OSPE

Question 1

Which drug is preferred for treatment of acromegaly? (octreotide/somatostatin)

Answer 1

Acromegaly is caused by hypersecretion of growth hormone (GH) resulting in an increase in serum (IGF-1) levels.

Octreotide is the preferred drug because
* longer-acting and more potent than somatostatin
* Less insulin inhibition which causes less diabetes-like symptoms

Question 2

1. To which group does this drug belong to?
2. Name 4 condition in which this drug can be
   used?

Answer 2

-Somatropin is recombinant human growth hormone.

Any 4 conditions
* GH deficiency in adults
* Short stature due to IGF deficiency
* Short stature in Turner’s syndrome
* AIDS related wasting of muscles
* Children with short stature –help to achieve normal adult height
* Pituitary dwarfism –as replacement therapy

Question 3

Explain the rationale of combining GnRH agonists with androgen receptor antagonists in prostatic carcinoma.

Answer 3

• In patients with prostatic carcinoma treated with GnRH agonists – due to their agonistic action on GnRH receptors, there will be an initial increase in FSH and LH secretion

-This causes increased synthesis of testosterone
Leading to “flare-up” of symptoms of prostatic carcinoma during first two weeks of treatment

-Rational for combination
The concurrent use of androgen receptor antagonists like flutamide/ bicalutamide with GnRH agonists block effect of testosterone on cancer cells and prevent “flare-up” of symptoms of prostatic carcinoma.

Question 4

Prescribe for a nulliparous woman who wishes to postpone her pregnancy.

Answer 4

• Tab. ethinyl estradiol 30 μg + levonorgestrel 150 μg
• Dispense 63 tablets
• Take one tablet daily for 21 days, starting on 5th day of menstruation
• Next course to be started after a gap of 7 days
• Review after 3 months

Question 5

OCP instructions

Answer 5

Start on 5th day of menstruation
*1 white tablet taken daily for 21days followed by 1 red tablet daily for 7days
* It is important to note that OCP has to be taken daily, preferable at the same
time for it to work effectively.
* Start the 2nd cycle of therapy from next day regardless of menstruation
* If a tab is missed, take 2 tabs next day
* If > 2 tabs are missed, stop OCPs and switch to other methods of contraception
* Noncompliance or missed pills would lead to failure of its contraceptive effect

** If the patient conceives, the pregnancy should be terminated (as the fetus will have a high risk of abnormalities)

Question 6

basis of clomiphene citrate for lady with infertility

Answer 6

Clomiphene citrate is an estrogen receptor antagonist and it is used in fertility treatment [Intrauterine insemination (IUI) , IVF] / Also used in PCOS.

Mechanism of action
-Clomiphene selectively blocks ER in the hypothalamus
-Opposes/abolishes negative feedback effect of estrogen
-Increased secretion of FSH/LH
-Induce ovulation

Question 7

Mention the condition where estradiol transdermal patch is used.

List 1 advantage & 1 disadvantage of this preparation over the oral preparation.

Answer 7

1. Contraception, To relieve menopausal symptoms, reduce fracture
2. Advantage: ↓ risk of thromboembolism (as ↓ drug reaches liver,
   - it ↓ clotting
   factor synthesis),
   reduce risk of gallstones n hepatic adenomas
   -Patches have the advantage of needing to be changed only once or twice weekly,

Disadvantage: Irritation at the site of administration, patch adherence depends on the skin

Question 8

FDC 8 AND 9

Answer 8

REFER NOTES

Question 9

List the uses of GnRH agonists with their routes of administration.

Answer 9

Uses of GnRH agonist
* Prostatic ca
* Breast cancer (in pre-menopausal women)
* Uterine fibroid, endometriosis, polycystic ovarian disease
* Precocious puberty
* Control ovarian hyperstimulation (in assisted reproduction)

NASAL SPRAY:Nafarelin,Buserelin
S/C: Goserelin ,Histrelin
IM DEPOT: Triptorelin

Question 10

A. Identify the group:lopinavir,ritonavir
B. What do you call the regimen where these two drugs are combined?
C. Explain why these two drugs are combined?

Answer 10

A. Protease inhibitors

B. Boosted PI regimen

C. Ritonavir→inhibits CYP3A4→decreases metabolism of
lopinavir→increases plasma concentration of lopinavir→ enhance patient exposure to lopinavir, thereby preventing or overcoming resistance and allowing less frequent dosing, potentially improving patient compliance

Question 11

32-year-old male, acute gonococcal urethritis.

Answer 11

Inj. Ceftriaxone - 500 mg IM
Tab. Azithromycin - 1 g
Dispense one vial of ceftriaxone 500 mg and one azithromycin 1 g tablet
Inject 500 mg of ceftriaxone intramuscularly STAT and administer 1 tab. azithromycin orally.

Question 12

30-year-old female ,trichomonas vaginitis.

Answer 12

Tab. metronidazole 500 mg
Dispense 21 tablets
Take one tablet orally thrice daily for 7 days

Question 13

DPC - Metronidazole prescribed for trichomoniasis

Answer 13

This drug is prescribed for the treatment of trichomoniasis
* Take one tablet thrice a day for 7 days
* You may have an altered taste perception and may feel nauseous while
taking this medication.
* Your symptoms may improve before the infection is completely cleared
However, take this drug for the full prescribed length of time
* You are advised not to drink alcohol while taking this medicine and for 48 hours after finishing the course of tablets, as this might cause
unpleasant side-effects

Question 14

30 year old female patient suffering from trichomonas vaginitis given ciprofloxacin

Answer 14

Trichomonas vaginitis is caused by an anaerobic protozoa, Trichomonas vaginalis. Ciprofloxacin is not effective in this case.

Question 15

30-year-old lady is complaining of intensive itching in and around vagina with discharge.The lab test reveals infection with an anaerobic, flagellated protozoan parasite.

1. Mention a drug useful in the following infection.
2. State two other uses of the prescribed drug.

Answer 15

1. Metronidazole
2. Giardiasis, H. pylori
   associated peptic ulcer,
   Abdominal sepsis caused by anerobic bacteria Pseudomembranous colitis caused by Clostridium difficile

Question 16

Match the following STDs with the drug used
1. Gonorrhea
2. Trichomonas vaginitis
3. Chlamydia trachomatis
4. Syphilis
5. Chancroid
6. Vaginal candidiasis
7. Genital herpes

Answer 16

Ceftriaxone
Metronidazole
Doxycycline
Benzathine penicillin
Azithromycin
Clotrimazole
Acyclovir

Question 17

List four drugs used for upper uti

Answer 17

Norfloxacin
* Ciprofloxacin
* Cotrimoxazole
* Cephalexin
* Cefpodoxime proxetil
* Amoxicillin + clavulanic acid
* Fosfomycin

Question 18

Match the following antiretroviral drugs with their mechanism of action

Answer 18

CCR5 inhibitor-Maraviroc
Integrase strand transfer inhibitors-Raltegravir
Non-nucleoside reverse transcriptase inhibitors-Efavirenz
Fusion inhibitor-Enfuvirtide

Question 19

post exposure prophylaxis regimen of HIV for a 35-year-old female doctor who sustained a needle stick injury

Answer 19

Tab. Emtricitabine 200 mg
Tab. Lopinavir + ritonavir 200+50 mg
Dispense 29 tablets each of the above drugs
Take one tablet each of the above drugs immediately Take one tablet each of the above drugs for next 28
days
Review after 4 weeks

Question 20

post exposure prophylaxis of HIV given Tenofovir

Answer 20

Tenofovir alone is not sufficient to fight HIV.
Multiple antiretroviral drugs are to be combined to reduce viral replication, to render viral particles non-infectious and to prevent development of resistance.

Tab. tenofovir 300 mg
Tab. emtricitabine 200 mg
Dispense 29 tablets each of the above drugs
Take one tablet each of the above drugs immediately Take one tablet each of the above drugs for next 28
days
Review after 4 weeks

Question 21

State FOUR indications of fluconazole.

Answer 21

• Treatment of Vaginal candidiasis
• Prevention of candidiasis
• Oropharyngeal candidiasis
• Prevention of relapse of oral candidiasis in AIDS patient.
• Cryptococcal meningitis
• Prevention of relapse of Cryptococcal meningitis in AIDS patient.

Question 22

35-year-old woman was diagnosed with paucibacillary leprosy.

Answer 22

Rifampicin 600mg once monthly (supervised)
* Clofazimine 300 mg once monthly (supervised Day 1), 50 mg ( self administered Day 2-28)
* Dapsone 100mg daily (supervised Day 1, self administered Day 2-28 )
* Review after 28 days
* Duration of treatment: 6 months

Question 23

40-year-old man was diagnosed with multibacillary leprosy.

Answer 23

• Rifampicin 600mg once monthly (supervised)
• Clofazimine 300 mg once monthly (supervised Day 1), 50 mg ( self administered Day 2-28)
• Dapsone 100mg daily (supervised Day 1, self administered Day 2-28 )
• Review after 28 days
• Duration of treatment: 12 months

Question 24

Tinea corporis infection

Answer 24

Miconazole ointment 2%
Dispense 1 ointment
Apply the above ointment 3 times daily until the lesions disappear, & the application should be continued for 1 more month after that

Question 25

25-year-old lady with vaginal candidiasis

Answer 25

• Clotrimazole 100 mg vaginal tablet - Dispense 7 tablets
• Insert 1 tablet of the above as deeply as possible into the vagina at bedtime for 7 days

Question 26

patient suffering from oral thrush/ oral candidiasis

Answer 26

• Clotrimazole troche 10 mg
• Dispense 56 troches
• Allow 1 troche to dissolve in mouth 4 times daily for 14 days
  (or) cap fluconazole 200 mg (per oral) on 1st day & then 100 mg/day for 14 days

Question 27

A 25-year-old man was diagnosed with fungal infections in the mouth. You prescribed him nystatin troche
What instructions need to be given to the patient?

Answer 27

Hold the lozenge in the mouth and allow it to dissolve slowly and completely.This may take 15 to 30 minutes. Swallow your saliva as the lozenge dissolves. Do not chew or swallow the lozenge whole.

If the patient misses a dose of this medicine, take it as soon as possible. However, if it is almost time for the next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Continue to take this medication until the full prescribed amount is finished even if symptoms disappear after a few days. Stopping the medication too early may allow the infection to continue, resulting in a return of the infection.

Side effects : Nausea, vomiting and flatulence. If symptoms persist, please consult your doctor

Question 28

A 30-year-old woman was diagnosed to have vaginal thrush. You prescribed her with clotrimazole pessary.
What instructions need to be given to the patient?

Answer 28

One pessary should be inserted at night. Using the applicator provided, the pessary should be inserted as high as possible into the vagina. This is best achieved when lying back with legs bent up.

❑A pessary will dissolve overnight in the moisture in the vagina. If you have problems with vaginal dryness, you may notice some undissolved pieces of pessary the following morning.

❑Treatment during the menstrual period should not be performed due to the risk of the pessary being washed out by the menstrual flow. The treatment should be finished before the onset of menstruation. Do not use tampons, intravaginal douches, spermicides or other vaginal products while using on this treatment

❑Vaginal intercourse should be avoided in case of vaginal infection and while using this product because the partner could become infected.

❑After you use the pessary, you might experience: Itching, rash, swelling, redness, discomfort, burning, irritation, vaginal peeling, discharge or bleeding and nausea. If you experience any of the above effects, tell your doctor immediately.

Question 29

patient with mild type 2 diabetes mellitus.

Answer 29

• Tab glipizide 5 mg
• Dispense 30 tablets
• Take 1 tab once daily, 30 minutes before breakfast for 1 month - Review after 1 month

Question 30

obese patient suffering fr t2DM

Answer 30

• Tab metformin 500 mg
• Dispense 60 tablets
• Take 1 tab twice daily with meals for 1 month - Review after 1 month

Question 31

diabetic patient with COPD

Answer 31

In COPD, there is ↓ O2 available for aerobic glycolysis →↑ anaerobic glycolysis →↑ risk of lactic acidosis
* Metformin can also cause lactic acidosis
* Hence, patient is prone to lactic acidosis
* Glipizide is a better drug (as it does not cause lactic acidosis)

• Tab glipizide 5mg
• Dispense 30 tablets
• Take 1 tab daily 30 minutes before breakfast for 1 month - Review after 1 month

Question 32

management of a case of diabetic ketoacidosis

Answer 32

1st Hour: Immediate Management
* A bolus dose of 0.1 U/kg I.V. of short acting regular insulin
* Commence a fixed rate intravenous insulin infusion (IVII): 0.1 unit/kg/hr.
* Once glucose level falls to 300 mg%, rate of infusion is reduced to 2 – 3 U/hr until patient becomes fully conscious.
* I.V. normal saline to correct dehydration and 5% glucose if the patient shows hypoglycaemia

❖NaHCO3 Added till blood pH ↑ to > 7.2 (as hyper acidosis causes hyperventilation)
❖KCl Added based on serum K+ level & ECG findings (as insulin drives K+ intracellularly may lead to dangerous hypokalaemia)
❖Other supportive measures

Question 33

management of nonketotic hyperosmolar hyperglycemic state.

Answer 33

Same as diabetic ketoacidosis, except that…
a) NaHCO3 is not required
b) fluid replacement should be faster
c) prophylactic heparin therapy is required (due to risk of thrombosis because
of hyperviscosity of blood & sluggish circulation)

Question 34

management of insulin/oral hypoglycemic induced hypoglycemia.

Answer 34

❖In mild to moderate hypoglycaemia where the individual can self-treat, he/she should ingest 15 grams of simple carbohydrate (e.g., 1 tablespoon of honey, 3⁄4 cup of juice, 3 teaspoon of table sugar) and repeat blood glucose after 15 minutes. If the level at 15 minutes is still <4.0 mmol/L, another 15 grams of carbohydrate should be taken.
❖In severe hypoglycaemia and unconscious individual, he/she should be given 20–50 mL of 50% Dextrose I.V. over 1–3 minutes. Outside the hospital setting, a tablespoon of honey should be administered into the oral cavity.
❖Alternatively, 1mg of glucagon (IV, IM or SC) is given. After the initial response, the patients should be given glucose or urged to eat to prevent recurrent hypoglycemia.

Question 35

ype I DM & you have decided to start him on mixed insulin (70% NPH + 30% regular insulin).
What instructions will you give to this patient?

Answer 35

i. Take prescribed dose of insulin 30 mins before taking meal
ii. Carry a diabetic card always
iii. Carry candy/ sugar
iv. If symptoms of hypoglycemia (fainting, dizziness, excessive sweating, tremors, palpitations) occur, consume candy/ sugar
v. If symptoms persist, visit the physician
vi. Change the sites of injection

Question 36

Analyze the FDC of
Metformin + Pioglitazone according to the criteria of FDC and comment.

Answer 36

notes

Question 37

Analyze the FDC of
Glipizide + Nateglinide

Answer 37

notes

Question 38

A 60-year-old alcoholic male on an oral antidiabetic agent developed lactic acidosis.
a) Which drug could have caused this complication?
b) Why did the patient develop the above complication?

Answer 38

• Metformin
• The patient is an alcoholic (which is prone to develop lactic acidosis). Lactic acidosis occurs when ethanol metabolism results in high hepatic NADH/NAD ratio, diverting pyruvate metabolism towards lactate and inhibiting gluconeogenesis.
• Metformin can cause lactic acidosis in liver impairment.
• Hence, both factors may be responsible for lactic acidosis in this patient.

Question 39

identify insulin device

Answer 39

notes

Question 40

Insulin pump

Answer 40

Advantages of insulin pumps:
* Less jabs.
* Take insulin as and when you need it.
* Have different basal rates at different times of day.
* Flexibility with food.
* Flexibility with exercise.
* Increased blood glucose control.
* Reducing episodes of severe hypoglycaemia.

Disadvantages of insulin pumps:
* Insulin pumps can prove more expensive. …
* You need to commit to testing your blood sugar 4-6 times daily or using a continuous glucose monitor.
* You need to count the carbohydrates in your food to work out the correct quantity of insulin

Question 41

Insulin Jet Injection

Answer 41

Advantages of a jet injector:
* Doesn’t use a needle
* Delivers insulin more quickly
* May use less insulin

Disadvantages of a jet injector:
* Expensive
* Requires device maintenance
* Has the risk of incorrect dosage, skin damage or pain and infection.

Question 42

Insulin Pens

Answer 42

Advantages of insulin pens:
* Ease of use, particularly for older adults and children
* Ability to fine-tune and deliver highly accurate doses
* Portable, discreet, and convenient nature of the pens
* Small and thin needle sizes that reduce fear and pain
* Ability to accurately pre-set doses using a dial
* Time-saving benefits due to prefilled and pre-set insulin levels
* Memory features to show when and how much the last dose was
* Range of accessories to allow for easier storage and use

Disadvantages of insulin pens:
* Not all types of insulin can be used
* It’s not possible to mix two different types of
insulin
* Can only be used for self-injection
* More expensive than the vial and syringe method
* Some insulin is wasted with each use
* Not universally covered by health insurance carriers

Question 43

Insulin syringe

Answer 43

Advantages of insulin syringes:
* Some syringes allow you to mix insulin types
* Less expensive than pens
* Vary in size, gauge and length
* Syringes are easily available, may not require a prescription to obtain and are covered by most insurance plans

Disadvantages of insulin syringes:

• Typically marked in 2-unit increments, which can make it hard for people who need to take odd-num doses
• The marked increments can be difficult to read for people with vision troubles
• Must carry the syringe and vial with you when traveling or outside of home

Question 44

Drug used in the management of thyroid storm and hyperthyroidism

Answer 44

Propylthiouracil. it inhibit the thyroid peroxidase catalyzed reactions in the biosynthesis of thyroid hormone, propylthiouracil additionally inhibits peripheral conversion of T4 to T3 by inhibiting 5’-deiodinase enzyme → less T3 production, making it the preferred thioamide in the management of thyroid storm.

Question 45

Drug used in the management of thyroid storm but not in long term treatment of hyperthyroidism

Answer 45

Lugol’s iodine. The most important action of iodide is inhibition of thyroid hormone release, known as ‘thyroid constipation’. With continued treatment, the hyperthyroidism may return in its initial intensity- ‘thyroid escape’ or may become even more severe than it was at first. Hence, iodides are NOT used in the treatment of hyperthyroidism.

Question 46

Prescription for 40-year-old male patient suffering from hypothyroidism due to endemic goiter.
Criticize, correct and rewrite the given prescription.

Answer 46

Criticism:
Liothyronine is not appropriate as it’s short acting and cardiotoxic.
Levothyroxine is preferred as it has long, more sustained & uniform action as well as low risk of cardiac arrhythmias.

Tab. levothyroxine 50 mcg
Dispense 30 tabs
Take 1 tab once daily 30 minutes before breakfast Review after 30 days

Question 47

Drug that cause permanent reduction in the thyroid hormone synthesis.

Answer 47

Radioactive iodine 131I. RAI therapy causes destruction of the thyroid parenchyma, which provides permanent reduction in the thyroid hormone synthesis. Lugol’s iodine and propylthiouracil inhibits thyroid hormone synthesis and release which is reversible upon stoppage of the drugs.

Question 48

Drug used in the management of thyrotoxicosis in pregnancy.

Answer 48

Propylthiouracil is used in the management of thyrotoxicosis in pregnancy because it has low placental transfer. The use of iodide in pregnancy causes foetal/infantile goitre and hypothyroidism, while radioactive iodine crosses placental barrier and causes genetic abnormalities and fetus deformity, thus not used in the management of thyrotoxicosis in pregnancy.

Question 49

A patient with recurrent hyperthyroidism was administered with radioactive iodine 131I. What instructions will you give to this patient?*** all 8 points very important

Answer 49

Greet the patient and explain the following:
* Try not to remain in close contact with other people for longer than necessary .
* Avoid pregnant women and young children for 7 days.
* Drink plenty of fluids starting 90 minutes after you take the dose of Iodine-131 for 3 days.
* Reserve a bathroom for your personal use for 7 days. Flush the toilet twice after each use.
* Launder your clothes, bedclothes, towels, etc. separately for 7 days.
* Use separate eating utensils and do not share personal items.
* Do not share a bed or bedroom with other siblings. Sleep alone for 7 days.
* Avoid pregnancy for 6-12 months after RAI therapy.
Ask the patient if they have any question.

Question 50

Explain the emergency management of thyroid storm (thyrotoxic crisis).

Answer 50

• Tab.propylthiouracil(500–1000mgloading,then250mg,4–6hourly)
• 5–10 drops of Lugol’s iodine 6–8 hourly for the first 10 days, should be given after administration of antithyroid drug for rapid improvement of thyrotoxicosis in
  thyroid storm.
• Inj. propranolol 2 mg IV, followed by 80 mg orally, 6 hourly to control heart rate and
  inhibit other peripheral action of thyroid hormone.
• High doses of glucocorticoids (IV hydrocortisone 100 mg, 6 hourly or
  dexamethasone 2 mg, 6 hourly).
• Supportive measures (IVfluids, antipyretic , cooling blankets).

Question 51

What instructions will you give while starting the patient on levothyroxine?

Answer 51

Greet the patient and explain the following:
Take one tablet on an empty stomach in the morning, 30 minutes before breakfast. Follow-up every 2 weeks for dose-titration (based on blood TSH level).
Ask the patient if they have any question.

Question 52

Explain the emergency management of adrenal crisis.

Answer 52

• Administer hydrocortisone succinate IV 100 mg stat., followed by same dose 8 hourly until patient is stable (after patient has stabilized, dose can be ↓ by 25 mg every 8 hrs)
• Correct volume depletion with isotonic NaCl IV supplemented with 5% glucose
• Treat underlying diseases (e.g. infections/ trauma/ hemorrhage)

Question 53

Explain the emergency management of myxedema coma.

Answer 53

• IV hydrocortisone 200 mg start then 100 mg 6–8 hourly should be administered prior to levothyroxine.
• Initial IV levothyroxine of 200–400 mcg followed by 1.6 mcg/kg/day (75% if administered intravenously) should be given thereafter.
• IV liothyronine (when available) may be given in addition to thyroxine. Loading dose 5–20 mcg followed by 2.5–10 mcg every 8 hours till patient regains consciousness.