CUMULATIVE PHARMACOLOGY REVIEW SESSION

Question 1

A 68 y/o male presents with heart failure, unacceptably low cardiac output, and intense reflex-mediated sympathetic activation of the peripheral vasculature that is attempting to keep vital organ perfusion pressure sufficiently high. He is edematous, and has ascites, because of the poor cardiac function and renal compensations for it. Which of the following agents should be avoided in this patient because it is most likely to compromise function of the already failing heart and the circulatory system overall?
A.Amiloride
B.Furosemide
C.Hydrochlorothiazide
D.Mannitol
E.Spironolactone

Answer 1

mannitol

Question 2

Mannitol (Osmotic Diuretics)

Answer 2

• Increases plasma osmolality initially until it is excreted by glomerular filtration
• Increased plasma osmolality withdraws water from the extracellular space and parenchymal cells into the blood
• If renal function is normal, renal blood flow and GFR rise and mannitol is eventually excreted
• If cardiac function is normal and adequate, circulating the extra volume is not a problem (up to a limit)
• With low cardiac output or compromised renal perfusion, increased blood volume and pressure may cause acute heart failure due to the additional volume and difficulty ejecting that volume against a higher afterload

Question 3

A 32 y/o male with stage 2 essential hypertension is treated with usually effective doses of an ACE inhibitor. After a suitable period of time blood pressure has not been lowered satisfactorily. He has been compliant with drug therapy and other recommendations (e.g., weight reduction, exercise). A thiazide is added to the ACE inhibitor regimen. Which of the following is the most likely and earliest untoward outcome of this drug add-on, for which you should monitor closely?
A.Fall of blood pressure sufficient to cause syncope
B.Hypokalemia due to synergistic effects of the ACE inhibitor and the thiazide on renal potassium excretion
C.Onset of acute heart failure from depression of ventricular contractility
D.Paradoxical hypertensive crisis
E.Sudden prolongation of the P-R interval and increasing degrees of heart block

Answer 3

hyperkalemia and cough are ae

Fall of blood pressure sufficient to cause syncope

Question 4

Which of the following statements correctly summarizes how losartan differs from lisinopril or its related drugs?
A.Lisinopril competitively blocks catecholamine-mediated vasoconstriction, losartan does not
B.Lisinopril effectively inhibits synthesis of angiotensin II, losartan does not
C.Losartan causes a higher incidence of bronchospasm and hyperuricemia
D.Losartan is preferred for managing HTN during pregnancy, whereas lisinopril is contraindicated
E.Losartan is suitable for administration to patients with heart failure, whereas lisinopril and related drugs should be avoided

Answer 4

Lisinopril effectively inhibits synthesis of angiotensin II, losartan does not

Question 5

A 55 y/o male with a 20-year history of type 2 diabetes mellitus comes to your clinic for his regular check-up. Current diabetes medications are metformin and glyburide. He is also taking an HMG-CoA reductase inhibitor to control his lipids and verapamil for Stage 1 hypertension. He looks good and feels well, but his blood pressure is not well controlled. You consider adding another antihypertensive drug. Which comorbidity or other factor would weigh against your selection of an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) as the add-on antihypertensive drug for this patient?
A.Bilateral renal artery stenosis
B.Bradycardia
C.Has had elevated HbA1cin the last year
D.Has heart failure
E.Is currently taking rosuvastatin

Answer 5

these dialate efferent arterioles

renoprotective as long as renal perfusion is good

BILATERAL ENAL ARTERY STENOSIS

Question 6

A 65 y/o male presents for a follow-up appointment after taking a drug for symptomatic relief of benign prostatic hypertrophy (BPH). In addition to its effects on smooth muscles of the prostate and urethra, this drug can lower blood pressure in such a way that it triggers reflex tachycardia, positive inotropy, and increased AV nodal conduction. The drug neither dilates nor constricts the bronchi. It causes the pupils of the eyes to constrict and interferes with mydriasisin dim light. Initial oral dosages of this drug have been associated with a high incidence of syncope. Which prototype is most similar to this unnamed drug in terms of the pharmacologic profile?
A.Captopril
B.Hydrochlorothiazide
C.Labetalol
D.Prazosin
E.Propranolol

Answer 6

prazosin

a1blocker

Question 7

You are contemplating starting ACE inhibitor therapy for a patient with primary hypertension. Which of the following patient-related condition(s) contraindicates use of and ACE inhibitor and so should be ruled out before you prescribe this drug?
A.Asthma
B.Heart failure
C.Hyperlipidemia, coronary artery disease
D.Hypokalemia
E.Possibility of pregnancy

Answer 7

pregnancy

all raas drugs are out for pregnancy

Question 8

A 38 y/o female was recently diagnosed with adrenal cortical adenoma. Among the pertinent Cushingoidsigns and symptoms are hypertension and weight gain from fluid retention; and hypernatremia and hypokalemia. Which drug would be the most rationale to prescribe, alone or adjunctively, to specifically antagonize both the renal and the systemic effects of the hormone excess?

A.Acetazolamide
B.Amiloride
C.Furosemide
D.Metolazone
E.Spironolactone

Answer 8

reverses hypernatremia and hypokalemia

salt sugar sex

spironolactone

Question 9

Urinary potassium concentrations are measured before and after several weeks of administering a loop diuretic at typical daily doses. Post-treatment urine potassium concentrations are substantially lower than those measured at baseline. Which of the following is the most likely explanation for this observation?
A.An expected response to the drug
B.Loop diuretics cause potassium-wasting only in in vitroexperimental models
C.Measurements of post-treatment urine potassium concentrations were erroneous
D.The patient has hypoaldosteronismfrom bilateral adrenalectomy
E.The patient has significantly impaired renal function

Answer 9

think about conc not amount

An expected response to the drug

Question 10

Changes in Urinary Electrolytes and Body pH in Response to Diuretics

Loop agents plus thiazides

NaCl
NaHCO3
K+
Body pH

Answer 10

+++++
+
++
↑

Question 11

Changes in Urinary Electrolytes and Body pH in Response to Diuretic

K+-sparing agents

NaCl
NaHCO3
K+
Body pH

Answer 11

+
(+)
-
↓

Question 12

Changes in Urinary Electrolytes and Body pH in Response to Diuretics

Carbonic anhydrase inhibitors

NaCl
NaHCO3
K+
Body pH

Answer 12

+
+++
+
↓

Question 13

Changes in Urinary Electrolytes and Body pH in Response to Diuretics

Loop agents

NaCl
NaHCO3
K+
Body pH

Answer 13

++++
0
+
↑

Question 14

Changes in Urinary Electrolytes and Body pH in Response to Diuretics

thiazides

NaCl
NaHCO3
K+
Body pH

Answer 14

++
+
+
↑

Question 15

Chlorthalidoneand torsemideand members of different diuretic classes, in terms of mechanisms of action and chemical structure, but they share the ability to cause hypokalemia. Which statement best describes the general mechanism by which these drugs cause their effects that lead to net renal potassium loss?

A.Act as aldosterone receptor antagonists, thereby favoring K+loss
B.Block proximal tubular ATP-dependent secretory pumps for K+
C.Increase delivery of Na+ to the distal nephron, where Na+reuptake creates a negative lumen potential that favors K+secretion
D.Stimulate a proximal tubular Na+/K+ATPase such that K+is actively pumped into the urine
E.Lower distal tubular urine osmolality, thereby favoring passive diffusion of K+into the urine

Answer 15

chlorthalidone is a thiazide

Increase delivery of Na+ to the distal nephron, where Na+reuptake creates a negative lumen potential that favors K+secretion

Question 16

A 52 y/o hypertensive male presents with inadequate blood pressure control with lisinopril. Triamterene is added to his drug regimen (these are the only two medications he takes). Which of the following is the most likely outcome?
A.Abrupt rise in blood pressure
B.Blood pressure control with an increased risk of hyperkalemia
C.Hypernatremia
D.Increased cardiac output
E.Worsening of the ACE inhibitor cough

Answer 16

triamterene is k sparing diuretic

Blood pressure control with an increased risk of hyperkalemia

Question 17

Collecting Tubule

Answer 17

• The most important site of K+secretion by the kidney
• Site at which all diuretic-induced changes in K+balance occur –more Na+delivered to collecting tubule leads to more K+secretion

Epithelial sodium channel (ENaC)
•Creates electrical gradient that facilitates secretion of K+(and H+)

Question 18

A 48 y/o male presents with acute heart failure as a result of septicemia. He has a history of poorly controlled Type I diabetes mellitus and a near-fatal allergic response to a sulfonamide antibiotic 10 years ago. He presents with significant edema and ascites. Which diuretic is most likely prescribed in addition to a combination of appropriate antibiotics and cardiac inotropes?
A.Ethacrynicacid
B.Furosemide
C.Hydrochlorothiazide
D.Mannitol
E.Metolazone

Answer 18

loop but diff than furosemide etc

the rest are sulfonamides

Ethacrynicacid

Question 19

A 32 y/o male presents with elevated fasting and postprandial blood glucose levels. Past medical history includes hypertension, which has been treated for the past six months using an oral diuretic. His HbA1cis elevated compared to measurements taken six months ago. Which of the following agents was most likely prescribed?

Answer 19

Chlorothiazide

Question 20

After lying in a recumbent position for a 45-minute dental procedure, a 44 y/o female stands up quickly and experiences a syncopalepisode. The cause is hypotension due to hypovolemiafrom excessive diuresis, attributed to a drug prescribed by her physician and taken for the past several months. Which of the following was the most likely cause?
A.Acetazolamide
B.Furosemide
C.Hydrochlorothiazide
D.Spironolactone
E.Triamterene

Answer 20

furosemide

Question 21

A 52 y/o male presents for his first visit with you after moving from a distant town. His only medications are an HMG-CoA reductase inhibitor, aspirin, and metolazone. The pharmacist who filled his prescriptions told the gentleman why he was taking the aspirin and the statin, but unfortunately referred to the metolazoneas a ‘water pill.’ Thus, you are asked about it. Assuming proper prescribing, which of the following is the most likely reason why metolazonewas prescribed?
A.Adjunctive management of an adrenal cortical tumor
B.Adjunctive management of hepatic cirrhosis from years of excessive alcohol consumption
C.Hypertension accompanied by a history of gout and diabetes
D.Treatment of essential hypertension
E.Treatment of edema and ascites from heart failure

Answer 21

Treatment of essential hypertension (thiazide)

thiazide like

first line for treatment of essential htn

Question 22

A 66 y/o female with heart failure, stage 2 essential hypertension, and hyperlipidemia (elevated LDL cholesterol and abnormally low HDL) is taking furosemide, captopril, atenolol, and simvastatin. During a scheduled physical exam, about a month after starting all of the above drugs, she reports a severe, hacking, and relentless cough. Other vital signs, and the overall physical assessment, are consistent with good control of both the heart failure and blood pressure and indicate no other underlying disease or abnormalities. Results of blood tests are not yet available. Which of the following is the most likely cause of the cough?

A.An expected side effect of the captopril
B.An allergic reaction to the statin
C.Dyspnea due to captopril’s known and powerful bronchoconstrictoraction
D.Hyperkalemia caused by an interaction between furosemide and captopril
E.Pulmonary edema from the furosemide

Answer 22

A.An expected side effect of the captopril

Question 23

You want to compare and contrast the cardiac and hemodynamic profiles of dihydropyridine-type calcium channel blockers (CCBs) and the nondihydropyridineCCB, verapamil (or diltiazem). Which of the following best summarizes how, in general, a nondihydropyridineCCB differs from nifedipine?
A.Causes a much higher incidence of reflex tachycardia
B.Causes significant dose-dependent slowing of AV nodal conduction velocity
C.Causes significant venodilation, leading to profound orthostatic hypotension
D.Has significant and direct positive inotropic effects
E.Is best used in conjunction with a β-blocker or digoxin

Answer 23

Causes significant dose-dependent slowing of AV nodal conduction velocity

Question 24

Your newly diagnosed hypertensive patient has vasospastic angina. Which drug or drug class would be the most rational for starting antihypertensive therapy because it exerts not only antihypertensive effects, but also directly lowers myocardial oxygen demand and consumption and tends to inhibit cellular processes that otherwise favor coronary vasospasm? Assume there are no other specific contraindications to the drug you choose.
A.ACE inhibitor or ARB
B.Beta blocker
C.Nifedipine
D.Thiazide diuretic
E.Verapamil

Answer 24

verapamil