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My MRCP > Clinical Pharmacology > Flashcards

Clinical Pharmacology Flashcards

1
Q

Acute intermittent porphyria

What drugs may precipitate attack?

AIP is caused by defect in porphobilinogen deaminase

A

Drugs which may precipitate attack in AIP
* barbiturates
* halothane
* benzodiazepines
* alcohol
* oral contraceptive pill
* sulphonamides

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2
Q

What is the effect of adrenaline?

Sympathomimetic amine - has both alpha + beta adernergic stim properties

A
  • Causes vasodilation
  • Increases vasoconstriction in skin + skidneys
  • Increases cardiac output and total peripheral resistance

Alpha adrenergic receptors
* Inhibits insulin secretion by pancreas
* Stimulates glycogenolysis in liver and muscle

Beta adrenergic receptors
* Stimulates glucagon secretion in pancrease
* Stimulates ACTH
* Stimulates lipolysis by adipose tissue

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3
Q

Give an example of beta1 and beta2 agonists

A

Beta-1 agonists
dobutamine

Beta-2 agonists
salbutamol

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4
Q

Give an example of alpha 1 and 2 agonists

A

Alpha-1 agonists
phenylephrine

Alpha-2 agonists
clonidine

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5
Q

Adrenoreceptor antagonists

Alpha-1 antagonist
Alpha-1a antagonist
Alpha-2 antagonist

A

Alpha antagonists
alpha-1: doxazosin
alpha-1a: tamsulosin - acts mainly on urogenital tract
alpha-2: yohimbine

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6
Q

Name a beta-1 antagonist and non-selective antagonist

A

Beta antagonists
beta-1: atenolol
non-selective: propranolol

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7
Q

Allopurinol interactions

A
  • Azathioprine
  • Cyclophosphamide - reduced renal clearance, marrow toxicity
  • Theophylline - increase plasma concentration
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8
Q

Describe the mechanism by which amiodarone causes hypothyroidism

A

The pathophysiology of amiodarone-induced hypothyroidism (AIH) is thought to be due to the high iodine content of amiodarone causing a Wolff-Chaikoff effect*
*an autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide

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9
Q

Beta-blocker overdose
Features
Management

A

Features
* bradycardia
* hypotension
* heart failure
* syncope

Management
* if bradycardic then atropine
* in resistant cases glucagon may be used

Haemodialysis is not effective in beta-blocker overdose

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10
Q

Ciclosporin

A

nephrotoxicity
hepatotoxicity
fluid retention
hypertension
hyperkalaemia
hypertrichosis
gingival hyperplasia
tremor
impaired glucose tolerance
hyperlipidaemia
increased susceptibility to severe infection

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11
Q

Digoxin
MOA

A

Mechanism of action
* decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter
* increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve
* digoxin has a narrow therapeutic index

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12
Q

Digoxin toxicity
Features

A

Features
* generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
* arrhythmias (e.g. AV block, bradycardia)
* gynaecomastia

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13
Q

Why is hypokalaemia a precipitating factor of digoxin toxicity

A

digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects

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14
Q

Management of digoxin toxicity

A

Management
Digibind
correct arrhythmias
monitor potassium

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15
Q

Drugs that cause impaired glucose tolerance

A

thiazides, furosemide (less common)
steroids
tacrolimus, ciclosporin
interferon-alpha
nicotinic acid
antipsychotics

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16
Q

Drug induced thrombocytopenia

A

quinine
abciximab
NSAIDs
diuretics: furosemide
antibiotics: penicillins, sulphonamides, rifampicin
anticonvulsants: carbamazepine, valproate
heparin

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17
Q

Drugs that cause urinary retention

A

tricyclic antidepressants e.g. amitriptyline
anticholinergics e.g. antipsychotics, antihistamines
opioids
NSAIDs
disopyramide

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18
Q

Side effects of sulfonylureas

A

Hypoglycaemic episodes
Increased appetite and weight gain
Syndrome of inappropriate ADH secretion
Liver dysfunction (cholestatic)

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19
Q

Side effects of glitazones

A

Weight gain
Fluid retention
Liver dysfunction
Fractures

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20
Q

Sife effects of isioniazid

A

mechanism of action: inhibits mycolic acid synthesis
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis, agranulocytosis
liver enzyme inhibitor

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21
Q

Side effects of pyrazinamide

A

mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I
hyperuricaemia causing gout
arthralgia, myalgia
hepatitis

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22
Q

Ethambutol
Side effect
MOA

A

mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan
optic neuritis: check visual acuity before and during treatment
dose needs adjusting in patients with renal impairment

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23
Q

Cellular targets of drugs

Name 4 main types of cellular targets

A
  • Ligand gated Ion channels
  • G-protein coupled receptors
  • Tyrosine kinase receptors
  • Nuclear receptors
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24
Q

Ligand gated ion channel

A

Ion channel coupled to a membrane receptor causing direct signalling
Nicotinic acetylcholine receptor
GABA receptor

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25
Q

GPCR

MOA
Eg

A
  • Drug binds to target that causes a sequence of events that leads to indirect signalling cAMP&raquo_space;
  • Second messengers cause the effect
  • Adrenoreceptors
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26
Q

Tyrosine kinase receptors

MOA
Eg

A
  • When drug activates TKR, leads to phosphorylation that causes cell growth and differentiation
  • Insulin
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27
Q

Nuclear receptors

A
  • Receptors located on nucleus of cell and activation or inhibition of receptors via decreased/increased gene transcription
  • Lipid-soluble drugs can only work as they need to penetrate cell membrane to get to nucleus
  • After penetration, the drug can form complex with receptor protein
  • Levothyroxine, steroid, spironolactone, oestrogen
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28
Q

Drugs that cause photosensitivity

A

Causes of drug-induced photosensitivity
thiazides
tetracyclines, sulphonamides, ciprofloxacin
amiodarone
NSAIDs e.g. piroxicam
psoralens
sulphonylureas

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29
Q

Antibiotics

Name bactericidal antibiotic

A

penicillins
cephalosporins
aminoglycosides
nitrofurantoin
metronidazole
quinolones
rifampicin
isoniazid

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30
Q

Bacteriostatic antibiotics
Name 5

A

chloramphenicol
macrolides
tetracyclines
sulphonamides
trimethoprim

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31
Q

HIV drugs

What is the mOA of enfuvirtide and maraviroc

A

Entry inhibitors that prevent HIV-1 from entering and infecting immune cells

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32
Q

HIV management

Name some NRTIs

A
  • Zidovudine
  • Abacavir
  • Emtricitabine
  • Didanosine
  • Lamivudine
  • Stavudine
  • Zalcitabine
  • Tenofovir
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33
Q

What is a general side effect of NRTI?
Describe side effects
Tenofovir
Zidovudine
Didanosine

A
  • General side effects NRTI - peripheral neuropathy
  • Tenofovir - renal impairment osteoporosis
  • Zidovudine: anaemia, myopathy, black nails
  • Didanosine: pancreatitis
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34
Q

NNRTI
Give 2 examples
Give 3 general SE

A

Non-nucleoside reverse transcriptase inhibitors (NNRTI)
examples: nevirapine, efavirenz
side-effects: P450 enzyme interaction (nevirapine induces), rashes

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35
Q

What is the MOA of the following drugs
Indinavir, nelfinavir, ritonavir, saquinavir
Side effects

A
  • Protease inhibitors
  • indinavir, nelfinavir, ritonavir, saquinavir
  • SE: diabetes, cushingoid
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36
Q

What is the MOA of raltegravir, elvitegravir, dolutegravir

A

Integrase inhibitors
* block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
* examples: raltegravir, elvitegravir, dolutegravir

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37
Q

Drugs in managing LUTS

Predominantly voiding symptoms - ‘poor stream’, what drugs are indicated?

A
  • if ‘moderate’ or ‘severe’ symptoms offer an alpha-blocker
  • if the prostate is enlarged and the patient is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered
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38
Q

Drugs in managing LUTS

Predominantly overactive bladder

A
  • antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
  • Mirabregron
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39
Q

What do you give if a patient presented with mixed overactive and voiding symptoms

A

if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added

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40
Q

What can be prescribed for nocturia

A
  • advise about moderating fluid intake at night
  • furosemide 40mg in late afternoon may be considered
  • desmopressin may also be helpful
41
Q

Diabetic drugs

Sulfonylureas
MOA
Common adverse effect

A
  • They work by increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present.
  • On a molecular level they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells.
  • Hypoglycaemic episode
  • Weight gain

Tolbutamide, gliclazide

42
Q

Prescribing in renal failure

Drugs to avoid in renal failure

A
  • antibiotics: tetracycline, nitrofurantoin
    NSAIDs
    lithium
    metformin
43
Q

Prescribing in renal failure

Which opioid is best?

A

Active metabolites of morphine accumulate in renal failure which means that long-term use is contraindicated in patients with moderate/severe renal failure. These toxic metabolites can accumulate causing toxicity and risk overdose.

Oxycodone is mainly metabolised in the liver and thus safer to use in patients with moderate to end-stage renal failure with dose reductions.

44
Q

Antifungals

Azoles

A

Mechanism of Action: Inhibits 14α-demethylase which produces ergosterol.
Adverse Effects: P450 inhibition, Liver toxicity.

45
Q

Antifungals

Amphotericin B

A

Mechanism of Action: Binds with ergosterol forming a transmembrane channel that leads to monovalent ion leakage (K+, Na+, H+, and Cl).
Adverse Effects: Nephrotoxicity, flu-like symptoms, hypokalemia, hypomagnesemia.
Notes: Used for systemic fungal infections.

46
Q

Antifungals

Terbinafine

A

Mechanism of Action: Inhibits squalene epoxidase.
Adverse Effects: Commonly used in oral form to treat fungal nail infections.

47
Q

Antifungals

Griseofulvin

A

Mechanism of Action: Interacts with microtubules to disrupt the mitotic spindle.
Adverse Effects: Induces P450 system, teratogenic.

48
Q

Antifungals

Flucytosine

A

Mechanism of Action: Converted by cytosine deaminase to 5-fluorouracil, which inhibits thymidylate synthase and disrupts fungal protein synthesis.
Adverse Effects: Vomiting.

49
Q

Antifungals

Caspofungin

A

Mechanism of Action: Inhibits synthesis of beta-glucan, a major fungal cell wall component.
Adverse Effects: Flushing.

50
Q

Antifungals

Nystatin

A

Mechanism of Action: Binds with ergosterol forming a transmembrane channel that leads to monovalent ion leakage (K+, Na+, H+, and Cl).
Adverse Effects: As very toxic, can only be used topically (e.g., for oral thrush).

51
Q

Diabetic drugs

Gliptins - DPP4 inhibitors

A
  • reduce the peripheral breakdown of incretins such as GLP-1 (incretins inhibit glucagon secretion and increase insulin secretion)
  • Dont confuse these with GLP-1 mimetics
  • Sitagliptin
52
Q

P450 enzyme system

Inducers of P450 system will lead to lower drug levels
(increased metabolism of drug)

A

antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John’s Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)

53
Q

P450 system

Inhibitors of the P450 system include

A

antibiotics: ciprofloxacin, erythromycin
isoniazid
cimetidine,omeprazole
amiodarone
allopurinol
imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin

54
Q

Phenytoin monitoring
*Phenytoin is a medication that has a narrow therapeutic index, meaning there is a small difference between therapeutic and toxic levels. *

A
  • Immediately before next dose (trough levels)
55
Q

Side effect of finasteride

A

Works by metaboliseing testosterone

Adverse effects
impotence
decrease libido
ejaculation disorders
gynaecomastia and breast tenderness

56
Q

drugs causing urticaria

A

aspirin
penicillins
NSAIDs
opiates

57
Q

Octreotide
MOA
Indications
SE

A

Overview
long-acting analogue of somatostatin
somatostatin is released from D cells of pancreas and inhibits the release of growth hormone, glucagon and insulin

Uses
acute treatment of variceal haemorrhage
acromegaly
carcinoid syndrome
prevent complications following pancreatic surgery
VIPomas
refractory diarrhoea

Adverse effects
gallstones (secondary to biliary stasis)

58
Q

Antiarrhythmics: Vaughan Williams classification

Quinidine
Procainamide
Disopyramide

A

Class 1a
Block sodium channels
Increases AP duration

58
Q

Anti-diabetic drug

MOA of meglitinides

A

increase pancreatic insulin secretion
like sulfonylureas they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
often used for patients with an erratic lifestyle
adverse effects include weight gain and hypoglycaemia (less so than sulfonylureas)
repaglinide nateglinide

59
Q

Antiarrhythmics: Vaughan Williams classification

Lidocaine
Mexiletine
Tocainide

A

Class 1b
Block sodium channels
Decreases AP duration

60
Q

Antiarrhythmics: Vaughan Williams classification

Flecainide
Encainide
Propafenone

A

Class 1c
Block sodium channels
No effect on AP duration

61
Q

Antiarrhythmics: Vaughan Williams classification

Propranolol
Atenolol
Bisoprolol
Metoprolol

A

Class II
Beta-adrenoceptor antagonists

62
Q

Antiarrhythmics: Vaughan Williams classification

Amiodarone
Sotalol
Ibutilide
Bretylium

A

Class III
Blocks K+ channels

63
Q

Antiarrhythmics: Vaughan Williams classification

Class IV

A

Verapamil
Diltiazem
CCB

64
Q

Management of bulimia

A

High dose fluoxetine

65
Q

Management of neuropathic pain if single agent not working

A

Drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added

66
Q

Procyclidine MOA

A

Antimuscarinic
Used in PD treatment
It blocks muscarinic acetylcholine receptors in the central and peripheral nervous system. This results in a reduction of cholinergic activity which helps to balance the dopamine-acetylcholine ratio in the brain

67
Q

Mirabegron

A

beta 3 agonist

68
Q
A
69
Q

Management of metformin during Ramadhan

A

During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset

70
Q

Quinine what is a side effect related to the ear?

A

ototoxicity - tinnitus

71
Q

Brupropion for smoking cessation - what is the MOA

A

The correct answer is Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist. Bupropion is an atypical antidepressant and smoking cessation aid. Its primary mechanism of action involves the inhibition of the reuptake of norepinephrine and dopamine, thereby increasing their synaptic concentrations. It also acts as a non-competitive antagonist of nicotinic acetylcholine receptors, which is thought to contribute to its efficacy in smoking cessation.

72
Q

Mineral bone disease management in CKD

1-alpha hydroxylation normally occurs in the kidneys → CKD leads to low vitamin D
the kidneys normally excrete phosphate → CKD leads to high phosphate

How does this cause osteomalacia?
How does this cause secondary hyperparathyroidism?

A

the high phosphate level ‘drags’ calcium from the bones, resulting in osteomalacia
low calcium: due to lack of vitamin D, high phosphate
secondary hyperparathyroidism: due to low calcium, high phosphate and low vitamin D

73
Q

Mineral bone disease management in CKD

Management - aim to reduce phosphate, PTH levels

A
  • Reduce dietary intake of phosphate
  • Use phosphate binders
  • Use alfacalcidiol, calcitriol
  • Parathyroidectomy
74
Q

Why cant we just give calcium supplements to CKD patients?

A
  • Alfacidiol is used instead in ESRD
  • Does not require activation in kidneys
75
Q

What antibiotic is associated with skin pigmentation

A

Minocycline

76
Q

Drugs causing haemolysis in G6PD

A

anti-malarials: primaquine
ciprofloxacin
sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas

77
Q

Fluconazole and ciclosporin - what is the interaction

A

Fluconazole inhibits the metabolism of ciclosporin which increases the risk of ciclosporin nephrotoxicity.

78
Q

MOA of oseltamivir vs aciclovir

A

Oseltamivir - Neuraminidase inhibitor
Aciclovir - DNA polymerase inhibitor

79
Q

Aspirin is reversible or non reversible cox inhibitor?

A

Reversible cox inhibitor
causes anti-platelet effect by its impact on TXA2

80
Q

What is the time lag of finasteride from initiation to when its effects are seen?

A

Up to 6 months. Finasteride, a 5-alpha reductase inhibitor, is used in the treatment of benign prostatic hyperplasia (BPH) and its effectiveness can take up to six months. This is because finasteride works by inhibiting the conversion of testosterone into dihydrotestosterone (DHT), which contributes to prostate enlargement. The reduction in prostate size and associated symptom relief, therefore, takes some time.

81
Q

Which of the following anti-epileptics are most assoc weight gain

Ethosuximide
Sodium valproate
Levetiracetam
Carbamazepine
Lamotrigine

A

Sodium valproate

82
Q

Drugs that cause raised prolactin

A

phenothiazines, metoclopramide, domperidone

83
Q

IgG

75%

A

Enhances phagocytosis of bacteria and viruses
Fixes complement and passes to the fetal circulation
Most abundant isotype in blood serum

84
Q

IgA

15%

A

Predominant immunoglobulin in breast milk
Found in secretions of digestive, respiratory, and urogenital tracts
Provides localized protection on mucous membranes
Most commonly produced immunoglobulin in the body (lower blood serum concentrations than IgG)
Transported across the interior of the cell via transcytosis

85
Q

IgM

10% frequency

A

First immunoglobulins to be secreted in response to an infection
Fixes complement but does not pass to the fetal circulation
Anti-A, B blood antibodies (pentamer when secreted)
Note: Cannot pass to the fetal circulation, preventing haemolysis

86
Q

IgD

1%

A

Role in immune system largely unknown
Involved in activation of B cells

87
Q

IgE

0.1%

A

Mediates type 1 hypersensitivity reactions
Synthesized by plasma cells
Binds to Fc receptors on mast cells and basophils
Provides immunity to parasites like helminths
Least abundant isotype in blood serum

88
Q

Drugs causing ocular problems

Cataracts
Corneal opacities

Cataracts - clouding of lens

A

Cataracts
* steroids

Corneal opacities
* amiodarone
* indomethacin

89
Q

Drugs causing ocular problems

Optic neuritis

A

ethambutol
amiodarone
metronidazole

90
Q

Drugs causing ocular problems

Retinopathy

A

chloroquine, quinine

91
Q

Drugs causing ocular problems

What does sildenafil cause?

A

Sildenafil can cause both blue discolouration and non-arteritic anterior ischaemic neuropathy

92
Q

Interferon

Interferon Alpha uses

A

produced by leucocytes
antiviral action
useful in hepatitis B & C, Kaposi’s sarcoma, metastatic renal cell cancer, hairy cell leukaemia
adverse effects include flu-like symptoms and depression

93
Q

Interferon beta

A

produced by fibroblasts
antiviral action
reduces the frequency of exacerbations in patients with relapsing-remitting MS

94
Q

Interferon gamma

A

predominately natural killer cells. Also by T helper cells
weaker antiviral action, more of a role in immunomodulation particularly macrophage activation
may be useful in chronic granulomatous disease and osteopetrosis

95
Q

Immunology

What would be the difference in results of Immunoglobulin electrophoresis for multiple myeloma vs waldenstroms

A

IgM paraproteinemia points to Waldenstroms
Monoclonal IgG OR IgA will be raised in MM

96
Q

Which one of the following is contraindicated in ischaemic heart disease and chronic heart failure?
Amiodarone, digoxin, bisoprolol, flecainide, warfarin

A

Flecainide - class IC anti-arrhythmic is associated with increased risk of arrhythmia (it slows down conduction of APs)

97
Q

Recommend Adult Life Support (ALS) adrenaline doses for anaphylaxis vs cardiac arrest

A

anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV

My MRCP (43 decks)

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