacy [Buprenorphine is more expensive than methadone. As a partial opioid agonist, buprenorphine has a ceiling on its respiratory depressant effect, it is thus safer. Unlike methadone, buprenorphine can be prescribed for treatment of opioid withdrawal symptoms in an outpatient setting.]

Pharmacokinetics definition

Absorption, distribution, and elimination. What your body does to the drug.

Recombinant tissue plasminogen activator (tPA, alteplase) MOA

Acts like endogenous tPA to convert plasminogen to plasmin to degrade fibrin

Unicyclic side effects

Agitation, insomnia

Selegiline MOA

Antagonist of monoamine oxidase type B [used in parkinsons - slows breakdown on neurotransmitters]

TCA side effects

Anticholinergic effects including dry mouth, constipation, dizziness, and effects on near vision [TCAs - NET, SERT, autonomic, and histamine blockade]

SNRI MOA

Are chemical analogs of the TCAs but reuptake blockade is limited to serotonin and norepinephrine

Which option is the safest to select when a medication is required to manage EPS adverse effects of dopamine antagonists such as haloperidol? A. Levodopa/Carbidopa at the recommended starting dose B. Amantadine or Trihexphenidyl C. Pramipexole D. Tolcapone

B. Amantadine or Trihexphenidyl

Identify the preferred medication for the pharmacologic treatment of chronic generalized anxiety disorder, not associated with MDD. A. Diazepam B. Buspirone C. Ambien D. Xanax

B. Buspirone [serotonin partial agonist]

Benzodiazepines: A. Are all short acting B. Can be responsible for memory loss C. Exacerbate alcohol withdrawal D. Have a narrow therapeutic index

B. Can be responsible for memory loss [-Very lengthy half-lives with rapid onset -Uses: anxiety, insomnia, agitation, ethanol withdrawal, procedures -Have a moderate TI - wide safety margin -S/E: falls, memory loss, tolerance/withdrawal, respiratory distress]

The CSF culture found Haemophilus influenzae, beta-lactamase positive. Which regimen is the BEST option for JM? A. Acyclovir alone B. Ceftriaxone alone C. Ampicillin and dexamethasone D. Ceftriaxone and dexamethasone

B. Ceftriaxone alone

Ramelteon (Remeron) is a melatonin agonist. Which statement about ramelteon is NOT correct? A. Proven benefits are for improvement in sleep onset (10 minutes vs placebo) but not for sleep maintenance. B. Clinical trials demonstrated superior efficacy over melatonin and superior safety over benzodiazepines. C. Studies of Ramelteon in patients > 65 years failed to demonstrate hypnotic efficacy. D. There was an overall increase in adverse effects in patients treated with ramelteon, but there was not an statistically significant increase in any specific adverse effect.

B. Clinical trials demonstrated superior efficacy over melatonin and superior safety over benzodiazepines.

Which of the following is recommended in regard to disease-modifying therapy (DMT)? A. Clinicians should counsel patients with relapsing MS that teriflunomide use is safe during pregnancy and conception B. Clinicians should counsel patients with relapsing MS who are considering discontinuing natalizumab that doing so is associated with an increased risk for relapse or MRI-detected disease within 6 months C. Clinicians should counsel patients with relapsing MS that DMTs are intended only for symptom improvement

B. Clinicians should counsel patients with relapsing MS who are considering discontinuing natalizumab that doing so is associated with an increased risk for relapse or MRI-detected disease within 6 months

One group of antipsychotic medications are referred to as neuroleptics. This term is used in many clinical papers, and in most Pharmacology Textbooks. The origin of this term is based on the observation that these medications induce a state of Catalepsy when administered to rodents. Catalepsy is a trance like state with a loss of voluntary motion. Limbs tend to remain wherever they are placed for example. In humans these medications produce a high incidence of extrapyramidal (EPS) side effects. Therefore neuroleptics would also be considered to be: A. Benzodiazepines B. Dopamine antagonists C. Serotonin antagonists D. First line agents to improve symptoms in Parkinson's Disease

B. Dopamine antagonists

Which statement is INCORRECT? A. Alcohol is classified as a depressant B. Euphoria is a direct effect of alcohol ingestion C. Slow metabolizers of alcohol are less likely to abuse this substance D. Intoxication is commonly dysphoric

B. Euphoria is a direct effect of alcohol ingestion [Intoxication is more commonly dysphoria]

Which statement is correct? A. Tremor the most common adverse effect of Lithium is seen only at high doses. B. Lithium clearance depends on GFR. Lithium should be used with caution in patients with renal impairment or renal disease; dosage reductions are recommended. Adequate fluid intake and maintenance of salt balance are essential during lithium therapy. Diuretics, ACE inhibitors, and ARBs should be used cautiously. C. Lithium serum concentrations should be measured one hour after a dose is administered. D. Lithium acts by activating the inositol and glycogen synthase kinase (GSK-3) signaling pathways.

B. Lithium clearance depends on GFR. Lithium should be used with caution in patients with renal impairment or renal disease; dosage reductions are recommended. Adequate fluid intake and maintenance of salt balance are essential during lithium therapy. Diuretics, ACE inhibitors, and ARBs should be used cautiously. A: can be seen at low doses too C: should be measured 10-12 hours after dose D. it suppresses inositol and GSK-3

Patients who have experienced an ischemic stroke should be on secondary prevention, including all of the following except (as long as there are no contraindications): A. Blood pressure medication to keep their blood pressure at goal B. Nicotine C. Aspirin or anticoagulation (depending on etiology) D. High dose statin

B. Nicotine

A cholinesterase inhibitor can be thought of as: A. Anticholinergic B. Procholinergic C. Glutamate Agonists D. Dopamine Agonists

B. Procholinergic

COMT inhibitors: A. Can cause serious renal toxicity B. Prolong the half-life of levodopa without increasing the peak serum concentration C. Are used as mono therapy in PD D. Decrease the risk of dyskinesia in patients managed with levodopa

B. Prolong the half-life of levodopa without increasing the peak serum concentration

An 83 year old male patient with AD has shown no signs of improvement from donepezil for at least the past year. His GI effects are becoming intolerable and his children want to know if he can stop this medication. Your advice: A. Stopping donepezil could exacerbate his GI symptoms B. Stopping donepezil might result in lower mental status scores C. Donepezil efficacy increases over time D. All of the above

B. Stopping donepezil might result in lower mental status scores

Which statement is MOST correct? A. Zolpidem (Ambien), Zaleplon (Sonata), and Eszopiclone (Lunesta) are considered to be non-benzodiazepines because they do not bind to the GABA receptor. B. The mechanism of action of benzodiazepine anti-anxiety effects appears to be based on dis-inhibition. C. Barbiturates and alcohol bind to the same site on the GABA receptor as benzodiazepines. D. Barbiturates and alcohol have a wider safety margin than benzodiazepines because in addition to facilitating the GABA receptor their pharmacologic effects are off-set via interference with membrane fluidity, and barbiturates also depress glutamate activity.

B. The mechanism of action of benzodiazepine anti-anxiety effects appears to be based on dis-inhibition.

A 23 y/o female patient suffers from absence seizures. Which of the following statements about her drug management is NOT correct? A. Ethosuximide and valproic acid are preferred drugs B. The patient should be examined every 2 or 3 mo for deep tendon reflex activity C. The use of valproic acid in pregnancy may cause congenital malformations D. Weight gain is common in patients on valproic acid

B. The patient should be examined every 2 or 3 mo for deep tendon reflex activity [Ethosuximide and valproic acid are preferred drugs for absence seizures because they cause minimal sedation. However, valproic acid causes gastrointestinal distress and weight gain and is potentially hepatotoxic. In addition, its use in pregnancy has been associated with teratogenicity (neural tube defects). Peripheral neuropathy, including diminished deep tendon reflexes in the lower extremities, occurs with the chronic use of phenytoin not valproic acid.]

The LP results return for patient JM with the following results: 1,500 WBC/mm3 with 90% neutrophils, protein 250 mg/dL, glucose 35 mg/dL, and HSV pcr negative. Gram stain and culture are pending. Which regimen is the BEST option for JM? A. Acyclovir alone B. Vancomycin, ceftriaxone, and dexamethasone C. Vancomycin and ceftriaxone D. Vancomycin, ampicillin, ceftriaxone, and dexamethasone

B. Vancomycin, ceftriaxone, and dexamethasone

A 22-year-old man with a 5-year history of heroin addiction would like stop using but he is concerned about taking another opioid to treat addiction. He has heard that clonidine is an alternative that is not an opioid and asks if it could work for him. Which statement is most correct? A. clonidine is a controlled substance and there are restrictions on prescribing it. The most important side effect is edema. B. clonidine is less effective than methadone in treating opioid withdrawal symptoms. Hypotension and syncope is the most important side effect. C. clonidine is not effective in treating opioid withdrawal symptoms. The most important side effect is nausea.

B. clonidine is less effective than methadone in treating opioid withdrawal symptoms. Hypotension and syncope is the most important side effect. [Clonidine is most effective at reducing the symptoms of opioid withdrawal related to noradrenergic overactivity, such as GI symptoms, hyperhidrosis, anxiety, and irritability. In a Cochrane review, treatment completion rates with clonidine were similar to those with methadone, but clonidine appears to be less effective than methadone in relieving withdrawal symptoms and more likely to cause adverse effects, such as hypotension - b/c it is an antihypertensive.]

Tension headache symptoms

Bilateral, mild to moderate pressure, band-like sensation, radiating pain to neck/occipital region

Levetiracetam MOA

Binds synaptic vesicle protein SV-2-A preventing vesicle release reducing neurotransmitter release [seizure prophylaxis post-bleed]

TCA MOA

Block reuptake of monoamine, histamine, acetylcholine, and alpha 2 adenoreceptors

Carbamazepine MOA

Blocks Na+ channels at therapeutic concentrations and inhibits high-frequency repetitive firing in neurons

Phenytoin MOA

Blocks Na+ channels at therapeutic concentrations and inhibits high-frequency repetitive firing in neurons

After discontinuation of a long-acting opioid such as methadone or extended-release oxycodone, withdrawal symptoms usually develop within 30 hours. How long do they usually persist? A. 4-6 days B. 7-10 days C. 10-14 days D. 18-21 days

C. 10-14 days [After discontinuation of a short-acting opioid such as heroin or immediate-release hydrocodone, withdrawal symptoms usually develop within 12 hours, and persist for 3-5 days. Symptoms of opioid withdrawal include nausea, vomiting, diarrhea, abdominal cramping, myalgia, increased lacrimation, mydriasis, piloerection, hyperhidrosis, agitation, and anxiety.]

Identify the True Statement A. Legal drugs cannot be abused B. The majority of substance abuse is seen from using illegal drugs C. Abuse of legal drugs is more prevalent than illegal drugs D. Health care professionals are not susceptible to drug abuse

C. Abuse of legal drugs is more prevalent than illegal drugs

The basic chemical nucleus of the atypical agents varies between agents to a greater extent than seen with the phenothiazines. However the basic phenothiazine structure is still a component of these medications. These drugs share a greater ability to alter the 5-HT/2A receptor than to interfere with the D2 receptor. When compared to the phenothiazines and to haloperidol which of the following statements is NOT correct? A. Side effects such as Parkinson's syndrome, akathisia, and acute dystonic reactions are reduced. Atypicals are less likely to increase prolactin. B. Weight gain, serum lipid elevation, lowering of the seizure threshold, and QT interval prolongation are the most concerning side effects of the atypical antipsychotic medications. C. Atypical antipsychotics are much less expensive than the neuroleptics. D. Since all of these medications are highly active in the central nervous system it is not surprising that they have long half lives, and that they are eliminated by the CYP 450 system of the endoplasmic reticulum.

C. Atypical antipsychotics are much less expensive than the neuroleptics.

Which medication has the strongest evidence to manage benzodiazepine discontinuation syndrome? A. Buprenorphine B. Gabapentin C. Buspirone D. Phenytoin

C. Buspirone

Dopamine does not cross the blood-brain barrier and if given into the peripheral circulation has no therapeutic effect in parkinsonism. However, (-)-3-(3,4-dihydroxyphenyl)-L-alanine (levodopa), the immediate metabolic precursor of dopamine, does enter the brain (via an L-amino acid transporter, LAT), where it is decarboxylated to dopamine. Which response is correct? A. L-Dopa is an opiate/hypnotic B. L-Dopa is a serotonin antagonist C. Carbidopa a peripheral dopa decarboxylase inhibitor, reduces peripheral conversion of levodopa to dopamine but does not interfere with central decarboxylation of levodopa. D. Levodopa is an anticholinergic

C. Carbidopa a peripheral dopa decarboxylase inhibitor, reduces peripheral conversion of levodopa to dopamine but does not interfere with central decarboxylation of levodopa.

The monoamine hypothesis of depression suggests that depression is related to a deficiency in the brain of the amount or function of serotonin, norepinephrine and dopamine. All of the statements below are CORRECT. The monoamine hypothesis explains all of the statements EXCEPT: A. Treatments such as reserpine which deplete monoamines are associated with depression. B. A clinical response to an SSRI can be reversed by eliminating tryptophan from the diet. A clinical response to an SNRI can be reversed by agents which deplete catecholamines. C. Central monoamine levels increase immediately with antidepressant use, while maximal beneficial results are not seen for many weeks. Adverse effects of SSRI, SNRI, and TCA agents are seen immediately. D. All available antidepressants appear to have significant effects on the monoamine system.

C. Central monoamine levels increase immediately with antidepressant use, while maximal beneficial results are not seen for many weeks. Adverse effects of SSRI, SNRI, and TCA agents are seen immediately.

In class we discussed the case of a 74F patient with AD successfully managed with donepezil and multiple non-pharmacologic methods. For the past two months she reports urinary frequency, and burning on urination. She has had episodes of urinary incontinence managed with daily oxybutynin since this December. In the past month (February) her personality has changed from cooperative to non-cooperative, she displays lack of interest, apathy and tearfulness. Her MMSE assessment has significantly deteriorated since her last visit 2 months previous. This patient significantly improved after: A. Increasing the dose of donepezil, and adding Memantine B. Adjusting her dose of thyroid replacement C. Discontinue oxybutynin, and work up and then treatment of lower UTI. D. Switching from donepezil to topical Rivastigmine

C. Discontinue oxybutynin, and work up and then treatment of lower UTI.

Abrupt withdrawal of antiseizure drugs can result in increases in seizure frequency and severity. Withdrawal is most easily accomplished if the patient is treated with: A. Carbamazepine B. Clonazepam C. Ethosuximide D. Phenobarbital

C. Ethosuximide [Dose tapering is an important principle in antiseizure drug withdrawal. As a rule, withdrawal from drugs used for absence seizures such as ethosuximide is easier than withdrawal from drugs used for partial and tonic-clonic seizures. Withdrawal is most difficult in patients who have been treated with barbiturates and benzodiazepines.]

A 9-year-old child is having learning difficulties at school. He has brief lapses of awareness with eyelid fluttering that occur every 5-10 min. Electroencephalogram (EEG) studies reveal brief 3-Hz spike and wave discharges appearing synchronously in all leads. Which drug would be effective in this child without the disadvantages of excessive sedation or tolerance development? A. Clonazepam B. Diazepam C. Ethosuximide D. Gabapentin

C. Ethosuximide [This child suffers from absence seizures, and 2 of the drugs listed are effective in this disorder. Clonazepam is effective but exerts troublesome CNS-depressant effects, and tolerance develops with chronic use. Ethosuximide is not excessively sedating, and tolerance does not develop to its antiseizure activity. Valproic acid (not listed) is also used in absence seizures.]

When Ceftriaxone and Ceftazidime enter the CNS they result in: A. Low CSF concentrations and High MICs to CNS Pathogens. B. AUC/MIC = about 50% of the Typical bonus paid to Wall Street Executives. C. High CSF concentrations and Low MICs to CNS Pathogens. D. Prohibited by insurance companies. [MIC = minimum inhibitory concentration]

C. High CSF concentrations and Low MICs to CNS Pathogens.

All of the following are risk factors for stroke (ischemic and hemorrhagic) except: A. Race (African Americans with great risk) B. Age C. History of psychiatric illness D. Smoking E. Cardiovascular disease (hypertension, hyperlipidemia, coronary artery disease)

C. History of psychiatric illness

All of the following could be symptoms of stroke (ischemic and hemorrhagic) except: A. Decreased consciousness B. Headache C. Hyperactivity D. Trouble speaking E. Trouble walking

C. Hyperactivity

Which of the following drugs has been shown to reduce the duration of significant MS relapses? A. Metoprolol B. Amantadine C. IV Methylprednisolone D. Metoprolol XL

C. IV Methylprednisolone [Intravenous methylprednisolone (1000 mg daily for 3-5 consecutive days) is administered to reduce the duration of significant MS relapses. However, methylpred does not alter the frequency or risk for future relapses or disease progression.]

Use of second generation antipsychotic medications (risperidone for example) in patients with AD dementia has been shown to: A. Increase quality of life B. Improve functioning C. Increase the risk of death D. All of the above

C. Increase the risk of death [This question is on the picky side, but I chose it because the risk of severe AE is high when antipsychotic medications are used in AD. A single RCT supports the use of antipsychotic agents in dementia. This trial found modest improvement for anger, aggression and paranoid ideation. There was no change in functioning, care needs or QOL. Mortality is nearly doubled in patients with AD dementia taking antipsychotic medications to manage agitation.]

A young male patient recently diagnosed as schizophrenic develops severe muscle cramps with torticollis a short time after drug therapy is initiated with haloperidol. The best course of action is: A. Discontinue haloperidol and observe the patient B. Add oral diphenhydramine C. Inject benztropine D. Switch the patient to fluphenazine E. Add risperidone to the regimen

C. Inject benztropine [Acute dystonic reactions are usually very painful and should be treated immediately with parenteral administration of a drug that blocks muscarinic receptors such as benztropine. Adding risperidone is not protective, and fluphenazine is as likely as haloperidol to cause acute dystonia. Oral administration of diphenhydramine is a possibility, but the patient may find it difficult to swallow and it would take a longer time to act.]

Consider acetylcholine's role as a neurotransmitter. A. Acetylcholine is generally an inhibitory neurotransmitter B. Excitatory transmitter acting on the N-Methyl-d-aspartate (NMDA) receptor. C. Is an excitatory neurotransmitter effecting memory and cognition in the cerebral cortex and opposing dopamine in the basal ganglia. D. Serves an excitatory role by inhibiting GABA receptors

C. Is an excitatory neurotransmitter effecting memory and cognition in the cerebral cortex and opposing dopamine in the basal ganglia.

Which statement concerning the drugs used in parkinsonism is accurate? A. Dopamine receptor agonists should never be used in Parkinson's disease before a trial of levodopa B. Selegiline is a selective inhibitor of COMT C. Levodopa causes mydriasis and may precipitate an acute attack of glaucoma D. The primary benefit of antimuscarinic drugs in parkinsonism is their ability to relieve bradykinesia E. Therapeutic effects of amantadine continue for several years

C. Levodopa causes mydriasis and may precipitate an acute attack of glaucoma [The non-ergot dopamine agonists (pramipexole, ropinirole) are commonly used prior to levodopa in mild parkinsonism. The mydriatic action of levodopa may increase intraocular pressure; the drug should be used cautiously in patients with open-angle glaucoma and is contraindicated in those with angle-closure glaucoma. Antimuscarinic drugs may improve the tremor and rigidity of parkinsonism but have little effect on bradykinesia. Selegiline is a selective inhibitor of MAO type B. Amantadine is effective for only a few weeks.]

Ampicillin is added to the empiric bacterial meningitis regimen for immunocompromised patients for the purpose of covering which organism? A. Streptococcus pneumoniae B. Neisseria meningitides C. Listeria monocytogenes D. Pseudomonas aeruginosa

C. Listeria monocytogenes

All of the following medications act as cholinesterase inhibitors except: A. Donepezil (Aricept) B. Rivastigmine (Exelon) C. Memantine (Namenda) D. Galantamine (Razadyne)

C. Memantine (Namenda) [Memantine is an NMDA Antagonist]

FDA approved a reversible MAO-Type B inhibitor safinamide in 2017. Safinamide: A. Is approved for use as mono therapy B. Retains selectivity at high doses C. Modestly improves "on time" without dyskinesia D. Is safer than irreversible MAO-B inhibitors

C. Modestly improves "on time" without dyskinesia

After approximately 5-8 years of carbidopa/levodopa treatment most patients develop: A. Nausea and vomiting B. Severe Constipation C. Motor fluctuations and dyskinesia D. Cognitive impairment

C. Motor fluctuations and dyskinesia

This medication is a humanized monoclonal antibody directed against integrin. It is administered IV once a month. JC antibody status should be assessed at 6-month intervals in all patients receiving treatment. Alternative therapy is recommended for antibody positive patients. A. Interferon Beta B. Dimethyl Fumarate C. Natalizumab D. Alemtuzumab

C. Natalizumab

Your patient asks about the use of Butterbur for prevention of migraine headaches. You check: A. Facebook B. Google C. Natural Medicines Database in Clinical Pharmacology

C. Natural Medicines Database in Clinical Pharmacology

A 16 y/o male patient suffers from a seizure disorder characterized by tonic rigidity of the extremities followed in 15-30 s of tremor progressing to massive jerking of the body. This clonic phase lasts for 1 or 2 min, leaving him in a stuporous state. Of the following drugs, which is most suitable for long-term management of this patient? A. Clonazepam B. Ethosuximide C. Phenytoin D. Pregabalin

C. Phenytoin [This patient is suffering from generalized tonic-clonic seizures. For many years, the drugs of choice in this seizure disorder have been carbamazepine, phenytoin or valproic acid. However, many newer drugs are also effective, including gabapentin, lamotrigine, levetiracetem, topiramate, and zonisamide. Clonazepam and ethosuximide are not effective in this type of seizure disorder. Pregabalin is approved for use only in partial seizures.]

Which statement is NOT correct? A. Chlordiazepoxide (Librium), Diazepam (Valium), and Clorazepate (Tranxene) are all metabolized via complex pathways to Oxazepam (Serax). B. Lorazepam (Ativan), and Oxazepam (Serax) are metabolized soley by conjugation (simple metabolism). C. Since Xanax (Alprazolam) and Halcion (Triazolam) are the shortest acting of the benzodiazepines they are considered the safest and the Drug of Choice for anxiety, and hypnosis. D. Temazepam (Restoril) is metabolized mainly by conjugation.

C. Since Xanax (Alprazolam) and Halcion (Triazolam) are the shortest acting of the benzodiazepines they are considered the safest and the Drug of Choice for anxiety, and hypnosis.

Which of the following are correct statements about phenytoin when used in the management of seizure disorders? A. Dose selection is largely by "trial and error" and large dose increases are often recommended as the safest way to achieve seizure control. B. The Therapeutic Index is very wide and adverse effects are uncommon. C. Symptoms of intoxication include slurred speech, dizziness, and confusion. D. Phenytoin is often coadministered with a carboxylase inhibitor to increase CNS activity.

C. Symptoms of intoxication include slurred speech, dizziness, and confusion.

This question refers to the patient case discussed in class. We started Risperidone oral tablets 1 mg twice a day. We evaluated her response about 2 hours after the dose was administered. We also checked serum chemistry. Why? A. 1 mg twice a day is the target dose for risperidone B. We checked all labs only to protect against law suits C. The peak effect of an oral dose of risperidone is typically seen in about 2 hours D. Dividing the daily dose increases side effects

C. The peak effect of an oral dose of risperidone is typically seen in about 2 hours

A 70 year old man with advanced PD asks your opinion about deep brain stimulation. (DBS) He has been taking carbidopa/levodopa plus selegiline for more than a decade. His dyskinesia is intolerable. Your advice about DBS treatment: A. DBS treated patients continuing medication have less dyskinesia B. DBS treated patients can have marked improvement in off - medication motor function C. Speech, freezing of gait, and cognition may worsen following DBS D. All are correct

D. All are correct

Phenytoin is one of a few drugs known to be subject to restrictive clearance. Medications having restrictive clearance: A. Have very low affinity for metabolic enzymes B. Increasing the dose may exceed the capacity to metabolize the medication C. Adding a medication having a higher affinity for metabolic enzymes can result in excessive levels of the target medication D. All of the above

D. All of the above

Identify the incorrect statement A. Opium was first described by the Ancient Sumerians B. At one time opium was used to treat alcoholism C. Heroin was invented as a cough suppressant, and later used to treat morphine addiction D. Combination of opioids and acetaminophen such as Vicodin ™ are not addictive

D. Combination of opioids and acetaminophen such as Vicodin ™ are not addictive

Triptans and ergot alkaloids are contraindicated in patients with all of the following medication problems except: A. Uncontrolled hypertension B. Cerebral vascular disease C. Coronary artery disease (CAD) D. Diabetes

D. Diabetes

This medication binds to Major Histocompatibility Complex (MHC) molecules, displacing bound Myelin Basic Protein (MBP). It is administered SC either daily or 3 times a week. Administration related reactions are similar to interferon. A. Alemtuzumab B. Teriflunomide C. Dimethyl Fumarate D. Glatiramer

D. Glatiramer

How would you manage a patient experiencing severe muscle cramps with torticollis right after you initiated treatment of schizophrenia with haloperidol? A. Add risperidone B. Stop haldol and observe the patient C. Order oral diphenhydramine D. Inject a muscarinic-receptor antagonist

D. Inject a muscarinic-receptor antagonist [Painful acute dystonic reactions should be treated immediately with a muscarinic antagonist such as benztropine. Adding risperidone is NOT protective. Oral diphenhydramine would help but this patient may find it very difficult to swallow and oral administration would result in a delayed time to peak effect.]

Which of the following medications is most suitable for management of essential tremor in a patient who has pulmonary disease? A. Diazepam B. Levodopa C. Propranolol D. Metoprolol E. Albuterol

D. Metoprolol [Increased activation of β adrenoceptors is implicated in essential tremor, and management commonly involves administration of a beta adrenergic antagonist. The more selective β1 blocker metoprolol is equally effective as propranolol and is a better option for a patient with pulmonary disease.]

Which statement concerning the adverse effects of antipsychotic drugs is most accurate? A. Acute dystonic reactions occur commonly with olanzapine B. Blurring of vision and urinary retention are common adverse effects of haloperidol C. The late-occurring choreoathetoid movements caused by conventional antipsychotic drugs may be alleviated by atropine D. Retinal pigmentation is a dose-dependent toxic effect of thioridazine

D. Retinal pigmentation is a dose-dependent toxic effect of thioridazine [Olanzapine has minimal DA blocking activity and is unlikely to cause acute dystonia Muscarinic antagonists like atropine exacerbate TD]

Identify the correct statement A. Tolerance is seen when adaptive responses to repetitive drug use are unopposed by the drug. B. Physical Dependence refers to compulsive and uncontrolled use of a medication. C. Psychological Dependence is seen when receptors are down regulated. D. Tolerance and Physical Dependence can be seen in patients who are not substance abusers.

D. Tolerance and Physical Dependence can be seen in patients who are not substance abusers. [Tolerance: receptor down regulation Physical dependence: physiologic process resulting from adaptation - up regulation of blocked receptors. Psychological dependence: compulsive, uncontrolled use of a medication.]

A 24yo M (JM) presents with fever, altered mental status, and neck stiffness. After performing a physical exam, there is concern for possible meningitis so a lumbar puncture is performed. Which of the following is the BEST initial regimen? A. Vancomycin, ceftriaxone, and acyclovir B. Vancomycin, ampicillin, ceftriaxone, acyclovir, and dexamethasone C. Vancomycin, cefepime, and dexamethasone D. Vancomycin, ceftriaxone, acyclovir, and dexamethasone

D. Vancomycin, ceftriaxone, acyclovir, and dexamethasone

Name two of the medications that should be used very cautiously in patients who are managed with lithium. (in particular, our PBL patient)

Diuretics: Hydrochlorothiazide ARBs: Losartan ACEis Beta blockers may mask lithium toxicity Narcoleptics

Gabapentin and Pregabalin MOA

Does not act directly on GABA receptors, however, modifies release of GABA

Cabergoline MOA

Dopamine agonist [used in PD]

Pramiprexole MOA

Dopamine agonist [used in PD]

Levodopa MOA

Dopamine precursor

Most benzodiazepines with the exception of the triazole type agents have wide safety margins and a large therapeutic index. Nevertheless benzodiazepines do have important side effects when used as hypnotic agents. Identify the most important side effects. A. Rebound insomnia B. Daytime Hangover C. Tolerance, compulsive use, dependence D. Respiratory depression in patients having moderate to severe respiratory disease E. All of the above are correct.

E. All of the above are correct.

What is the recommendation found in the Natural Medicines Database for Butterbur?

Effectiveness: Possibly Effective - Taking butterbur orally seems to prevent migraine headache. Doses of at least 75 mg twice daily seem to be necessary for significant benefit. Lower doses of 50 mg twice daily may not be effective in adults. Safety: Possibly Safe

Methylphenidate MOA

Enhances DA by blocking DAT

Treatment of absence seizures

Ethosuximide, valproate *Phenytoin and carbamazepine exacerbate

Serotonin inhibits the GABA receptor. True or False?

False

Name each of the 3 medications that are FDA approved for multiple sclerosis that can be administered orally.

Fingolimod Dimethyl fumarate (DMF) Teriflunomide

An absolute contraindication to methylphenidate or amphetamine use?

Glaucoma

SNRI side effects

Increased blood pressure, heart rate, and CNS activation, along with serotonin effects such as nausea, gastrointestinal upset, diarrhea

Bacteriostatic

Inhibits bacterial growth

Aminocaproic acid MOA

Inhibits fibrinolysis through inhibition of plasminogen activator substances [used to treat hemorrhagic stroke]

SSRI MOA

Inhibits the serotonin transporter

This medication has the strongest evidence for efficacy and for long term safety.

Interferon Beta

Nicardipine MOA

Intravenous dihydropyridine calcium channel blocker [used to treat hemorrhagic stroke]

Levetiracitam MOA

Modifies release of glutamate and GABA via interaction with the synaptic vesicular protein

Morphine MOA

Mu-opiate receptor agonist

Atomoxetine MOA

NE reuptake inhibitor

SSRI side effects

Nausea, gastrointestinal upset, diarrhea

Treatment for Subarachnoid hemorrhage

Nimodipine

Ergotamine tartrate MOA

Non-selective 5-HT1 receptor agonist

Ibuprofen MOA

Non-steroidal anti-inflammatory, cyclooxygenase (COX) isoenzyme (COX-1 and COX-2) inhibitor

Nimodipine MOA

Oral, lipophilic, dihydropyridine calcium channel blocker [use in all patients with SAH; improves function if patient has vasospasm]

The lab reports that the Lithium serum concentration you ordered for your patient is out of range. What is your differential for an out of range drug level?

Patient compliance- dose consistency; timing error; drug/diet interactions Lab- timing error. Samples should be taken 10-12 hours after a dose, after at least 5 days on the current regimen. Symptoms of excessive or inadequate dose? Reason to suspect excessive or inadequate dose? (Renal, compliance, drug interactions, meq/kg dose in range) No symptoms, no reason to suspect? What to do? Patient doing well on therapy? Slightly out of range recheck in a couple of days. Greatly out of range- hold dose x ?, recheck in one day and at 5 days.

Pharmacodynamics definition

Pharmacologic effects. What the drug does to your body

Treatment of partial seizures

Phenytoin, carbamazepine

Treatment of tonic-clonic seizures

Phenytoin, carbamazepine, valproate

Treatment for ischemic stroke with no contraindications to treatment

Recombinant tissue plasminogen activator (tPA)

Sumatriptan MOA

Selective serotonin 5-HT1B and 5-HT1D receptor agonist [reduces inflammation and constricts blood vessels to stop migraine]

Unicyclic Antidepressant (ex: Buproprion)

Somewhat resembles amphetamine in structure

Amphetamine MOA

Stimulates NE, DA, and serotonin release

Bacteriocidal

The antibacterial is lethal to the bacteria

Diazepam use in status epilepticus

The most effective class of drug in most patients for stopping the attacks and is given directly by intravenous push

Lorazepam use in status epilepticus

The most effective class of drug in most patients for stopping the attacks and is given directly by intravenous push

5-HT/2 Antagonists effect

These antidepressants are highly sedating

5-Hydroxytryptamine is a neurotransmitter for pathways that influence pain; mood and behavior; depression and anxiety; and nausea and vomiting. True or False?

True

Dopamine is a neurotransmitter for pathways that influence motor control, mood and emotion, and also nausea and vomiting. True or False?

True

Dopamine, Epinephrine and Norepinephrine are catecholamines. True or False?

True

Four Factors that affect CNS Penetration are: Molecule Size; Lipid Solubility; Protein Binding; and Inflammation. True or False?

True

The following question is a possible idea for a Capstone project: Is there sufficient evidence to compare the efficacy and safety of Aripiprazole to atypical antipsychotic agents such as risperidone or quetiapine? True or False?

True

The hallucinogens LSD (lysergic acid diethylamide) and mescaline are serotonin (5-HT) agonists. This discovery led to the search for 5-HT antagonists for the treatment of schizophrenia. True or False?

True

The phenothiazine antipsychotic medications share the phenothiazine nucleus which is composed of 3 fused 6 member ring structures. The different medications in this class all share the same nucleus although the side chains attached to the nucleus are different. However haloperidol a very high potency neuroleptic has a different (butyrophenone) chemical structure. True or False?

True

Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia. True or False?

True

Cluster headache symptoms

Unilateral, severe, sharp pain with ipsilateral cranial autonomic symptoms

Migraine headache symptoms

Unilateral, throbbing pain, light and noise sensitivity

Phenytoin use in status epilepticus

Used in continuing therapy

Treatment of intracranial hemorrhage associated with warfarin use

Vitamin K and PCC (FEIBA or Kcentra) or FFP

You prescribed a patient with migraines naratriptan 2.5 mg at the onset of migraine, and valproic acid for migraine prophylaxis. The naratriptan works about 50% of the time for her, but it always takes too long to start acting. A) Which medication is most likely associated with her weight gain? B) when could she repeat the dose of naratriptan and how many doses per day could she take? C) Is it likely that a different triptan would be successful for treatment or do you have try a drug from a different pharmacologic class?

a. The valproic acid is most likely associated with her weight gain b. She can take a second dose of naratriptan at 4 hours; however she should not exceed two doses per day, as the max dose is 5mg/day. c. A different triptan can be tried; patients that fail one triptan can typically be switched successfully to another triptan.