ACAAI Review Book Ch 7: Pharmacology and Therapeutics

Question 1

Potential mechanisms and immunologic changes associated with immunotherapy include all of the following except:

A. increased IFNy/IL-4 ratio
B. decreased IgA in respiratory secretions
C. initial increase (month) then a steady decrease (years) in allergen-specific IgE
D. decreased seasonal rise in allergen-specific IgE
E. decreases basophil hyperreactivity

Answer 1

B. decreased IgA in respiratory secretions

INcreased IgA in respiratory secretions

Question 2

Potential mechanisms and immunologic changes associated with immunotherapy include increases in all of the following except:

A. IgG blocking antibody (initially IgG1 and IgG2 -> IgG4)
B. CD4+CD25+ regulatory (IL-10, TGF-B) and percent of CD8+ T cells
C. allergen-specific lymphocyte proliferation
D. Th1 cytokines (IFNy, IL-12), shift from Th2 cytokines (IL-4, IL-5, and IL-13); Th1/Th2 ratio
E. IFNy/IL-4 ratio

Answer 2

C. allergen-specific lymphocyte proliferation

DECREASED allergen-specific lymphocyte proliferation

Question 3

Potential mechanisms and immunologic changes associated with immunotherapy include decreases in all of the following except:

A. modified allergic response to allergens over time (early and late response to NAC, bronchial sensitivity to histamine)
B. low affinity IgE receptor, FcERII (CD23)
C. basophil hyperreactivity
D. recruitment of eosinophils, basophils and mast cells in nose/lung
E. Th1 cytokines (IFNy, IL-12), shift from Th2 cytokines (IL-4, IL-5, and IL-13); Th1/Th2 ratio

Answer 3

E. Th1 cytokines (IFNy, IL-12), shift from Th2 cytokines (IL-4, IL-5, and IL-13); Th1/Th2 ratio

this INCREASES

Question 4

Standardized extracts include all of the following except:

A. cat
B. dog
C. dust mites
E. grasses
F. weeds

Answer 4

B. dog

Question 5

All of the following allergens cross react except:

A. timothy grass
B. bermuda grass
C. Kentucky blue grass
D. orchard grass
E. perennial rye
F. sweet vernal

Answer 5

B. bermuda grass

Question 6

Which two of the following do not cross react with the rest?

A. timothy grass
B. Bahia 
C. Kentucky blue grass
D. orchard grass
E. johnson
F. sweet vernal

Answer 6

B. Bahia & E. johnson

cross react with each other, not the others

Question 7

All of the following ragweed allergens cross react except which 2:

A. short 
B. giant
C. southern
D. slender
E. false
F. western

Answer 7

C. southern
D. slender

cross react with each other and cocklebur & marsh elder

Question 8

All of the following weed allergens cross react except:

A. Russian thistle
B. sage
C. lambs quarter
D. burning bush
E. Kochia

Answer 8

B. sage

cross reacts with wormwood & mugwort

Question 9

All of the following tree allergens cross react except:

A. birch
B. juniper
C alder
D. hazel
E. hornbeam

Answer 9

B. juniper

cross reacts with cedar & cypress

other trees:

• Oak, Beech, Chestnut OBC
• Pecan, Hickory PH
• Ash, Olive, Privet AOP

Question 10

Dust mite extract in >10% glycerin is safe to mix with which of the following extracts:

A. cat
B. dog
C. pollen
D. cockroach
E. mold
F. all of the above

Answer 10

F. all of the above

• ragweed & cat extracts in >50% glycerin resist degradation when mixed with high protease extracts

Question 11

Mold and cockroach extracts should not be mixed with pollen because they contain:

A. high glycerin content
B. higher IgE binding affinity
C. non standardized extracts
D. proteolytic enzymes that degrade pollen

Answer 11

D. proteolytic enzymes that degrade pollen
= reduced IgE binding affinity

glycerin = inhibitor of proteolytic activity

phenol = antibacterial property

Venoms contain proteases that can degrade each other and should NOT be mixed
(except vespids hornets & yellow jackets)

Question 12

effective maintenance dose for most inhalant allergens is:

Answer 12

5-20 ug of the major allergen per 0.5 mL mainenance dose

1000-4000 BAU/AU

Question 13

All of the following are true about systemic reactions except:

A. they occur in approximately 2% of patients
B. they are more likely to occur in patients who experience a large local reaction
C. they are more likely to occur in patients who frequently experience large local reactions
D. most occur within the first 30 minutes
E. they occur in approximately 0.2% of injections

Answer 13

B. they are more likely to occur in patients who experience a large local reaction

• greater risk of fatal reactions in patients taking beta blockers.
• fatal reaction risk 1 in 2.5 million

Question 14

All of the following incur a greater risk of systemic reactions except:

A. unstable asthma
B. history of previous SR
C. after"priming" of pollen season
D. during build up phase
E. first injection from new vial
F. during accelerated or rush protocols

Answer 14

C. after”priming” of pollen season

DURING priming

Question 15

All of the following are relative contraindications to starting/build up IT except:

A. immunodeficiency
B. pregnancy
C. malignancy
D. mild, well controlled asthma
E. significant cardiovascular disease
F. ACE inhibitors in VIT

Answer 15

D. mild, well controlled asthma

• poorly controlled or severe asthma

Question 16

All of the following are relative contraindications to SLIT except:

A. prior severe SR to SLIT
B. HS reactions to inactive ingredients
C. significant cardiovascular disease
D. severe asthma
E. eosinophilic esophagitis

Answer 16

C. significant cardiovascular disease

EPI for all

Question 17

tbale 7-5 page 361 for 4 types of histamine receptors

Answer 17

H1-antihistamines are INVERSE AGONISTS

which bind the receptor and stabilize it in the inactive form, shifting equilibrium to inactive state

Question 18

Antiallergic and antiinflammatory effects of H1-antihistamines include all of the following except:

A. inhibit release of mast cell and basophil mediators through inhibition of calcium ion channels
B. reduce early allergen response via fewer ahesion molecules, eos, neutros, cytokines, LTs, and PGs in lavage fluid in when pretreatement in allergen challenge
C. upregulate NFkB
D. inhibit expression of cell adhesion molecules
E. inhibit eosinophil chemotaxis

Answer 18

C. upregulate NFkB

DOWNregulate to cause:

D. inhibit expression of cell adhesion molecules
E. inhibit eosinophil chemotaxis

Question 19

All of the following antihistamines would require consideration of dose adjustment in a patient with hepatic impairment except:

A. cetirizine
B. diphenhydramine
C. chlorpheniramine
D. fexofenadine
E. doxepin
F. hydroxyzine
G. desloratidine

Answer 19

D. fexofenadine

• the only one that is only RENALly metabolized

RENAL + hepatic =
A. cetirizine
G. desloratidine
levoceterizine

Question 20

All of the following antihistamines would require consideration of dose adjustment in a patient with renal impairment except:

A. cetirizine
B. levoceterizine
C. loratidine
D. fexofenadine
E. desloratidine

Answer 20

C. loratidine

only HEPATIC metabolism

Question 21

Potential adverse effects of H1 antihistamines due to blocking effects on receptors and ion channels include all of the following except:

A. ion channels: QT prolongation
B. antiserotonergic: decreased appetite
C. anti-alpha-adrenergic: hypotension, dizziness, reflex tachycardia
D. antimuscarinic/anticholinergic: dry mouth, urinary retention, sinus tachy
E. anti-H1 receptor: sedation, incr. appetite, decreased cognitive and psychomotor performance

Answer 21

B. antiserotonergic: decreased appetite

INCREASED appetite (cyproheptadine/periactin)

A. ion channels: QT prolongation
- blockade of the rapid component of the delayed rectifier potassium current (IKr) and long QT can -> torsades de pointes

Question 22

Mechanism of beta agonists:

Answer 22

binds B2-beta GPCR and increases cAMP

• activates protein kinase A
• phosphorylation & muscle relaxation

Question 23

Salmeterol has a slower onset of action (30 min) compared to formoterol (2-3 min) due to:

Answer 23

more lipophilic

Question 24

Actions of beta-agonists include all of the following except:

A. increases mucociliary clearance
B. protect epithelium againts bacteria
C. binds B2-beta GPCR and increases cAMP leading to muscle relaxation
D. potentiate microvascular permeability
E. inhibit cholinergic neurotransmission

Answer 24

D. potentiate microvascular permeability

SUPPRESS

see page 366 for more actions & studies ICS/LABAs & B-agonist adverse effects

& page 367 for tachyphylaxis

Question 25

Patients with what mutations may be at an increased risk of worsening lung function with regular use of albuterol:

Answer 25

B2-adrenergic receptor polymorphisms - B16 Arg/Arg homozygotes - agonist receptor downregulation - induces resistance to SM-relaxing effects of B2 agonists

Question 26

All of the following may increase a patient's risk during an asthma exacerbation except: ``` A. labetalol B. nadolol C. pindolol D. propranolol E. timolol F. metoprolol ```

Answer 26

F. metoprolol & atenolol are cardioselective (B1>B2) = less risk for bronchoconstriction the others are nonselective a/w blunted response to B2-agonists

Question 27

CysLT1 receptors are expressed on inflammatory cells, bronchial epithelium, muscles and have the highest affinity for which leukotriene: ``` A. LTA4 B. LTB4 C. LTC4 D. LTD4 E. LTE4 ```

Answer 27

D. LTD4 >LTC4 > LTE4 mediate pro-asthmatic actions- sustained bronchoconstriction, mucus secretions, and increase vascular permeability leukotriene antagonists: - -- attenuate EPR & LPR in Ag challenge - -- AERD: improved FEV1, less B-agonist, decreased exac. blocked by CysLT1R-antagonists: montelukast (highest affinity), zafirlukast (dose-dep liver toxicity & warfarin interaction ^PTT), pranlukast. pg 368 for chart asthmatics: - higher levels of cysLT production - sputum cysLTs correlate w/ severity - high levels in AERD

Question 28

Adverse effects of Zileuton

Answer 28

5-LO & cytochrome CYP1A2 inhibitor - elevated ALT (monitor Q3mo, avoid in pts w/ hepatic dysfunction or heavy alcohol use) - headache, dyspepsia, myalgias, leukopenia

Question 29

Doses of all of the following medications should be reduced if a patient is starting zafirlukast or zileuton except: A. warfarin B. fexofenadine C. propranolol D. theophylline

Answer 29

B. fexofenadine

Question 30

All of the following are mechanisms of mast cell stabilizers cromolyn sodium and nedocromil sodium except: A. inhibits IgE mediated calcium channel activation & mast cell degranulation B. blocks eos activation C. blocks neutros activation, chemotaxis, and mediator release D. inhibits local IgE production E. modulates parasympathetic nerve reflexes

Answer 30

E. modulates parasympathetic nerve reflexes SYMPATHETIC - prevents EPR & LPR athmatic reactions - protects against exercise, cold, irritants, chemical, saline, mannitol challenges - NOT METHACHOLINE OR HISTAMINE

Question 31

Anticholinergics: - increased parasympathetic tone in asthma & COPD releases ACH -> stimulates muscarinic receptors -> bronchoconstriction, mucus secretion, vasodilation

Answer 31

M2: inhibitory R on parasympathetic nerves decreases ACH release M3 GPC-ACH-R: primary mediator of SM contraction in airways

Question 32

Ipratropium bromide can cause a paradoxical bronchoconstriction via what receptor: A. M1 B. M2 C. M3

Answer 32

B. M2 - blocking M2 -> increased ACH release from vagus -> may ^ bronchoconstriction - synergistic w/ B-agonists and decreases hospitalization rate in asthmatics - tiotropium has longer duration of action 2/2 100x slower dissociation from M1 & M3

Question 33

All of the following are mechanisms of action of theophylline except: A. inhibition of phosphodiesterases leading to increased cAMP B. decreased HDAC2 C. antagonism of adenosine receptors, preventing mast cells from releasing histamine and LT and causing bronchoconstriction D. increased IL-10 E. inhibition of phosphoinositide-3-kinase-delta (PI3K-d)

Answer 33

B. decreased HDAC2 E. inhibition of phosphoinositide-3-kinase-delta (PI3K-d) leads to INCREASED HDAC2 = can reverse corticosteroid resistance due to reduced HDAC2 activity PDE inhibitors = incr. cAMP = bronchodilation & antiinflammatory effects metabolized in liver by cytochrome p450 - adverse effects @ plasma levels >20 mg/L

Question 34

All of the following can lead to an increased serum level (decreased clearance) of theophylline except: ``` A. macrolide antibiotics B. ranitidine C. zileuton D. ciprofloxacin E. allopurinol F. CHF ```

Answer 34

B. ranitidine NOT ranitidine, CIMETIDINE

Question 35

All of the following can lead to an decreased serum level (increased clearance) of theophylline except: ``` A. rifampin B. tobacco and marijuana use C. ethanol D. older age E. carbamazepine, phenobarbital, phenytoin ```

Answer 35

D. older age YOUNGER AGE

Question 36

Steroids inhibit the LPR but NOT EPR of Ag challenge ICS does not prevent progressive loss of lung function GC-RBeta dominant negative effect = inhibits glucocorticoid response elements & antiinflammatory protein synthesis = incr expression a/w fatal & nocturnal asthma

Answer 36

effects in inflammatory cells & side effects pg 375 SUBCAPSULAR POSTERIOR cataracts protease inhibitors (ritonavir) + ICS (fluticasone) -> high systemic concentrations & Cushing's

Question 37

IgE binds what chain of the FcERI receptor on mast cells and basophils? A. alpha B. beta C. gamma

Answer 37

A. alpha Omalizumab binds the CH3 domain (Fc portion) of FREE IgE molecule, preventing it from binding to FcεRI

Question 38

Omalizumab is associated with a decrease in all of the following except: ``` A. free IgE and eosinophils B. expression of FcERI on effector cells C. circulating IL-13 and FENO D. total IgE E. mediator release from mast cells and basophils F. B lymphocytes ```

Answer 38

D. total IgE

Question 39

Mepolizumab mechanism of action: A. IgG4/κ monoclonal antibody B. IgG1/κ monoclonal antibody C. IgG1k monoclonal antibody that binds α chain of human IL-5R Fcγ RIIIa region

Answer 39

B. IgG1/κ monoclonal antibody inhibits bioactivity of IL-5 by blocking IL-5 from binding the alpha chain of the IL-5 receptor complex expressed on eosinophils

Question 40

Benralizumab mechanism of action: A. IgG4/κ monoclonal antibody B. IgG1/κ monoclonal antibody C. IgG1k monoclonal antibody that binds α chain of human IL-5R

Answer 40

C. IgG1k monoclonal antibody that binds α chain of human IL-5R via its Fab fragments = preventing the interaction between IL-5 and its receptor mechanism of activating ADCC & eosinophil apoptosis? - through its Fc constant region, benralizumab binds to the FcγIIIRa receptor expressed by natural killer cells, thus inducing eosinophil apoptosis operated by the release of proapoptotic proteins such as granzymes and perforins

Question 41

All of the following are true about AERD except: A. it is a non-IgE mediated reaction B. increased expression of leukotriene C4 synthase and cysLT1 receptor C. increased LTD4 causes acute bronchocontstriction and increased vascular permeability D. urine LTD4 can be measured to reflect the increase production of cysLTs E. PGE2 is an inhibitor of the 5-lipoxygenase pathway, which is decreased by COX1 inhibition but COX2 inhibitors are tolerated

Answer 41

D. urine LTD4 can be measured to reflect the increase production of cysLTs LTE4!!! in urine

Question 42

ratio of chest compressions to breaths in an adult and child

Answer 42

adult 30:2 <8 yo 15:2 EPI: 0.01 mg/kg SC/IM 1:1K IV 1:10K p 397

Question 43

Recommendations for vaccine administration include all of the following except: A. live vaccines must be separated by 28 days if not given on the same day B. all vaccines can be given on the same day C. wait at least 6 months after IVIG or RBC product before giving live vaccines D. wait at least 6-8 months after IVIG or RBC product before giving non-live vaccines E. wait at least 2 weeks after live vaccine before giving IVIG or RBC product

Answer 43

C. wait at least 6 months after IVIG or RBC product before giving live vaccines 3 MONTHS! Arthus reactions: Type 3 IC HS- common w/ 4-5 dose DTaP ``` LMNOP and RSV live vaccines: Live vaccines include: MMR Nasal flu Oral polio Rotavirus Smallpox, Shingles Varicella ```

Question 44

table 7-20 page 403 topical corticosteroids

Answer 44

table 7-21 page 405 opthalmic treatments

Question 45

Risk factors for drug allergy include all of the following except: ``` A. history of prior drug allergy B. higher dose C. IV route D. low-molecular weight agents E. frequent, repetitive, or longer courses F. female gender ```

Answer 45

D. low-molecular weight agents HIGH MW Atopy- a/w latex and RCM

Question 46

Which of the following mutations is associated with abacavir reactions in caucasians and is an indication for testing before initiating therapy? A. HLA-A*3101 B. HLA-B*5701 C. HLA-B*1502 D. HLA-B*5801

Answer 46

B. HLA-B*5701

Question 47

Which of the following mutations is associated with carbamazepine reactions in Han Chinese that can result in SJS/TEN? A. HLA-A*3101 B. HLA-B*5701 C. HLA-B*1502 D. HLA-B*5801

Answer 47

C. HLA-B*1502 A. HLA-A*3101- Carb in Europeans D. HLA-B*5801- allopurinol in Asians, SCARs

Question 48

What is the major determinant of penicillin? A. Penicillin G B. penicilloate C. penilloate D. benzylpenicilloyl polylysine

Answer 48

D. benzylpenicilloyl polylysine (Pre-Pen) - most PCN allergy related to MAJOR determinant - 97% NPV of PCN SPTs - PCN IgE abs decrease 10%/yr = 50% will have negative SPT @ 5 years = 80% @ 10 years 10% pts have delayed non-IgE MP rash w/ AMP/AMOX + EBV = 80% get rash

Question 49

A patient with a history of penicillin allergy needs a cephalosporin. What is the next best step? A. skin test to cephalosporin B. give the cephalosporin C. direct challenge with amoxicillin D. perform penicillin skin testing; if negative, can safely receive cephalosporin

Answer 49

D. perform penicillin skin testing; if negative, can safely receive cephalosporin

Question 50

Penicillin has cross reactivity with which of the following drugs on skin testing, with much rarer rates of clinically important cross reactivity? A. aztreonam B. ceftazidime C. sulfonamides D. carbapenems

Answer 50

D. carbapenems (imipenem & meropenem) CEFTAZ & AZTREOnam!!! cross react TMP/SMX: - HIV = T cell mediated delayed MP rash - Type I HS = N4 sulfonamidoyl hapten major determinant

Question 51

The following are associated with increased incidences of radiocontrast adverse reactions except: ``` A. women B. asthma or atopy C. cardiovascular disease D. prior history of reaction E. multiple prior radiocontrast events ```

Answer 51

E. multiple prior radiocontrast events - nonspecific mast cell degranulation 2/2 MRGPRX2-receptor

Question 52

High risk agents associated with SJS include all of the following except: ``` A. PCN B. sulfonamides C. aromatic anticonvulsants D. allopurinol E. vancomycin F. NSAIDs G. pantoprazole & tramadol ```

Answer 52

E. vancomycin (can cause linear IgA bullous dermatitis w/ tense blisters & RMS 2/2 direct MC activation) mechanism: reactive metabolites cause Fas/FasL mediated apoptosis of epidermal cells & CTL activation & perforin release sx: mucous membranes, epidermal necrosis, target lesiosn - steroids CONTRAINDICATED in TEN

Question 53

What is the most likely timing between exposure to therapy and onset of reaction in drug rash with eosinophilia and systemic symptoms? ``` A. immediate (minutes to 1-2 hours) B. delayed (4-6 hours) C. days (>24 hours) D. 1 week E. weeks (2-3 weeks) ```

Answer 53

E. weeks (2-3 weeks) - SX: fever, LAD, hepatitis, facial edema, can worsen after d/c drug

Question 54

What is the most likely hypersensitivity mechanism in drug rash with eosinophilia and systemic symptoms? ``` A. Type I B. Type II C. Type III D. Type IVa E. Type IVb F. Type IVc G. Type IVd ```

Answer 54

E. Type IVb - drug specific CD4/CD8 T cells - mechanism a/w reactivation of chronic persistent HHV viruses, CMV, and EBV - can be a/w autoimmune complications up to 4 years later

Question 55

What is the most likely hypersensitivity mechanism in fixed drug eruption? ``` A. Type I B. Type II C. Type III D. Type IVa E. Type IVb F. Type IVc G. Type IVd H. vagal reaction ```

Answer 55

F. Type IVc - blue purple macule in same location w/ each drug exposure - a/w TMP/SMX bactrim and phenolphthalein, tetracyclines, NSAIDs

Question 56

What is the most likely mechanism of reaction in a patient at the dentist's office who experiences flushing, hypotension, chest tightness, SOB, and bradycardia after local injection of lidocaine? ``` A. Type I B. Type II C. Type III D. Type IVa E. Type IVb F. Type IVc G. Type IVd H. vagal reaction ```

Answer 56

H. vagal reaction BRADYcardia (vs tachy in ANA) no SPT, use graded challenges

Question 57

MCC perioperative ANA in: - US - non US

Answer 57

- US = abx (cefazolin) | - non US = NMBA (quaternary ammonium agents, succinylcholine)

Question 58

What is the most likely mechanism of reaction in a patient receiving biologic therapy who experiences fever, rash, bronchospasm, GI sx, with elevated LFTs, LDH and uric acid? ``` A. Type I B. Type II C. Type III D. Type IVa E. Type IVb F. Type IVc G. Type IVd H. vagal reaction I. cytokine release syndrome (type alpha) ```

Answer 58

I. cytokine release syndrome (type alpha) see DK slide 78, page 413

Question 59

Patient with IgE antibodies to galactose-alpha-1,3-galactose are at a higher risk for anaphylaxis with what medication

Answer 59

Cetuximab

Question 60

Immune mediated hemolytic anemias are classically due to all of the following drugs except: A. quinidine B. methyldopa C. penicillin D. heparin

Answer 60

D. heparin - heparin a/w THROMBOCYTOPENIA (HIT) - specific IgG to heparin platelet factor 4 -> immune complex formation -> HIT - immune thrombo also a/w: quinidine, PTU, gold, sulfa, vanc

Question 61

A patient with cough, migratory infiltrates, peripheral eosinophilia, and pulmonary fibrosis after drug exposure is most likely classically due to all of the following drugs except: ``` A. bleomycin B. nitrofurantoin C. vancomycin D. methotrexate E. NSAIDs F. Amiodarone ```

Answer 61

C. vancomycin Pulm drug HS: A. bleomycin B. nitrofurantoin - IP and pleural effusion D. methotrexate Eosinophilic PNA: E. NSAIDs IP: F. Amiodarone

Question 62

What is the most likely timing between exposure to therapy and onset of reaction with fever, rash, urticaria, LAD, arthralgias, in serum sickness reactions? ``` A. immediate (minutes to 1-2 hours) B. delayed (4-6 hours) C. days (>24 hours) D. 1 week E. weeks (1-3 weeks) ```

Answer 62

E. weeks (1-3 weeks) SSR: - causes: heterologous antiera, snake antivenom - labs: low complement, high C1q binding assay - mechanism: immune complex formation, Type III HS rxn - TX: steroids & AH, no desensitization

Question 63

A child presents with fever, rash, urticaria, LAD, arthralgias, after receiving a medication 2 weeks ago. What is the most likely implicated agent? ``` A. penicillin B. sulfonamide C. cefaclor D. phenytoin E. a monoclonal antibody ```

Answer 63

C. cefaclor MCC SSLR in KIDS!!! - due to altered metabolism -> toxic intermediates The other answers all cause SSR, too, but less in kids

Question 64

A patient presents with photodistributed erythema and annular, scaly plaques 4-8 weeks after starting hydrochlorothiazide. What is the most likely associated antibody profile? A. antihistone antibodies B. anticentromere antibodies C. anti-Ro (SSA) and anti-La (SSB) antibodies D. anti-HCTZ drug specific antibodies

Answer 64

C. anti-Ro (SSA) and anti-La (SSB) antibodies - drug induced CUTANEOUS lupus - cutaneouS = SSA + SSB (S = Skin)

Question 65

A patient presents with myalgias and arthralgias which have gradually progressed over the last few months after starting procainamide. What is the most likely associated antibody profile? A. antihistone antibodies B. anticentromere antibodies C. anti-Ro (SSA) and anti-La (SSB) antibodies D. anti-HCTZ drug specific antibodies

Answer 65

A. antihistone antibodies - drug induced SYSTEMIC lupus - sySTemic = antihiSTone ab

Question 66

A patient presents with photodistributed erythema and annular, scaly plaques 4-8 weeks after starting a new medication, and is found to have anti-Ro (SSA) and anti-La (SSB) antibodies. The most likely implicated medication can include all of the following except? ``` A. hydrochlorothiazide B. procainamide C. calcium channel blockers D. ACE inhibitors E. antifungals ```

Answer 66

B. procainamide (DI systemic lupus) - this case is drug induced CUTANEOUS lupus

Question 67

A patient presents with myalgias and arthralgias which have gradually progressed over the last few months after starting a new medication, and is found to have anti-histone antibodies. The most likely implicated medication can include all of the following except? ``` A. hydralazine B. procainamide C. phenytoin D. isoniazid E. ACE inhibitors ```

Answer 67

E. ACE inhibitors (DI cutaneous lupus) - this case is drug induced SYSTEMIC lupus

Question 68

Which 2 of the following chemotherapeutic agents can cause anaphylactoid reactions that may be treated or prevented with steroids and antihistamines? A. taxanes B. platinum compounds C. aspariginase D. excipients

Answer 68

A. Taxanes (paclitaxel, docetaxel) D. Excipients (cremophor-EL) C. aspariginase- can cause anyphylactoid or IgE med.

Question 69

All but which of the following chemotherapeutic agents can cause IgE mediated reactions that may be desensitized if necessary? A. taxanes B. carboplatin C. cisplatin D. oxiplatin

Answer 69

A. taxanes PLATINUM compounds = DESENS. MC reactions s/p 7 cycles carbo > cis > oxo

Question 70

see DK's slide on contrast reactions

Answer 70

risk for contrast reactions w/ atopy

Question 71

All of the following are contraindications to desensitization except: A. hemolytic anemia B. nephritis C. hepatitis D. immune complex-mediated reactions (serum sickness) E. antibody dependent cytotoxic reactions F. cell mediated exfoliative or blistering skin reactions (DRESS, SJS/TEN)

Answer 71

E. antibody dependent cytotoxic reactions

Question 72

Antihistamines and antileukotrienes decrease LRs what schedule of IT?

Answer 72

RUSH and cluster AIT Might reduce frequency of systemic reactions in conventional, rush and cluster

Question 73

Consider discontinuation of what med only for venom IT

Answer 73

ACE-I

Question 74

All of the following can increase steroid metabolism, and may require higher doses of steroid therapy, except: ``` A. rifampin B. carbamazepime C. phenobarbital D. OCPs E. phenytoin F. antacids ```

Answer 74

D. OCPs (DECREASE) Also: - ketoconazole - methylpred affected by: clarithromycin might need to increase steroid dose if patient is on RIPE therapy

Question 75

which major form of the glucocorticoid receptor mediates steroid resistance?

Answer 75

GRbeta is an inactive form of the receptor that is involved in steroid resistance

Question 76

Glucocorticoids influence gene transcription using 2 distinct pathways. Which pathway mediates the drugs adverse side effects?

Answer 76

All the unwanted effects of steroids come from trans-activation (Trans-repression inhibits transcription factor function (NKkB, NF-AT), inflammatory cytokines, chemokines, enzymes, etc)

Question 77

Glucocorticoids can directly enhance gene expression via trans-activation (target gene activation) and increase transcription of all of the following anti-inflammatory genes except: ``` A. IL-10 B. GILZ C. NFkB D. MKP-1 E. IkBa ```

Answer 77

C. NFkB- inhibited A. IL-10- basically the only cytokine NOT inhibited B. GILZ- GCC_induced leucine zipper protein) D. MKP-1 (Map kinase phosphatase-1) E. IkBa- inhibits NFkB

Question 78

true or false: The major pathway thought to suppress inflammation is trans-activation and direct suppression of gene expression rather than transcription factor interference (trans-repression).

Answer 78

false. used to think that, but now we think: Steroids are a sponge that soak up transcription factors that enhance inflammatory reactions for gene transcription and their upregulation. Also binds TF on its response element and sterically inhibits its promotor (see page 168 of notes for picture)

Question 79

All of the following are mechanisms by which GCC mediate anti-inflammatory functions except: A. Destabilize mRNA before it can be translated into DNA and make inflammatory factors B. influence gene transcription by altering chromatin structure = prevent DNA from unwinding, and promotors aren’t available for gene transcription C. activate HAT activity in low concentrations D. recruit HDAC in low concentrations E. repression of genes for RANTES, eotaxins, ICAM-1, VCAM-1, E-selectin, NOS, COX-2, PLA2, bradykinin B2-receptors

Answer 79

C. activate HAT activity in HIGH concentrations = increased anti-infl. gene transcription (IkBa, IL-10) B. influence gene transcription by altering chromatin structure = prevent DNA from unwinding, and promotors aren’t available for gene transcription D. recruit HDAC in low concentrations = repression of pro-infl. gene transcription

Question 80

The glucocorticoid receptor beta (GRb) does not bind to GC, but may bind GRalpha and inhibit GRE via what effect?

Answer 80

dominant negative increased expression of GRb a/w: - steroid resistant asthma - fatal asthma - nocturnal asthma - NP

Question 81

true or false: inhaled glucocorticoids affect the late and early phase bronchial response and airway hyperresponsiveneness

Answer 81

FALSE, only LATE

Question 82

All of the following are beta-2 selective, non-catecholamine bronchodilators except: ``` A. terbutaline B. albuterol C. fenoterol D. salmeterol E. formoterol F. vilanterol G. indacaterol ```

Answer 82

C. fenoterol - and metaproterenol (non-selective) SHORT: A. terbutaline B. albuterol LONG (>12 hrs): D. salmeterol- SLOW (30 min). PARTIAL agonist = cant result in maximal bronchodilation E. formoterol- FAST onset (2-3 min). FULL agonist- >80% maximal B2-agonist receptor activation = dose dependent effect VERY LONG (>24 hrs): F. vilanterol G. indacaterol carmoterol Catecholamine: - isoproterenol - epinephrine

Question 83

true or false: B2-receptor desensitization results in diminished responsiveness that develops over weeks when receptors are repeatedly exposed to agonists, and downregulation of the B2-adrenergic receptor, affecting the ability of agonists to bronchodilate.

Answer 83

false: Tachyphylaxis doesn’t affect ability to bronchodilate, but does shorten duration/bronchoprotective affect of BDL ex. 12 hrs vs 6-8 hrs

Question 84

ipratropium mechanisms

Answer 84

blocks M2 & M3 receptors with equal affinity 1) blocking M3 decreases Ach-induced bronchoconstriction 2) M2 receptors can be inhibitory and excitatory: - excitatory: comprise majority of MR in airway and stimulation = bronchoconstriction. - inhibitory: agonist (Ach) = inhibit Ach release. antagonist (anticholinergic) = blocking inhibitory receptors = increased Ach release from vagus = paradoxical bronchospasm

Question 85

tiotropium mechanism

Answer 85

equal binding affinity for M2 & M3 receptor - dissociates from M2 receptor 10x faster than M3 - dissociates from M3 receptor 100x slower than ipratropium = overall more M3 selective -> more blocking M3 bronchoconstriction, and less paradoxical M2 bronchoconstriction - longer duration of action

Question 86

Which of the following results in reduced production of LTB4? A. zafirlukast B. zileuton C. montelukast D. pranlukast

Answer 86

B. zileuton - blocks 5-LO = blocks LTB4 & cysLTs

Question 87

Which is more potent in causing bronchoconstriction-histamine or cysteinyl leukotrienes?

Answer 87

LTE

Question 88

All of the following antagonize the cysLT1 receptor except: A. zafirlukast B. zileuton C. montelukast D. pranlukast

Answer 88

B. zileuton LTD4 > LTC4 > LTE4 do not antagonize the cysLT2 receptor

Question 89

true or false: anti-leukotriene therapies attenuate both the late and early phase response to antigen challenge

Answer 89

TRUE

Question 90

Which histamine receptors are not mast cell mediated?

Answer 90

H3 & H4 1st gen AH- smaller, polar, hydrophobic = lipophilic = enter blood brain barrier, sedation 2nd gen-opposite

Question 91

Which of the following drugs is incorrectly matched with their non-H1-AH effects? A. 1st generation AH- antimuscarinic and anticholinergic effects B. promethazine- beta adrenergic blocking C. diphenhydramine- local anesthetic effects D. cyproheptadine- antiserotinergic effect

Answer 91

B. promethazine- ALPHA adrenergic blocking 1st gen AH are extensively metabolized by the hepatic CYP450 system = potential interactions with drugs that inhibit CYP450 (Ex. macrolides)

Question 92

Which of the following are mechanisms of action of theophylline is responsible for many of its seriously adverse effects: A. inhibition of phosphodiesterases leading to increased cAMP B. decreased HDAC2 C. antagonism of adenosine receptors, preventing mast cells from releasing histamine and LT and causing bronchoconstriction D. increased IL-10 E. inhibition of phosphoinositide-3-kinase-delta (PI3K-d)

Answer 92

C. antagonism of adenosine receptors, preventing mast cells from releasing histamine and LT and causing bronchoconstriction because it also leads to CNS stimulation, cardiac arrythmias, gastric hypersecretion, GE reflux, diuresis

Question 93

Reslizumab mechanism of action: A. IgG4/κ monoclonal antibody B. IgG1/κ monoclonal antibody C. IgG1k monoclonal antibody that binds α chain of human IL-5R Fcγ RIIIa region

Answer 93

A. IgG4/κ monoclonal antibody

Question 94

nephelometry mechanism

Answer 94

measure immune complex formation in the liquid phase measures scattered light to detect concentration of antibodies and levels of immunoglobulins

Question 95

HAE treatment guidelines for testing in the asymptomatic child of a parent with HAE?

Answer 95

C1INH testing be delayed until 1 year of age

Question 96

antihypertensives that can worsen rhinitis

Answer 96

- β-blockers - ACE-I - ameloride - hydralazine - reserpine - calcium channel blockers - methyldopa - α-receptor antagonists (prazosin) - phospophodiesterase-5 inhibitors (sildenafil)