Past Paper MCQ

PHARMACOLGY MCQ

(Autonomic Pharmacology)

MCQ Questions1) You are an Emergency Department Registrar. At 2am a patient presents with asystolic BP of less than 100. The left ventricular filling pressure of more than 20mmHG and a cardiac output of less than 2.5L/min. In this patient what is your first line of treatment?

a. normal salineb. diureticsc. inotropesd. vasodilatorse. vasodilators and inotropes ANSWER - ?

Cardiac Output (Q) = Heart Rate x Stroke Volume = 5 L/min Cardiac Output can normally Increase 700% during Exercise Q is Increased by: Anxiety and excitement (50-100%), Eating (30%),

Exercise, High environmental temperatures, Pregnancy, Adrenaline Q is Decreased by: Standing from lying, Rapid arrhythmias, Heart

disease NB - Heart receives 15% of the Cardiac Output at Rest

2) Which does not cause vasoconstrictiona. lactate b. serotonin c. adrenaline d. ADH

3) Regarding neurotransmitters in the braina. strychnine stimulates glycine receptors – antagonizes glycine

receptorsb. atropine antagonises GABA receptors – antagonize muscarinic

receptorsc. butyrophenones stimulate dopamine receptors – antagonize DA

receptorsd. ondansotron antagonises seretonin receptors – YESe. atenolol stimulates noradrenaline receptors – erm….no

Summary of Neurotransmitters Acetylcholine Noradrenaline Seretonin Glycine Dopamine

2

4) Beta-Blockers

i) Regarding adrenoceptor antagonists, which of the following is ‘selective’?

a. labetololb. pindolol c. propranolol ANSWER –

Bd. phenoxybenzamine

ii) Beta-blockersa. cannot be used with calcium channel blockersb. can be used in variant anginac. works in angina by vasodilatationd. increases myocardial oxygen consumption All options are

FALSE

iii) Propanolola. Is a sodium channel blockerb. Is lipid solublec. Is excreted unchanged ANSWER – ?B

iv) Regarding the Beta Blocker Propranolol:Which statement is CORRECT?

a. has Na+ blocking activity b. is beta 1 selective c. has intrinsic sympathomimetic activity d. is poorly lipid soluble ANSWER – A

v) Metoprolola. Is an Unselective Beta-blockerb. Is only renally excreted c. Half life is 3-4 hoursd. Has a very high first pass metabolisme. IV dose is the same as oral dose ANSWER – C

vi) Regarding the Beta Blocker Propranolola. Is a highly selective B receptor antagonistb. Is poorly lipid solublec. Has sodium channel blocking activity ANSWER – C

Labetalol – has effects on alpha and beta receptors. T ½ 4.9 hours Sotalol – also has effects on potassium channels (class III) Pinodol – Beta 1 Selective Nadolol – very long acting Propranolol – Relatively UN-selective Beta Blocker (makes asthma

worse)- Notably the Exception in most cases when it comes to Beta Blockers- Poorly absorbed orally (unlike most other Beta Blockers) - t ½ 3-6 hours- Crosses the Blood Brain Barrier – Seizures in Overdose

NB Phenoxybenzamine - an unselective Beta Blocker

3

5) Beta-Blockers 2

i) The most lipid soluble beta blocker isa. Propranololb. Atenololc. Metoprolold. Pindolole. Sotalol ANSWER – A

ii) Propranolola. is a highly selective beta receptor antagonistb. is poorly lipid solublec. has sodium channel blocking action d. has intrinsic sympathomimetic activitye. has an oral bioavailability of > 50 % ANSWER – C

iii) Characteristics of the drug propranolol include all of the following EXCEPT

a. lipid solubilityb. local anaesthetic actionc. half life of 3-6 hoursd. bioavaliability of 30 %e. beta sympathetic selectivity ANSWER – E

6) Inhaled Anticholinergic Drugs

i) The Drug Ipratropium (Atrovent®)a. can cause significant side effects that can last up to 4 hoursb. has a significant effect on the central nervous systemc. has a marginally less systemic action than atropine d. equally effective in bronchodilation as a β2 receptor agonist

ANSWER - Aii) Regarding ipratropiuma. It readily enters the CNSb. It causes miosisc. It is well absorbed orallyd. It inhibits mast cells ANSWER - Ee. It can cause severe effects which last for 4 hours

iii) Ipratropium bromidea. does not usually cause acute angle glaucomab. does not cause the development of tolerancec. inhibits mucociliary clearanced. does not work synergistically with salbutamol

Ipratropium is an Isopropryl Quaternary Atropine Derivative Anticholinergic with T ½ of 3 hours and onset over 20 minutes Generally minimally absorbed and the drug is not metabolised

7) Cholinergic Drugs

i) Regarding the acetylcholinesterase inhibitors (e.g. physiostigmine, neostigmine) which of the following is TRUE?a. These drugs reverse the effects of suxamethoniumb. These drugs cause tachycardiac. They cause decreased secretionsd. They reverse the effects of tubocurarine ANSWER – D

ii) Anticholinesterasesa. antagonise tuburocarine

4

b. antagonise suxc. are never used in myasthenia gravisd. regenerate Ach ANSWER – A

iii) Anticholinesterases (various stems in past pharmacology exams)a. Are not useful in myasthenia gravisb. Antagonise suxc. Antagonise tubocurarined. Decrease BP ANSWER – C

iv) The cholinesterase inhibitor with the shortest duration of action isa. physostigmineb. edrophonium c. neostigmined. parathione. malathion ANSWER – B

vii) Praloxidimea. regenerates acetylcholineb. regenerates acetylcholine receptorc. regenerates acetylcholinesterase d. regenerates succinylcholine

ANSWER – C

These drugs are used in reversal of anaesthesia and a small dose of Glycopyrolate or Atropine are often required to counteract the cholinergic effects of the drug

These drugs have a number of useful applications including the following:Edrophorium (Tensilon®) Testing (Myasthaenia Gravis)Bethanachol - Atonic Bladder Pilocarpine – Glaucoma‘Stigmine’ treatment of Anticholinergic SyndromeReversal of paralysis at the end of operationDonezepil in Alzheimer'sLength of Action – ‘Phonium (short) – ‘Thion (long).

Pralidoxime reactivates cholinesterase after organophosphate binding / inhibition

5

8) Anticholinergic Drugs 2

i) Benztropine causesa. Miosis – mydriasisb. Diarrhoea – constipationc. Confusion – this oned. Bronchorroea – dries up secretionse. GIT haemorrhage – don’t think so

ANSWER – B

ii)) The major side effect of benztropine is (NB centrally acting)a. miosis b. confusion c. diarrohead. GIT haemorrhage e. Bronchorrhea

ANSWER – B iii) Side effects of atropine are all EXCEPT

a. Bronchodilationb. Increased GI motilityc. Bradycardia with low dosesd. Cutaneous vasodilatation at high doses ANSWER –

B

Anticholinergic effects:- Hot as Hare (hyperthermic)- Blind as Bat (blurred vision)- Dry as a Bone (dry mouth and reduced secretions and GIT

motility)(urinary retention)

- Red as a Beet (flushed)- Mad as a Hatter (agitation, confusion)

9) Drugs and the Eye

i) Regarding the treatments for glaucoma, which INCREASES aqueous outflow?

a. timololb. lantanoprostc. carbechold. adrenalinee. acetazolamide ANSWER - B

6

ii) Match these eye drugs with their mechanism of actiona. pilocarpine and ciliary contraction b. prostaglandins and decreased aqueous production c. b-blockers and increased outflow ANSWER – A

iii) Regarding the treatment of glaucoma, which DECREASES aqueous outflow?a. Timolol b. Lantanoprost c. Carbechol d. Adrenaline e. Acetazolamide

iv) Treatment of glaucoma does not includea. alpha blocker – alpha stimulationb. beta blocker – timololc. carbonic anhydrase inhibitor – acetazolamided. cholino-mimetic agents – pilocarpine

v) Effects of occular medications:a. pilocarpine – ciliary muscle contractionb. prostaglandin = reduced secretionc. timolol = pupil ilatation

vi) Regarding the eye, which of the following causes decreased outflow?

a. timololb. adrenalinec. carbechold. prostaglandins ANSWER – All False

vii) Drugs used to treat glaucoma; which is CORRECT pairinga. pilocarpine – ciliary muscle contraction b. timolol – ciliary muscle contraction c. acetazolamide – increased aqueous production d. latanoprost – increased aqueous productione. dipivefrine – decreased outflow ANSWER – A

They Seem to like this ‘eye’ autonomic question: Pilocarpine – ciliary muscle contraction (cholinoceptor agonist) Muscarinic Blocker like Atropine would decrease outflow Timolol – β-blocker →↓ secretion Acetazolamide – CA inhib →↓ HCO3 prodn Latanoprost – prostaglandin →↑ outflow

9) Depolarsiing Muscle Relaxants

i) Concerning the IV drug Suxamethonium, which is TRUE?a. acts via non-competitive blockade of receptorsb. has no significant CVS side effectsc. is broken down by ‘pseudocholinesterase’ at the Neuromuscular Junctiond. cannot be used for Rapid Sequence Intubation

ANSWER – A

ii) Suxamethoniuma. Is a non-depolarising neuromuscular blocking agentb. Is contraindicated in all eye operationsc. Stimulates cardiac muscarinic receptors and autonomic gangliad. Its action is directly terminated by the action of plasma cholinesterase

7

e. Should not be administered to patients with burns > 24 hours old because of its hypercalcaemic effect

ANSWER – ?C

Suxemethonium is an acetylcholine dimer 80% or more is metabolized before it reaches target site (NMJ) Side effects (basically increased everything except HR) - ↑IOP ↑?ICP

↑Saliva ↑Gastric Secretions ↑ BP ↑ Muscle Pains ↑ Trismus and Malignant Hyperthermia Avoid in Hyperkalaemia and Burns more than 24-48 hours old

11) Toxicology Presentations

i) You are an Emergency Department Registrar. At 2am a patient presents who

ingested a ‘substance’. They are confused and agitated. They have mydriasis and a temperature of 39 degrees Celsius. This is LEAST likely caused by:a. adrenalineb. amphetaminesc. aspirind. chlordiazepoxide ANSWER – D

ii) A young male punter comes in with a high blood pressure, mydriasis and a high temperature. Which drug has he most likely taken?a. Atropineb. Adrenaline c. Aspirin d. Naloxone e. Cocaine ANSWER – Eiii) A man presents with dilated pupils, confusion, hyperpyrexia. Which of the following drugs would not account for this

a. atropine OD – could well be this oneb. morphine – this onec. datura – ???

iv) A healthy young man recieves a normal dose of a drug which induces midriasis and increased systolic blood pressure . The drug could be:

a. adrenaline – this oneb. acetylcholine

8

v) A young man presents with dilated pupils, confusion and hyperpyrexia. Which of the following could not account for these effects.

a. Atropineb. Daturac. Morphine – this one

vi) A 51 year old presents to hospital with classic cardiac chest pain. Further investigation includes and angiogram, which is normal. The cardiologist makes a diagnosis of "vasospasm". Which is most likely to cause this?

a) Adrenalineb) Propranololc) Prazocind) Atropine ANSWER – A

vii) A patient presents with difficulty walking, agitated, a temperature of 39 degrees and dilated pupils. Which is least likely to produce this effect?

a. atropine OD – cause all the aboveb. amphetamine OD – cause agitation, staggeringc. aspirin OD – causes hyperpyrexia, agitationd. tricyclic OD – doesn’t cause these – seizures +

arrythmiase. angels trumpet – aka datura – contains atropine

viii) A young man is injected with an iv drug. He shows a resultant tachycardia, midriasis, normal blood pressure and reduced sweating. The most likely drug is

a. nicotinic antagonist – no – would have muscular symptomsb. muscarinic antagonist – this one – eg atropinec. cholinomimitic – would be miosis, decreased HR,

increased sweatingd. adrenergic agonist – would raise BP, and increase sweatinge. adrenergic antagonist – would be bradycardic

ix) An overdose patient has tachycardia, hypertension and urinary retention; what did they overdose on?a. Aspirinb. Amphotericinc. Tricyclics

Chlordiazepoxide is a long acting benzodiazepine The other drugs could cause a similar clinical picture Atropine may have an effect when applied directly to the eye

12) Autonomic effects of Psychiatric Medications

i) Regarding Amitryptiline (Tricyclic Antidepressant) which are NOT effects

a. Diarrhoea and Increased Bowel Soundsb. Sedationc. Urinary retentiond. Postural hypotensione. Impotence ANSWER – Aii) Regarding SSRI’sa. haemodialysis is useful in ODb. inhibit cytochrome P450c. have minimal drug interactionsd. have anti-muscarinic effects

9

e. ?protein bindingANSWER – B

The most dangerous drug in overdose isa. imipramine b. moclobenide c. sertraline d. trazodone e. paroxeteine

ANSWER – A

Antidepressant with the highest antimuscarinic effect isa. amitryptilineb. imipramine

ANSWER – B

SSRI - highly protein bound SSRI – unlikely to be ‘dangerous’ in OD (citalopram has significant

cardiac effects including QT prolongation in OD)

Tricyclics (TCAs) may have Anticholinergic effects:- Hot as Hare (hyperthermic)- Blind as Bat (blurred vision)- Dry as a Bone (dry mouth and reduced secretions and GIT

motility)(urinary retention)

- Red as a Beet (flushed)- Mad as a Hatter (agitation, confusion)

10) Muscle Relaxantsi) Regarding non-depolarising muscle relaxantsa. Pancuronium is eliminated via the kidneyb. Rocuronium is an isoquinolone derivativec. Rocuronium undergoes Hoffman eliminationd. Vecuronium is eliminated predominantly via the kidneye. Atracurium is eliminated via plasma pseudocholinesterase

ANSWER – Aii) Neuromuscular junction blockers; which is INCORRECTa. vecuronium is predominantly kidney excreted

b. atracurium is inactivated by Hofmann elimination c. pancuronium has a longer duration of action than vecuronium

d. pancuronium and vecuronium have the same structure

ANSWER – A

iii) The muscle relaxant commonly associated with tachycardia is low dose

a. Suxamethonium b. Atracurium c. Vecuronium d. Pancuronium e. Tubocurare ANSWER – D

10

iv) Which of the following statements are FALSE regarding vecuroniuma. it has minimal cardiovascular effectsb. its duration of action is less than ten minutes c. it is predominantly renally excreted d. it has a significantly longer duration of action than pancuronium

ANSWER – B

v) Which is true of neuromuscular blockersa. atracurium causes hypotension in volume depleted patientsb. pancuronium causes histamine release c. vecuronium is an isoquinolone derivatived. ‘gallium’ is eliminated by the liver e. gentamicin increases their efficacy ANSWER – E

vi) Which drug decreases the effect of neuromuscular blockade?a. Atropine b. Tubocurarine c. gentamicin d. neostigmine ANSWER – D

vii) Which statement is true regarding recovery from irreversible neuromuscular blockade?a. it relies on receptor turnover – yes

viii) The muscle relaxant with the longest duration of action isa. atracurium b. mivacurium c. pancuronium d. vecuronium ANSWER – C

ix) Vecuronium, all of the following are true excepta. Has minimal CVS effectsb. Is predominantly renally excreted – no, liver excretionc. Has a significantly longer duration of action than pancuronium – no, panc

longer

x) Atracuriuma. Has a longer duration of action than vecuronium b. Is associated with histamine release c. Is a steroid derivative d. Is eliminated by non renal/liver dependant mechanisms

ANSWER – B

xi) Regarding pancuronium - which is incorrect?a. It is a steroidb. It does not release histamine c. It is renally excreted d. It has a shorter duration of action than vecuronium

ANSWER – Dxii) Termination of irreversible neuromuscular block involvesa. regeneration of receptors –this oneb. increase in end plate Ach

Atracurium is usually used in renal failure patients as it undergoes Hoffman Degradation

Panc and vec are same structure – steroid derivative – no histamine release. Panc causes tachy

11

Atrac tubo – isoquinoline derivatives – histamine release as well as sux

21) Prazosin; which is correcta. it is non-selective - alpha-1 selectiveb. reduces afterload and preload – alpha-1 cause

vasoconstriction (therefore inhibiting lowers systemic BP)c. half life is 18 hours - 2-3hoursd. alters lipid levels - ??e. causes lupus like syndrome - don’t think so

28) Prazosina. is non-selectiveb. worsens lipid levelsc. causes SLE like syndromed. reduces BP by affecting both resistance + capacitance vessels this one –

alpha

29) Prazosina. Has a half life of 18 hoursb. Adversely affects lipid profilesc. Produces a reflex bradycardiad. Has a first dose hypotensive effect ? this onee. Can increase CO by decreasing preload and leaving afterload unchanged

Alpha Blockers . . .

12) i) L-dopa; which is correcta. abrupt stop can increase tremor – causes rebound hypertensionb. precursor to dopamine – yes, by L amino acid

decarboxylasec. ? 25% reaches the brain – 1-3% only

ii) What is true of L-Dopa?a. 33% reaches the CNS – 1-3%b. it is the precursor of dopamine – truec. suddenly stopping it will cause tremor – rigidityd. it’s half life is about 5 hours – 1 houre. 40% less is required if it is given with a peripheral carboxylase inhibitor

– up to 75%iii) Regarding the treatment of Parkinsons, which is INCORRECT

a. L-dopa is contraindicated in acute psychoses – trueb. Bromocriptine has less CNS effects than L-dopa

– FALSE more CNS effectsAdministration of L-dopa with a dopa decarboxylase inhibitor decreases side effects

12

iv) In the treatment of parkinsons diseasea) Antimuscarinics are better for the treatment of (?) tremor

than dopamine agonists – less effectiveb) Administration of L-dopa with a dopa decarboxylase inhibitor

decreases side effects – truev) L-Dopa

a. 1-3% reaches the brain – trueb. Precursor to tyrosine – no, both precursor to dopaminec. abrupt stop can increase tremor – no rigidityd. rarely needs increase in dose once effective – needs to keep increasing

hence dose holidays

Parkinson’s Drugs . . .

Which of the following drugs has a pure beta agonist effect in the circulation?

a. Adrenalineb. Levosimendinc. Noradrenalined. Isoprenaline

ANSWER – D

Which adrenergic agent has a pure beta agonist effect in the circulation?a. Adrenalineb. Noradrenalinec. Isoprenaline d. Levosimendin

ANSWER – C

What is the correct order of catecholamine synthesis?a. Tryptophan – dopa – dopamine – adrenaline – noradrenaline –

nob. Tysosine - dopa- dopamine – adrenaline – noradrenainec. Tyrosine – dopa – dopamine – noradrenaline – adrenaline –

yesd. Tyrosine – dopamine – dopa – noradrenaline – adrenalinee. Tyrosine – dopamine – dopa – adrenaline – noradrenaline

Isoprenaline’s effects include all EXCEPTa. hyperglycaemiab. increased glycerolc. bronchodilationd. increased diastolic pressure

ANSWER – D

13

The drug Dobutaminea. Results in ATP -> AMP – activates adenylyl cyclase ATP -> cAMPb. Can decrease systemic vascular resistance / afterload – c. .d.

ANSWER – C

SalbutamolInitially causes a drop in PaO2Cause hyperkalemiaCause hypercarbia

Alpha receptor activation causesuterine relaxationcutaneous vessel dilaation

14

VIVA

Pharmacology Notes

Most Common Topics are listed first

15

List of Topics for the PHARMACOLGY VIVA(BRACKET DENOTES THE APPROX NUMBER OF OCCURENCES AS OF 2009)

Topics for VIVA – PHARMACOLOGY ACEM Section 1 Basic Pharmacology (always one question from

this area)Pharmacokinetics (Half Life, Clearance, Elimination Kinetics, Biotransformation, First Pass Metabolism) Other Basic Topics, (New agents Agonists and Antagonists, Receptors, 2nd Messengers, Drug Responsiveness, Potency and Efficacy, Volume of Distribution, Steady state, Loading Does

(20+)Age, Pregnancy, Drugs in Children (7)

Section 2 – Antibiotics and Antivirals

Antibiotics (Beta Lactams Macrolides) (27) Acyclovir and Antiretrovirals (3)

Section 3 – Cardiac Drugs

Anti Anginals, CCF and Beta-Blockers (sotalol) (11)

Antihypertensives (Emergency, ACE inhibitor) (6) Sodium Channel Blockers and LA (6)Calcium channel Blockers (6)Atropine (3)Adenosine (3) Frusemide / Diuretics (3)Amiodarone (3)Digoxin (2) Adrenaline (Vasopressors and Resus Drugs) (5)

Section 4 – CNS Drugs

16

Suxemethonmium ( and DPMR) (7)Tri-cyclic Antidepressants, SSRI (5)Benzodiazepines (4)Phenytoin (4)Barbiturates (4)Carbamazepine (3)Propafol (3) Ketamine (3)Nitrous Oxide, Halothane and Sevoflurane (2)Haloperidol and Antipsychotics (2)MOA Inhibitors (2) Anti-emetics (2)Alcohol and Methanol (2)Sodium valproate (1)

Section 5 – Endocrine Drugs

Glucagon and Insulin (4)Steroids (4)Oral Hypoglycaemics (3)

Section 6 – Opioids and Analgesics

Aspirin and NSAIDS and COX (7) Opiates and Receptors (6)Paracetamol (2)Colchicine (1)

Section 7 – Anticoagulants and Thrombolysis

Heparin (4)Thrombolysis (3)Warfarin (2)

17

Clopidogrel (2)

Section 8 – Respiratory Drugs

Salbutamol (2)Cromoglycate (1)Benztropine (1)Ipratropium (1)Methylxanthines (1)

Section 9 – Immunisation, GI Drugs and Toxicology

PPIs and H2 Antagonists (3)Immunisation (Active, Passive, Specific) (2)Methods of Decontamination (1)

Section 10 – New Topics

RCT and other methods of analysis of new drugsDrugs in PregnancyDrugs in the ElderlyToxicology

18

The Pharmacology TemplatePHARMACOKINETICS

- Introduction (Drug, class, prototype drug, history etc)- Absorption and Routes of Administration and Bioavailability - Distribution- Metabolism of Drug- Clearance- Half Life- Dosing- Monitoring

PHARMACODYNAMICS

- Introduction (as above)- Mechanism of Action of the Drug- Organ Effects (E.g. CV, Resp, GI, CNS)- Side Effects- Indications (Primary Secondary)- Contraindications- Toxidromes- Major Drug Interactions- Other Specific Idiosyncratic Issues with the Drug

Memorise this template and use it as a framework for answering questions in the Viva. I found it a very useful way of forming my answers.At this stage I would recommend www.4um.com/tutorial/pharmak.htm and page 36-38 of ‘Basic and Clinical Pharmacology’ for rapid reference.

19