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Autacoids and Anti-inflammatory Drug Pharmacology
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1.About 10% to 20% of asthma patients aged 20 years to 30 years develop wheezing or more severe respiratory s igns and symptoms in response to a certain class of The offending drugs indirectly shunt (redirect) arachidonic acid metabolism to the formation of leukotrienes, which have bronchoconstrictor and proinflammatory properties. To which one of the following drugs or drug groups does this explanation most l ikely apply?
- Acetylcholinesterase inhibitors (eg, neostigmine)
- β-Adrenergic blockers (propranolol, many others)
- Nonsteroidal anti-inflammatory drugs (traditional agents such as aspirin)
- Opioids such as morphine
2. Febuxostat i s the fi rst new drug in i ts class in four It i s indicated for managing hyperuricemia, including that which i s drug-induced, but i s not indicated for symptom-suppression during an acute gout attack. Its basic mechanism of action i s inhibition of purine degradation at the formation of hypoxanthine (HX), preventing further metabolism of HX to xanthine and uric acid. It should not be administered to patients receiving purine antimetabolites (eg, mercaptopurine, thioguanine, for certain cancers) because the metabolic inactivation of those anticancer drugs will be inhibited and toxicity may occur. Based on the description given, what drug i s most s imilar to febuxostat?
3. A patient receives a drug that inhibits the l ipoxygenase pathway of arachidonic acid What naturally occurring metabolite(s) will be produced in lesser amounts in response to this drug?
- Prostacyclin (PGI2)
- Uric acid
4. A patient has mild cutaneous and systemic manifestations of a seasonal allergic Before you prescribe a short course of diphenhydramine for symptom relief, you should realize that this drug has one mechanism of action resembling, causes many s ide effects s imilar to, and shares many contraindications, that apply to an “autonomic” drug which you should be very familiar. What i s that drug?
- Phentolamine Physostigmine
5. A patient presents with a history of frequent and severe migraine When we give one of the more commonly used drugs for abortive therapy, sumatriptan, upon which of the following “local control substances” i s i t mainly acting?
- Thromboxane A2
6. A male patient with severe arthritis will be placed on long-term therapy with You recognize the ri sk of NSAID-induced gastrointestinal ulceration, and so want to prescribe another drug for ulcer prophylaxis. Which drug would you most l ikely choose, as an add-on to indomethacin, assuming that there are no specific contraindications to i ts use?
7. Aspirin causes s ignificant bronchoconstriction and bronchospasm in a patient who was subsequently identified as being “aspirin-sensitive.” Which mechanism summarizes best why or how aspirin provoked the respiratory problems in this patient?
- Induced drug-mediated hypersensitivity of H1 receptors on airway smooth muscles
- Induced drug-mediated hypersensitivity of muscarinic receptors on airway smooth muscles
- Enhanced formation of antibodies directed against the salicylate on airway mast cells
- Inhibited synthesis of endogenous prostaglandins that have bronchodilator activity
- Reduced (blocked) epinephrine binding to β2-adrenergic receptors on airway smooth muscle cells
8. A child takes what comes close to being a lethal dose of What i s the most l ikely pathology that ultimately can lead to death involved in this drug overdose?
- Acute nephropathy
- A-V conduction disturbances, heart block
- Liver failure
- Status asthmaticus
- Status epilepticus
9. A patient with asymptomatic hyperuricemia i s started on In a couple of days, he develops acute gout. What i s the mechanism by which probenecid, early in the course of treatment with i t, triggered this acute gouty arthritic episode?
- Accelerated synthesis of uric acid
- Co-precipitated with uric acid in the joints
- Induced an idiosyncratic response that triggered urate precipitation
- Induced systemic acidosis, favoring uric acid crystallization
- Reduced renal excretion of uric acid
10. Epidemiologic data published in the early 1980s found a probable relationship between aspirin and a serious adverse response when the drug was administered to children with influenza, chickenpox, and other vi ral i l Although no causal relationship between aspirin, vi ral i l lness, and this adverse effect was proven, you sti l l caution the parents or caregivers of children to avoid giving any aspirin or aspirin-containing product when there i s even a remote possibility that a child’s i l lness might involve a vi rus. Avoidance of aspirin i s necessary to avoid which specific adverse response?
- Renal failure
- Reye syndrome
- Thrombocytopenia and related bleeding disorders
11. Such drugs as methotrexate, hydroxychloroquine, or penicillamine are often turned to for managing rheumatoid arthritis that i s not controlled adequately with “traditional” NSAIDs (eg, aspirin, ibuprofen, diclofenac, or indomethacin). Which statement most correctly summarizes how those drugs differ from a typical NSAID?
- Activate the immune system to neutralize inflammatory mediators
- Are primary therapies for gouty arthritis
- Are remarkably free from serious toxicities
- Provide much quicker relief of arthritis s igns, symptoms
- Slow, stop, possibly reverse joint pathology in rheumatoid arthritis
12. For quite a while the “coxibs” (selective COX-2 inhibitors) were prescribed in preference to nonselective cyclooxygenase inhibitors for managing such conditions as rheumatoid Now we have basically one drug in this class, celecoxib. Which statement best describes an action or property of this COX-2 inhibitor?
- Associated with a lower ri sk of gastric or duodenal ulceration
- Cures arthritis, rather than just give symptom relief
- Effectively inhibits uric acid synthesis
- Has a lower ri sk of adverse or fatal cardiac events
- Has s ignificantly faster onset of action
13. Glucocorticoids are widely used for a host of inflammatory reactions and the diseases they In terms of inflammatory responses and underlying metabolic reactions, which enzyme or process i s the main target of these drugs when they are given at pharmacologic (supraphysiologic) doses?
- Cyclooxygenases (COX-1 and -2)
- Histidine decarboxylase
- 5′-l ipoxygenase
- Phospholipase A2 (PLA2)
- Xanthine oxidase
14. Bradykinin plays important roles in local responses to ti ssue damage and a variety of inflammatory It also has vasodilator activity. Which statement i s correct about this endogenous peptide?
- Captopril inhibits i ts metabolic inactivation
- Drugs that are metabolized to, or generate, nitric oxide, counteract bradykinin’s vascular effects
- Increased blood pressure i s the predominant cardiovascular response
- Newer histamine H1 blockers (eg, fexofenadine; “second-generation” antihistamine) also competitively block bradykinin receptors
- The main renal responses to endogenous bradykinin are arteriolar constriction and reduced GFR
15. A newborn has oxygenation and hemodynamic problems because of a patent (open) ductus Which drug usually would be administered in an attempt to close the lesion?
- Prostaglandin E1 (PGE1; alprostadil)
16. A 29-year-old woman develops frequent, debilitating migraine Sumatriptan i s prescribed for abortive therapy. Not long after taking the drug she i s rushed to the hospital. Her vi tal s igns are unstable, and she has muscle rigidity, myoclonus, generalized CNS i rri tability and altered consciousness, and shivering. You learn that for several months she had been taking another drug with which the triptan interacted. Which add-on drug most l ikely caused these acute and serious problems?
17. A patient (assume he or she i s taking no other drugs) has been taking doses of aspirin that are too high for several Low-grade aspirin toxicity (salicylism) develops. What s ign or symptom would be consistent with salicylism and the high salicylate levels that caused i t?
18. Aspirin generally should be avoided as an anti-inflammatory, analgesic, or antipyretic drug by patients with hyperuricemia or That i s because i t counteracts the effects of one important drug the hyperuricemic patient may be taking. Which drug has i ts desired uric acid-related effects reduced or eliminated by this prototypic NSAID?
19. Misoprostol, an analog of PGE1, i s sometimes used adjunctively to stimulate gastric mucus production and help reduce the incidence of gastric ulcers associated with long-term or high-dose NSAID therapy for What i s the other main use for this l ipid-derived autacoid?
- Closure of a patent ductus arteriosus in newborns
- Contraception in women who should not receive estrogens or progestins
- Induction of abortion in conjunction with mifepristone (“RU486”)
- Prophylaxis of asthma in l ieu of a corticosteroid
- Suppression of uterine contractility in women with premature labor
20. A patient who was transported by ambulance to the Emergency Department took a potentially lethal overdose of What drug would be a helpful, i f not l i fesaving, adjunct to manage this severe aspirin poisoning?
- Amphetamines (eg, dextroamphetamine)
- Sodium bicarbonate
21. We look at data that summarize the actions of two prototypic histamine receptor blockers: diphenhydramine as the exemplar of the older antihistamines (competitive histamine receptor antagonists); and fexofena-dine as a representative agent of the “second-generation” antihistamines. Which statement correctly describes, compares, or contrasts these drugs or the pharmacologic groups to which they belong?
- Diphenhydramine and other drugs in i ts class (ethanolamines) tend to cause drowsiness more often than fexofenadine and related second- generation antihistamines
- Diphenhydramine i s a preferred antihistaminic for patients with prostate hypertrophy or angle-closure glaucoma, whereas fexofenadine and related drugs are contraindicated
- Diphenhydramine overdoses tend to cause bradycardia, whereas fexofenadine overdoses tend to cause s ignificant increases of heart rate
- Fexofenadine and related second-generation histamine antagonists have intrinsic bronchodilator activity, which makes them suitable as primary/sole therapy for people with asthma
- Fexofenadine, and drugs in i ts class, have better efficacy in terms of suppressing histamine-mediated gastric acid secretion
22. A patient has been taking one of the drugs l i sted below for about 4 months, and i s experiencing the desired therapeutic effects from i t. The physician now prescribes indomethacin to treat a particularly severe flare-up of rheumatoid Within a matter of days the therapeutic effects of the fi rst drug wane dramatically, i ts actions antagonized by the indo-methacin. Which drug was affected by the indomethacin?
- Allopurinol, given for prophylaxis of hyperuricemia
- Captopril, given for essential hypertension
- Fexofenadine, given for managing seasonal allergy responses
- Sumatriptan, given for abortive therapy of migraine headaches
- Warfarin, given for prophylaxis of venous thrombosis
23. A patient takes an acute, massive overdose of aspirin that, without proper intervention, will probably be What would you expect to occur in the advanced (late) stages of aspirin (salicylate) poisoning?
- Metabolic alkalosis
- Respiratory alkalosis
- Respiratory plus metabolic acidosis
- Ventilatory stimulation
24. A patient presents in the emergency department with an overdose of a The physician knows what the drug i s , and so orders appropriate “symptomatic and supportive care,” plus multiple doses of N-acetylcysteine. Upon which drug did the patient overdose?
- Diphenhydramine Loratadine
25. A patient has acute The physician initially thinks about prescribing just one or two oral doses of colchicine, 12 hours apart, but then decides otherwise. What i s the main and most common reason for avoiding colchicine, even with a very short oral course, and prescribing another drug for the acute gout instead?
- Bone marrow suppression
- GI distress that i s almost as bad as the acute gout discomfort
- One or two oral doses seldom relieve gout pain
- Refractoriness/tolerance with just a dose or two
26. A patient with hyperuricemia i s placed on an “antigout” Before starting the drug you measure the total uric acid (amount, not concentration) in a 24-hour urine sample and then do the same several weeks after continued drug therapy at therapeutic doses. The post- treatment sample shows a s ignificant reduction in urate content. There were no new pathologies developing during therapy, and the patient’s daily purine intake did not change at all. What drug most l ikely accounted for these findings?
27. We administer sodium bicarbonate to a patient who has severe hyperuricemia and i s at great ri sk of developing urate stones in his urinary What i s the basis for using the bicarbonate?
- Causes antidiuretic effect, reducing urate content of the urine
- Causes metabolic alkalosis that inhibits catalytic activity of xanthine oxidase
- Counteracts metabolic acidosis that i s characteristic of severe hyperuricemia
- Lowers urate elimination by lowering glomerular fi l tration rate
- Reduces solubility of urate in the urine
28. A patient with annoying hay fever (seasonal allergy) symptoms (mainly rhinorrhea) goes to the store, intent on purchasing an oral medication to make them more comfortable. They see the prices for loratadine and related second-generation antihistamines and are shocked about how high they are. Nearby on the shelf they see store-brand allergy relief pills that are much less expensive, the cheapest ones having diphenhydramine as the sole active ingredient. If they were to take full therapeutic doses of the diphenhydramine, based on label directions, which effects or s ide effects are they most l ikely to experience as an additional price to be paid for their allergy relief?
- Drowsiness, somnolence
- “Heartburn” from increased gastric acid secretion
- Urinary frequency
29. Your patient has rheumatoid arthritis that has been largely refractory to diclofenac, ibuprofen, indomethacin, and In addition, she has experienced s ignificant GI distress, and several GI bleeds, following attempts to get better anti-inflammatory effects by raising the doses. We start her on therapy with etanercept. What i s the most l ikely mechanism by which etanercept suppresses the s igns, symptoms, or underlying patho-physiology of rheumatoid arthritis?
- Inhibits eicosanoid synthesis by inhibiting phospholipase A2
- Inhibits leukocyte migration by blocking microtubular formation
- Neutralizes ci rculating tumor necrosis factor (TNF-α)
- Selectively and effectively inhibits COX-2
- Stimulates collagen and mucopolysaccharide synthesis in the joints