Chapter 6. DRUGS AFFECTING INFLAMMATORY, IMMUNE AND TISSUE METABOLIC RESPONSES
«NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)»
119. A newborn has blood gas and hemodynamic problems because of a patent (open) ductus arteriosus. Which drug would be administered in an attempt to close the ductus?
120. A patient with severe arthritis will be placed on long-term therapy with indomethacin. All other factors being equal, which drug is the most likely to administer as an add-on (adjunct) to prevent gastric ulcers caused by this NSAID?
121. A patient with hyperuricemia is placed on an “antigout” drug. Before starting the drug you measure the total uric acid (amount, not concentration) in a 24 h urine sample and then do the same several weeks after continued drug therapy at therapeutic doses. The posttreatment sample shows a significant reduction in urate content. There were no new pathologies developing during therapy, and the patient’s daily purine intake did not change at all. Which drug was given?
122. A patient has acute gout. The physician initially thinks about prescribing just one or two oral doses of colchicine, 12 h apart, but then decides otherwise. The main reason for avoiding colchicine, even with a very short oral course, is the development of the following?
a) Bone marrow suppression
c) GI distress that is almost as bad as the acute gout discomfort
e) One or two oral doses seldom relieve gout pain
f) Refractoriness/tolerance with just a dose or two
123. A 20 year female weighing 55 kg is admitted to the emergency department having consumed 10 gm of paracetamol together with alcohol 6 hrs earlier. What is a result and manifestations of such interaction?
124. A young man arrives at A&E. He has recently broken up with his girlfriend and decided to kill himself. He swallowed a number of paracetamol (acetaminophen) tablets but 3 or 4 hours later decided that he did not, after all, want to commit suicide. When questioned about the number of tablets taken, he is rather uncertain, but thinks he has taken about 30. Apart from feeling nauseous, the man lacks other significant symptoms.
(a) Should this patient be given activated charcoal?
(b) You decide the patient is at risk of liver damage. What antidote would you administer?
(c) What is the mechanism of paracetamol hepatotoxicity and how does the antidote work?
«HORMONES: HYPOTHALAMIC AND PITUITARY HORMONES; THYROID AND PARATHYROID DUGS.
125. A 44-year-old traveling salesman was recently diagnosed with type 2 diabetes mellitus. The physician prescribed an exercise and diet plan, but this gentleman wouldn’t be complaint. He habitually has a morning cup of coffee, gets in his car in the morning, and drives until he gets to his next appointment late afternoon. He says he rarely stops and eats in between. The next approach is to use a single oral antidiabetic drug, but you are concerned about the drug causing or worsening hypoglycemia in this “meal-skipper”. Which drug poses the greatest relative risk of causing or exacerbating hypoglycemia?
126. A 75-year-old woman with diabetes is taking an oral antidiabetic drug. One day she goes without eating for 18 hrs. Her serum glucose concentration is 48 mg/dL (hypoglycemic) upon arrival at the emergency department, where she is deemed to be in critical condition. Which drug is most likely aggravated this fasting hypoglycemia?
127. A patient with a history of type 2 diabetes mellitus presents in the emergency department. His complains include non-specific gastrointestinal symptoms, including nausea and vomiting. He states he is bloated and has abdominal pain. His appetite has been suppressed for several days. He has malaise and difficulty breathing. His liver is enlarged and tender; liver function tests indicate hepatic damage. Serum bicarbonate is low and lactate levels are high. Kidney function is falling rapidly. The diagnosis is lactic acidosis, and the suspicion is that it was caused by an antidiabetic drug. Which drug is this patient most likely to be taking?
128. A man with type 2 diabetes is receiving a combination of oral drugs used to maintain glycemic control. If he becomes hypoglycemic, ingesting some sugar (sucrose) will work less well, and certainly less quickly, to restore blood glucose levels if he is taking which drug?
129. A 60-year-old man on long-term therapy with a drug develops hypertension, hyperglycemia, and decreased bone density. Blood tests indicate anemia. Stool samples initially were positive for occult blood and then developed a “coffee-grounds” appearance. Which drug is most likely responsible for the patient’s symptoms?
130. A woman goes into premature labor early enough that there are great concerns about inadequate fetal lung development and the risk of fetal respiratory distress syndrome. Ritodrine therapy is started to slow labor, but parturition seems imminent. What other adjunct should be administered prepartum, specifically for the purpose of reducing the risks and complications of the newborn’s immature respiratory system development?
131. You have prescribed an oral agent to help control a patient’s blood sugar because of type 2 diabetes. In explaining how the drug works, you describe it as a “starch blocker” that inhibits the intestinal uptake of complex carbohydrates in the diet. You advise also that flatus or some cramping or “grumbling sounds” in the belly may develop. Which drug best fits this description?
132. A patient with hypothyroidism following thyroidectomy will require lifelong hormone replacement therapy. Which drug generally would be most suitable?
133. A young sexually active woman with recurrent, moderate asthma is taking prednisone for suppression of airway inflammation and using two inhaled adrenergic bronchodilators: salmeterol for prophylaxis and albuterol for acute intervention (rescue therapy). She begins taking an oral contraceptive (estrogen-progestin combination). What is the potential interaction?
134. A 27-year-old woman is diagnosed with hypercortism. To determine whether cortisol production is independent of pituitary gland control, you decide to suppress ACTH production by giving a high-potency glucocorticoid. Which glucocorticoid is the best for this indication?
135. A patient with Cushing’s syndrome is being treated by X-irradiation of the pituitary. It may take several months of treatment for adequate symptomatic and metabolic improvement. Until that time, which drug might be administered adjunctively to suppress glucocorticoid synthesis?
«DRUGS USED TO TREAT ALLERGIC DISORDERS»
136. A patient with allergic disorder experiences significant bronchoconstriction and urticaria. Histamine, released from mast cells, is incriminated as an important contributor to these responses. Which of the following drugs may pose extra risks for this patient – not because it has any bronchoconstrictor effects in its own right, but because it quite effectively releases histamine from mast cells?
137. A 70 year old man was administered penicillin IV. Within 5 min, he developed generalized urticarial, swelling of lips, hypotension and bronchospasm. What is the first choice drug to administer?
138. An elderly male aged 74 years was brought to the hospital since he had not passed urine for the past 24 hours and had severe pain in lower abdomen. On examination there was a bulge in the pubic region due to full urinary bladder. On catheterization, he passed 1,5 L urine and the pain was relieved.
He gave the history of having difficulty in passing urine, poor stream, frequent urge to urinate and post-void dribbling for the last 3 years. Over the past few days he had been experiencing episodes of vertigo for which he was prescribed a medicine that he was taking for 2 days. Examination of the prescription revealed that he was taking tab. Dimenhydrinate 50 mg 3 times daily. Could there be any relationship between the anti-vertigo medication and the episode of acute urinary retention?
139. A taxi driver aged 30 years presented with sudden onset running and itchy nose, bouts of sneezing, partial nasal blockage, redness and watering from the eyes, but no fever, bodyache or malaise. He gave history of similar episodes occurring off and on during the spring season. A diagnosis of seasonal allergic rhinitis was made and the doctor decided to prescribe anti-allergic medication. Which anti-allergic medicine would be suitable for this patient? Which anti-allergic drugs should be avoided?
140. A 40-year-old man is given an intravenous injection of penicillin for pneumonia. A few minutes later, he is found with profound hypotension, is dyspnoeic with wheezing and has an urticarial rash.
(a) What has happened to this patient?
(b) What mechanisms are involved?
(c) Outline the appropriate treatment of this patient
141. Which vitamin, also an ingredient in some prescription medications for severe. refractory acne vulgaris, is “highly” teratogenic and should not be administered to pregnant women?
142. A patient with tuberculosis is being treated with isoniazid. She develops paresthesias, muscle aches, and unsteadiness. Which vitamin needs to be given in supplemental doses in order to reverse these symptoms – or used from the outset to prevent them in high-risk patients?
143. You have a patient who has been consuming extraordinary large amounts of alcohol for several years. He goes into acute withdrawal and manifests nystagmus and bizarre ocular movements and confusion (Wernicke’s encephalopathy). Although this patient’s alcohol consumption pattern has been accompanied by poor nutrient intake overall, you specifically manage the encephalopathy by administering which of the vitamins?
144. A 44-year-old obese man has extremely high plasma triglyceride levels. Following treatment with a drug triglyceride levels decrease to almost normal. Which agent is most likely to have caused this desired change?
«DRUGS AFFECTING CALCIUM METABOLISM»
145. Some patients who are taking high doses of a biphosphonate for Paget’s disease of the bone develop an endocrine-metabolic disorder. Which is the most likely disorder?
146. You are doing summer volunteer work at a health clinic in a very poor region of the world. A 25-year-old man is diagnosed with vitamin D-resistant rickets. Aside from high-dose vitamin D and oral phosphate, an additional therapeutic approach might be to use which drug?
147. A 55-year-old postmenopausal woman develops weakness, polyuria, polydipsia, and significant increases of serum creatinine concentration. A computed tomogram (CT scan) indicates nephrocalcinosis. A drug is considered to be the cause. Which drug is most likely responsible?
148. A patient develops marked skeletal muscle tetany soon after a recent thyroidectomy. This symptom can be reversed most quickly by administration of which drug?
149. A 65-year-old woman with atrial fibrillation has been taking warfarin for several months with no problems. She visits her GP and complains that she has vaginal irritation. Her doctor diagnoses vaginal candidiasis and prescribes oral fluconazole. Later the woman notices blood in her urine on two or three occasions.
(a) Why has the woman been prescribed warfarin?
(b) Could the fluconazole be associated with the blood in her urine?
(c) What methods are available for treating overdoses of warfarin?
150. A 55-year-old man has heart failure. He is being treated with digoxin, furosemide, and triamterene. He presents with atrial fibrillation. Serum electrolyte levels are normal; serum digoxin concentrations are at the high end of the normal range. The arrhythmia is electrically converted. In addition to beginning anticoagulant therapy for prophylaxis of thromboembolism, the physician starts oral quinidine, at a usually effective dose. What reason is the most likely outcome of adding the quinidine?
151. A 64-year-old man with arteriosclerotic heart disease (ADH) and CHF who has been treated with digoxin complains of nausea, vomiting, and diarrhea. His ECG reveals a bigeminal rhythm. The symptoms and ECG findings occurred shortly after another therapeutic agent was added to his regimen. A drug-drug interaction is suspected. Which add-on agent is most likely provoked the problem? (Lovastatin, Hydrochlorothiazide, Phenobarbitone, Nitroglycerin, Captopril).
152. A 54-year-old man with other well-treated medical disorders has erectile dysfunction. He takes a dose of sildenafil and shortly thereafter develops acute and severe hypotension. Upon arrival at the emergency
department his blood pressure is very low, he is tachycardic, and an ECG shows changes indicative of acute myocardial ischemia. Which other medication was this man most likely taking?
153. A man who has been at the local tavern, drinking alcohol heavily, is assaulted. He is transported to the hospital. Among various findings is an infection for which prompt antibiotic therapy is indicated. Given his high blood alcohol level, which antibiotic(s) should be avoided because of a high potential of causing a serious disulfiram-like reaction that might provoke ventilatory or cardiovascular failure? Assume that were it not for the alcohol consumption, the antibiotic prescribed would be suitable foe the infectious organisms that have been detected.
154. An adult patient is being treated with a parenteral aminoglycoside for a serious Pseudomonas aeruginosa infection. They require immediate surgery. They are premedicated with midazolam. A dose of succinylcholine is administered for intubation, with skeletal muscle paralysis maintained during surgery with pancuronium. Balanced anesthesia is maintained with nitrous oxide, isoflurane, and oxygen. Which of he following is the most likely outcome of having the aminoglycoside “on board” in the perioperative setting along with all these other drugs?
155. A 30-year-old mother of 2 children weighing 60 kg was taking combined oral contraceptive pill containing levonorgestrel 0,15 mg + ethinylestradiol 3 mmg per day cyclically (3 weeks treatment – 1 week gap). She developed fever with cough and was diagnosed as a case of pulmonary tuberculosis after sputum smear examination. She was put on isoniazid (300 mg) + rifampin (600 mg) + pyrazinamide (1,5 g) + ethambutol (1,0 g) daily for 2 months, followed by isoniazid (600 mg) + rifampin (600 mg) thrice weekly. In the 3rd month she failed to have the usual withdrawal bleeding during the gap period of contraceptive cycle. After 10 days her urinary pregnancy test was found to be positive.
(a) What could be the reason for failure of the oral contraceptive?
(b) What precaution could have prevented the unwanted pregnancy?
156. A 60-year-old woman complained of weakness, lethargy and easy fatigability. Investigation showed that she had iron deficiency anaemia (Hb 8 g/dl). She was prescribed caps. ferrous fumarate 300mg twice daily. She returned after one month with no improvement in symptoms. Her Hb level was unchanged. On enquiry she revealed that she felt epigastric distress after taking the iron capsules, and had started taking antacid tablets along with the capsules. What could be the possible reason for the failure to respond to the oral iron medication?
157. A 50-year-old type-2 diabetes mellitus patient was maintained on tab. glibenclamide (a sulfonylurea) 5 mg twice daily. He developed toothache for which he took tab. aspirin 650 mg 6 hourly. After taking aspirin he experienced anxiety, sweating, palpitation, weakness, ataxia, and was behaving abnormally. These symptoms subsided when he was given a glass of glucose solution.
(a) What could be the explanation for his symptoms?
(b) Which alternative analgesic should have been taken?
«POISONS AND ANTIDOTES»
158. A 60-year-old man has been using a kerosene space heater and candles to keep warm in the winter. He is transported to the hospital with complaints of severe headaches, nausea, dizziness, and a diminution in vision. He has a decreased arterial blood oxygen (O2)-carrying capacity without a change in the PO2. Which of following most likely accounts for these findings?
a) Carbon monoxide (CO)
c) Nitrogen dioxide
e) Sulfur dioxide
159. A 22-year-old girl is brought to the emergency department by a friend. They had been at a bar for about an hour, and then the patient suddenly became drowsy but was still conscious. She fell and cut her head, and she says ”yes, it hurts”. Her ventilatory rate and depth are depressed, but not to a worrisome degree. Her patellar reflexes are blunted and she is ataxic. She responds slowly to questions, but is unable to recall anything that happened after arriving at the bar. Her friend stated that the patient had only one cocktail and hadn’t been drinking before they went out.
A. It is most likely that someone “spiked” the patient’s drink with which of the following drugs?
a) A barbiturate
b) A benzodiazepine
c) An opioid
d) Chloral hydrate
f) Pure (grain) alcohol
B. Which drug should you administer first, specifically to confirm or reject your suspected diagnosis and hopefully to normalize the patient’s vital signs?
160. A 50-year-old man has been consuming large amounts of alcohol (ethanol) on an almost daily basis for many years. One day, unable to find any ethanol, he ingests a large amount of methanol (wood alcohol) that he found in his garage. What is the most likely consequence of this and what are the treatment options?
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