ESA 4 - CPT all qs

Question 1

Question 1

A 57 year old man attends a hypertensive clinic after having his blood pressure measured at his local pharmacy during their hypertension awareness program. His blood pressure is confirmed to be 155/100 at the clinic. He reports no other significant medical history.

a) What classification would you assign this blood pressure based on the joint BHS/NICE guidelines? (1 mark)

Answer 1

155/100 mmHg = STAGE 2

Question 2

Case 1

A 57 year old man attends a hypertensive clinic after having his blood pressure measured at his local pharmacy during their hypertension awareness program. His blood pressure is confirmed to be 155/100 at the clinic. He reports no other significant medical history.

b) With the information that you have, what class of antihypertensive would you suggest for this patient and suggest an appropriate drug. (2 marks)

Answer 2

Calcium Channel Blocker (Dihydropyridine) (1 mark)
(1 Mark for any one of the following or others in the class) Amlodipine Nifedipine Nicardipine

NOT verapamil or diltiazem

Question 3

Case 1

A 57 year old man attends a hypertensive clinic after having his blood pressure measured at his local pharmacy during their hypertension awareness program. His blood pressure is confirmed to be 155/100 at the clinic. He reports no other significant medical history.

c) ACE Inhibitors can reduce hypertension. (i) Name the conversion step at which these drugs act (ii) Name two actions of ACE inhibitors that contribute to lowering blood pressure. (2 marks)

Answer 3

i) At the point of converting Angiotensin 1 to Angiotensin II by ACE (1 mark)
1/2 mark each for any two of the following:
ii) Reduced vasoconstriction Reduced sympathetic activity
Reduced aldosterone release leading to reduced salt and water retention

Question 4

Case 1

A 57 year old man attends a hypertensive clinic after having his blood pressure measured at his local pharmacy during their hypertension awareness program. His blood pressure is confirmed to be 155/100 at the clinic. He reports no other significant medical history.

d) State two ADRs that you would discuss with a patient when prescribing an ACE inhibitor. (2 marks)

Answer 4

Award 1 mark for any of the following – max two marks:
Dry cough (10-15%) Angioedema uncommon but more prevalent in African Caribbean populations Renal failure (incl. renal artery stenosis) Hyperkalaemia

Question 5

Case 1

A 57 year old man attends a hypertensive clinic after having his blood pressure measured at his local pharmacy during their hypertension awareness program. His blood pressure is confirmed to be 155/100 at the clinic. He reports no other significant medical history.

e) In patients with resistant hypertension, who have been prescribed drugs in accordance with guidelines up to and including step three, additional add on drugs can be prescribed. Name ONE class of drug that may be considered, provide an example from this class and briefly describe how it lowers blood pressure. (3 marks)

Answer 5

Spironolactone is a mineralocorticoid receptor antagonist. Prevents aldosterone action (reduction of blood volume) OR

Alpha blocker cause vasodilation reducing the pressure at which blood is ejected into vasculature OR

Beta blocker – beta adrenergic receptor antagonist, lower renin levels, negative chronotropic and inotropic effects, decreased cardiac output

Question 6

Question 2

A 42 year old female has recently been diagnosed with type II diabetes. She is attending the GP for a medication review.

a) What clinical marker will the GP measure to access how well her diabetes is being controlled and what target (%) would they be hoping for? (2 marks)

Answer 6

HbA1c (1 mark) 6.5% in first two treatment steps (1 mark)

Question 7

Question 2

A 42 year old female has recently been diagnosed with type II diabetes. She is attending the GP for a medication review.

b) She is currently taking metformin TDS. How does metformin help control her diabetes? (3 marks)

Answer 7

Decrease insulin resistance (sensitivity of own insulin), (1 mark) increasing glucose uptake and utilisation in target tissues (skeletal muscle) (1 mark). Reduces hepatic glucose production. (Limits weight gain) (1 mark).

Question 8

Question 2

A 42 year old female has recently been diagnosed with type II diabetes. She is attending the GP for a medication review.

c) What non-pharmacological intervention would be recommended upon diagnosing type II diabetes? What considerations should be discussed with patients when initiating therapy which are often related to poor adherence? (3 marks)

Answer 8

Non-pharmacological intervention (1 mark)
Managed weight reduction (1 mark)

Considerations to be discussed (2 marks)
Increased risk of weight gain (1 mark) Hypoglycaemia (1 mark)

Question 9

Question 2

A 42 year old female has recently been diagnosed with type II diabetes. She is attending the GP for a medication review.

d) People with type II diabetes are at greater risk of suffering from atrial fibrillation. Which class of drug would you recommend for rate control in atrial fibrillation? Which drug would you prescribe? (2 marks)

Answer 9

Beta blocker (1 mark) – bisoprolol (1 mark)
OR
Calcium channel blocker (1 mark) – either verapamil (1 mark)
OR
diltiazem (1 mark)

Question 10

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

a) Initial results show that the oral bioavailability of the drug is 0.2. If the total amount of BAY 28672 given orally was 70 mg, what amount of the drug would be available to afford a therapeutic effect? (1 mark)

Answer 10

We are told F (oral bioavailability) = 0.2 So if the total amount given was 70 mg and the oral bioavailability was 0.2 then 0.2 x 70 mg = 14mg (1 mark)

Question 11

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

b) The low oral bioavailability means the i.v. route is preferred for administration. A plot of its pharmacokinetic profile is shown below. By using the graph below estimate the half-life of the drug.

Pharmacokinetics following single iv administration
x-axis: Time in Hours 0 10 20 30 40 50 60 70 80 90 100
y-axis: Plasma Concn (mg/L) 0 2.5 5 7.5 10 12.5

(1 mark)

Answer 11

20 hrs (1 mark)

Question 12

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

c) Results from the study revealed that BAY 28672 had a clearance rate of 5ml/kg/hr. With this information calculate the apparent volume of distribution.

The equation: t1/2 = 0.693 x Vd/CL should help you. (3 marks)

Answer 12

Step 1. 20 hrs = 0.7 x Vd/5ml/kg/hr
Step 2. 20 hrs x 5 ml/kg/hr = 0.7 xVd = 100 ml/kg (the hours cancel)
Step 3. 100 ml/kg/0.7 = Vd = 142 ml/kg
(1 mark for each step)

Question 13

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

d) The volume of distribution of a modified preparation is calculated and reported to be significantly higher than the previous drug. How would you expect the t ½ to compare to the old drug? (1 mark)

Answer 13

Increase. Vd is proportional to t1/2 (1 mark)

Question 14

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

e) One of the participants in the phase 0 trial, develops breast cancer aged 55 (unrelated to the trial). Name the type of hormone replacement therapy (HRT) that increase the risk of breast cancer. Provide an example drug from this class. (2 marks)

Answer 14

Opposed oestrogen therapy (1 mark)

Estradiol with medroxyprogesterone, levonorgestrel or dydrogesterone. Many other combinations but above are commonly used. Specific dose combinations and trade names do not need to be learnt.

Longer term unopposed HRT can increase risk of breast cancer and is suggested to be associated with increased age and other risk factors.

Question 15

Question 3

You are the Lead Clinician in a clinical trial for a new chemotherapeutic drug, BAY 28672. You are responsible for overseeing analysis of the pharmacokinetic properties of the drug in a Phase 0 trial.

f) Tamoxifen is discussed as an appropriate chemotherapeutic agent. What does this information suggest about the breast cancer diagnosis and to what class of chemotherapies does it belong? (2 marks)

Answer 15

Oestrogen receptor positive (1 mark) SERM (1 mark)

Question 16

Question 4

A 58 year old man has been transferred to a local hospice with metastatic renal cell carcinoma. He is suffering from significant metastatic bone pain particularly acute in both ankles. On arrival he is taking diclofenac before bed and co-codamol TDS.

1) Why is diclofenac prescribed to this patient? (Think about its mechanisms of action compared to opioids and bone metastases). [3 marks]

Answer 16

Diclofenac is an NSAID that has both analgesic and anti-inflammatory effects. Pain of bone metastases will be compounded by inflammation. It will inhibit the prostaglandin mediated sensitisation of nociceptors to pain and reduce inflammation.

Question 17

Question 4

A 58 year old man has been transferred to a local hospice with metastatic renal cell carcinoma. He is suffering from significant metastatic bone pain particularly acute in both ankles. On arrival he is taking diclofenac before bed and co-codamol TDS.

Following review of the patients medications a week after arriving at the hospice, morphine BID replaced the co-codamol. Oramorph (morphine, oral solution) prn, metoclopramide TDS and omeprazole SID were also prescribed.

2) Why was morphine, oral solution also prescribed? [1 mark]

Answer 17

Morphine, oral solution is used to manage breakthrough pain exacerbations.

Question 18

Question 4

A 58 year old man has been transferred to a local hospice with metastatic renal cell carcinoma. He is suffering from significant metastatic bone pain particularly acute in both ankles. On arrival he is taking diclofenac before bed and co-codamol TDS.

Following review of the patients medications a week after arriving at the hospice, morphine BID replaced the co-codamol. Oramorph (morphine, oral solution) prn, metoclopramide TDS and omeprazole SID were also prescribed.

3) The patient’s use of morphine, oral solution increased over the following four days. How should his analgesia be changed? [1 mark]

Answer 18

This suggests that pain management is not adequately controlled and long acting morphine BID dose should be reviewed.

Question 19

Question 4

A 58 year old man has been transferred to a local hospice with metastatic renal cell carcinoma. He is suffering from significant metastatic bone pain particularly acute in both ankles. On arrival he is taking diclofenac before bed and co-codamol TDS.

Following review of the patients medications a week after arriving at the hospice, morphine BID replaced the co-codamol. Oramorph (morphine, oral solution) prn, metoclopramide TDS and omeprazole SID were also prescribed.

4) Why was metoclopramide prescribed and how does it afford its therapeutic action? [3 marks]

Answer 19

Nausea is an unwanted side effect of opioid analgesics, particularly in the early stages of treatment. Metoclopramide is a dopamine receptor antagonist that acts at the chemoreceptor trigger zone and also has prokinetic gut activity to reduce nausea.

Question 20

Question 4

A 58 year old man has been transferred to a local hospice with metastatic renal cell carcinoma. He is suffering from significant metastatic bone pain particularly acute in both ankles. On arrival he is taking diclofenac before bed and co-codamol TDS.

Following review of the patients medications a week after arriving at the hospice, morphine BID replaced the co-codamol. Oramorph (morphine, oral solution) prn, metoclopramide TDS and omeprazole SID were also prescribed.

5) Why is omeprazole prescribed and how does it differ to ranitidine? [3 marks]

Answer 20

Omeprazole is a proton pump inhibiter that blocks acid secretion and should be prescribed alongside NSAIDs being given on a long term basis to reduce the possibility of NSAID induced gastric or duodenal ulceration. Ranitidine is an H2 receptor antagonist that reduces histamine mediated gastric acid secretion.

Question 21

Question 5

A 23 year old female has epilepsy in the form of generalised tonic-clonic seizures.

1) In addition to an MRI, which diagnostic test may be used in supporting a diagnosis of epilepsy? [1 mark]

Answer 21

Electroencephalogram (EEG)

Question 22

Question 5

A 23 year old female has epilepsy in the form of generalised tonic-clonic seizures.

2) Name one sodium channel blocker that could be prescribed as a first line treatment in the management of a patient with generalised tonic-clonic seizures? [1 mark]

Answer 22

Sodium valproate OR lamotrigine (more appropriate in a female of child bearing age)

Question 23

Question 5

A 23 year old female has epilepsy in the form of generalised tonic-clonic seizures.

3) This patient has recently started a new sexual relationship and discusses contraception with her GP. What advice should be given to the patient by the GP? [2 marks]

Answer 23

Many AEDs increase metabolism of oestrogen and so a larger (often doubled) dose of the COCP is needed. Barrier contraception should also be considered particularly during changes in AED medication.

Question 24

Question 5

A 23 year old female has epilepsy in the form of generalised tonic-clonic seizures.

4) Neural tube defects are more prevalent in neonates being carried by mothers taking certain antiepileptic drugs. Which vitamin deficiency is associated with this malformation? [1 mark]

Answer 24

Folic acid

Question 25

Question 6

A 49 year male is admitted to hospital following several episodes in which he describes a racing heart rate. He reports that these episodes have lasted for 30 minutes or so. He also reports feeling breathless and lightheaded. Following initial investigations, supraventricular tachycardia (SVT) is confirmed and he is prescribed amiodarone which is titrated over a number of weeks.

1) According to the Vaughan Williams classification which class does amiodarone belong? [1 mark]

Answer 25

Class III

Question 26

Question 6

A 49 year male is admitted to hospital following several episodes in which he describes a racing heart rate. He reports that these episodes have lasted for 30 minutes or so. He also reports feeling breathless and lightheaded. Following initial investigations, supraventricular tachycardia (SVT) is confirmed and he is prescribed amiodarone which is titrated over a number of weeks.

2) Describe how amiodarone is effective in controlling SVT? [3 marks]

Answer 26

It blocks potassium channels, prolonging the action potential duration and increasing the absolute refractory period (and see below)

Question 27

Question 6

A 49 year male is admitted to hospital following several episodes in which he describes a racing heart rate. He reports that these episodes have lasted for 30 minutes or so. He also reports feeling breathless and lightheaded. Following initial investigations, supraventricular tachycardia (SVT) is confirmed and he is prescribed amiodarone which is titrated over a number of weeks.

3) What effect will amiodarone have on AV conduction? [1 mark]

Answer 27

Slow AV conduction

Question 28

Question 7

A 40 year old female presents to her GP after developing painful metacarpophalangeal joints in both hands.

1) She is prescribed which class of drug and asked to return for review in 8 weeks if her symptoms haven’t improved? [1 mark]

Answer 28

NSAID would be appropriate at this stage (evidence of some inflammation should also have been included in the stem to lead this part of the question)

Question 29

Question 7

A 40 year old female presents to her GP after developing painful metacarpophalangeal joints in both hands.

Over the next few weeks the pain in her hands is reduced but then persists and her knees and wrists also become painful and swollen. Rheumatoid arthritis is confirmed and methotrexate is prescribed.

2) What frequency should methotrexate be prescribed and why? [2 mark]

Answer 29

Once weekly, metabolites (polyglutamates) have a long half-lives (1-2 weeks).

Question 30

Question 7

A 40 year old female presents to her GP after developing painful metacarpophalangeal joints in both hands.

Over the next few weeks the pain in her hands is reduced but then persists and her knees and wrists also become painful and swollen. Rheumatoid arthritis is confirmed and methotrexate is prescribed.

3) What consideration should be made if the initial drug is to be continued to be prescribed alongside methotrexate? [2 marks]

Answer 30

Methotrexate is highly protein bound and co administration of NSAID may displace methotrexate - dosing will need to be monitored.