PHARMA ● PHARMACOLOGY-THERAPEUTICS SHIFT

SHIFTING EXAM 2
L01a Respiratory; L01b: Corticosteroids; L02: Anti-Hypertensives; L03: Diuretics, L04: Anti-Anginal
Drugs, etc., L05a: Pharmacotherapy of Heart Failure, L05b: Anti-Arrhythmic Drugs, L06: General
18/11/22 02
Principles of Anti-Infective Agents, L07: Specific Antimicrobials – Penicillins and Cephalosporins,
Laboratory Experiment

FOR MULTIPLE CHOICE

QUESTIONS (WITH CHOICES) RATIONALIZATION ANS

1 A known hypertensive, asthmatic baker develops
palpitation after starting isosorbide mononitrate for
his angina. Which of the following may be added if
he is well controlled with losartan?
A. Diltiazem
B. Amlodipine
C. Ivabradine
D. Atenolol
2 Which of the following best describes the effect of
lidocaine on the action potential?
A. It moderately slows conduction and
moderately prolongs the action potential.
B. It markedly slows the conduction velocity
and minimally prolongs the action potential.
C. It minimally slows conduction and shortens
the action potential.
D. It prolongs the action potential and does
not affect the conduction velocity.
Ivabradine C
● Bradycardic drug
● Selective If sodium channel blocker
● It reduces the cardiac rate by inhibiting the hyperpolarization-associated
sodium channel in the SA node
● Advantage: lack of effect on GI and bronchial smooth muscles
● Mechanism of Action
○ By reducing heart rate
PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
Lidocaine C
● Class IB Binding Kinetics
● Rapid binding kinetics
● Minimally slow conduction
○ Due to the rapid binding
● No K-blocking
○ Due to its class
● Shortened action potential
○ Due to the absent K-blocking activity of the drug
PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS

3 Which of the following is a multi-channel D

antiarrhythmic drug?
A. Amiodarone
B. Dronedarone
C. Vernakalant
D. All of the above

PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS
4 A 60-year-old male has diabetic nephropathy. Which Eplerenone B
of the following diuretics can slow the progression of ● Newer generation MRA, Anti fibrotic, and anti inflammatory
albuminuria in his case? ● Useful for Diabetic nephropathy
○ Slowing of proteinuria/albuminuria
A. Ethacrynic acid
○ Interferes with the effect of aldosterone which has fibrotic and
B. Eplerenone inflammatory effects
C. Hydrochlorothiazide ○ Measure of damage: spillage of protein
D. Metolazone
PHARMA.S2.L03.DIURETICS
5 For a drug to be able to improve survival, it must ● After a myocardial infarction, a remodeling process occurs that is similar to C
A. Have an inotropic property scarring. There is the deposition of connective tissue that is not contractile
B. Have a diuretic property as against the normal surrounding viable myocardium. The area thins out
and progressively dilates.
C. Prevent ventricular remodeling
● ACEIs and ARBS delay the progression of heart failure by attenuating the
D. All of the above process of ventricular remodeling.
○ They decrease fibers tissue and connective tissue deposition
hence they prevent ventricular remodeling.
● Preventing ventricular remodeling improves patient survival.

PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
6- A 30-year-old male, chronic methamphetamine user from Tondo, presents with dyspnea, orthopnea, and PND. His echo showed
9 an ejection fraction of 30%. Crackles were heard all over the lungs. The vital signs are: BP 110/70, PR 110/min, RR 20/min
6 Which of the following will provide the most rapid Loop Diuretics C
relief of his symptoms? ● Furosemide, Bumetanide, Torsemide, Ethacrynic acid
A. Losartan ● Exert their action at the thick ascending loop of Henle (TAL)
○ “High ceiling diuretics”
B. Ramipril
○ Produces the greatest diuretic effect.
C. Furosemide ● Furosemide and Ethacrynic Acid reduce pulmonary congestion and LV filling
D. Spironolactone pressure even before the onset of diuretics.
○ Crackles heard all over the lungs is a sign of pulmonary
congestion.

PHARMA.S2.L03.DIURETICS
7 Which of the following should not be given at this Carvedilol C
time? ● Bisoprolol, Carvedilol & Metoprolol
A. Ramipril ○ Reduce mortality in patients that have stable class II and III HF
■ Contraindicated in class IV patients (i.e., those with
B. Eplerenone
frank pulmonary edema) because of their negative
C. Carvedilol inotropic properties
D. Digoxin
PHARMA.S2.L05a.PHARMACOTHERAPY OF HEART FAILURE
8 Which inotropic agent will you give? Digoxin C
A. Dopamine ● Digoxin acts by inhibiting the Na/K ATPase pump
B. Dobutamine ○ Works only during the resting phase of the action potential
● Initially, digoxin prolongs the action potential duration because of the
C. Digoxin
increased intracellular Ca.
D. Any of the above ● Later, there will be enhanced egress of K out of the cell causing a shortening
of the action potential duration.
● Cardioversion < Rate Control
● ↑AV node refractory period = ↓ventricular response in AF = ↓cardiac rate

PHARMA.S2.L05a.PHARMACOTHERAPY OF HEART FAILURE

9 Which of the following will improve his survival? Sacubitril-valsartan D
A. Sacubitril-valsartan ● Neprilysin Inhibitor
B. Perindopril ● Neprilysin degrades substrates including angiotensin II, and vasoactive
peptides relevant to cardiovascular physiology like the ANP, BNP and CNP
C. Spironolactone
● Another group of drugs that prevent ventricular remodeling
D. All of the above ● By increasing the levels of these peptides, this combination of drug does the
following:
○ Induce diuresis that helps treat and prevent congestion
○ Produce vasodilation
○ Decrease cardiac fibrosis and hypertrophy
ACEI
● Monotherapy for uncomplicated hypertension
● Hypertension with compelling indications:
○ Heart failure
○ After MI from ppt; (Note: Acute MI from lecture)
○ High CHD risk
○ Diabetes Mellitus
○ Chronic Kidney Disease (including DM Nephropathy)
Spironolactone
● blocks aldosterone by decreasing sodium reabsorption and potassium
secretion.
● It is nonselective, so it acts to other mineralocorticoid receptor
● It binds and potently inhibits androgen and estrogen receptors → causes
gynecomastia & menstrual irregularities
● Clinical Indication: Hyperaldosteronism
For 10-11
Quantitative analysis
A.) If 1) is greater than 2)
B.) If 1 less than 2
C.) If 1 and 2 are equal
D.) They cannot be compared
10 Negative inotropic properties of 1) Diltiazem and 2) B
Verapamil

PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
11 Antiplatelet effect 1.) Tirofiban and 2.) Cilostazol
12 The success of reperfusion with 1) reteplase and 2.) RETEPLASE
Percutaneous coronary intervention
Write A if true and B if false
13 Slow onset with long duration of action : Formoterol
= salmeterol
14 Urinary retention: Sympathomimetic =
antimuscarinic
15 Risk for oral candidiasis: ICS MDI = ICS DPI
16 TY is a 55- year old teacher, known asthmatic and
hypertensive who recently had a myocardial
infarction. He was started on ramipiril and
amlodipine while still in the hospital. If his BP on
consult is 150/100 with CR of 89/min, which of the
following will you add
A. Propanolol
B. Bisoprolol
A
TIROFIBAN
○ Contains the amino acid sequence Arg-Gly-Asp (RGD), which is the main
recognition sequence for integrin receptors such as IIb/IIIa.
● Inhibit ligand binding by their occupancy of the receptor but do not
block the vitronectin receptor.
● Since it has a short half-life, it must be given by continuous
infusion
CILOSTAZOL
● Mechanism of action:
○ Promotes vasodilation and inhibition of platelet aggregation
PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
B
● It works more rapidly and diffuses more freely to the clot
● Does not compete with plasminogen for fibrin binding, allowing plasminogen
to be transformed into clot-dissolving plasmin
Percutaneous Coronary Intervention (PCI)
● Cannulate the artery using a catheter with a balloon
● Inflating the balloon crushes the plaque and opens up the artery. When
deflating, the stent is left behind to keep it open
● However, the endothelium becomes rougher due to crushing of the plaque
so there is a risk for platelet activation, aggregation, and thrombus formation
PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
B
PHARMA.S2.L01.RESPIRATORY DRUGS AND CORTICOSTEROIDS
Atropine toxicity B
INHALED CORTICOSTEROIDS A
● Local side effects:
○ Dysphonia (due to atrophy of vocal cords)
○ Thrush (Oropharyngeal candidiasis)
○ Hoarseness and cough
PHARMA.S2.L01.RESPIRATORY DRUGS AND CORTICOSTEROIDS
BENEFITS OF BETA BLOCKERS B
● Short term:
○ Improvement of symptoms through an increase in left ventricle
ejection fraction (LVEF)
○ Improvement of nyha (New York Heart Association) class
○ Improvement of daily activities
○ Reduced hospitalization rate and length of hospital stay
● Long Term:
○ Slowing progression of CHF
 C. Carvediol ○ Increase survival rate
D. Any of the above PHARMA.S2.L05a.PHARMACOTHERAPY OF HEART FAILURE

17 The drug of choice for a 30 year old with severe A

asthma who is (+) for IL-4 receptor? Targeted (Monoclonal Antibody) Therapy
A. dupilumab
B. lebrikisumab Antibody Isotype Target
C. mepolizumab
D. reslizumab Omalizumab Humanized IgG1 IgE

Mepolizumab Humanized IgG1 IL-5

Benralizumab Humanized IgG1 IL-5 receptor

Reslizumab Humanized IgG4 IL-5

Lebrikizumab Humanized IgG4 IL-13

GSK679586 Humanized IgG1 IL-13 receptor alpha 1

and 2

Tralokinumab Humanized IgG4 IL-13 receptor alpha 1

and 2

Dupilumab Humanized IgG4 IL-4 receptor

PHARMA.S2.L01.RESPIRATORY DRUGS AND CORTICOSTEROIDS
For #18-20: QUANTITATIVE COMPARISON:
A. If 1>2
B. If 2>1
C. If 1=2
D. If there is no relationship
18 Negative inotropic property of 1) diltiazem and 2) B
verapamil Comparison of Different Calcium Channel Blocker Drugs

CCB Coronary Suppression Suppression Suppression

Vasodilation of cardiac of SA node of AV node
contractility

Verapamil ++++ ++++ ++++ +++++

Diltiazem +++ ++ +++++ ++++

Nifedipine +++++ + + 0

IMPORTANT. All can treat Prinzmetal angina because they dilate coronary arteries.
● Avoid Verapamil in severe LV dysfunction like Post MI patients developing
CHF because it has the greatest negative inotropic property (further
suppression of cardiac contractility).
● Use Diltiazem for Sinus Tachycardia especially to those with
contraindications with beta-blockers (greatest suppression of SA nodes).
● Use Verapamil for Atrial Fibrillation/Flutter (greatest suppression of AV
nodes).

PHARMA.S2.L04.ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
19 Half life of 1) amlodipine and 2) verapamil Verapamil
●
Amlodipine
📕
Half-life: 7 hours ( :4-7 hours)
A

● Half-life: 30-50 hours

Note: CCBs have short half lives except Amlodipine and Felodipine. These
Dihydropyridine CCBs are given once a day.

PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
20 Systemic vascular resistance after intake of 1) B
nifedipine and 2) diltiazem PHARMACOLOGICAL EFFECTS OF CONVENTIONAL CCBs
DHP NDHP
Nifedipine Verapamil Diltiazem
Heart Rate ↑ ↓ ↓↓
(Reflex
 Tachycardia)
AV Node No effect ↓↓ ↓
(Increases the
refractory period →
decreasing HR)
Systemic Vascular ↓↓↓ ↓↓ ↓
Resistance
Coronary Vascular ↓↓↓ ↓↓ ↓↓
Resistance
Myocardial 0 or ↓ ↓↓ 0 or ↓
Contractility

PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
21 A 45 year old secretary complains of palpitation C
described as rapid beating of the heart after her PHARMACOLOGICAL EFFECTS OF CONVENTIONAL CCBs
consult for hypertension. Which of the following is
DHP NDHP
the most likely given drug
A. verapamil Nifedipine Verapamil Diltiazem
B. diltiazem Heart Rate ↑ ↓ ↓↓
C. nifedipine (Reflex
D. carvedilol Tachycardia)
AV Node No effect ↓↓ ↓
(Increases the
refractory period →
decreasing HR)
Systemic Vascular ↓↓↓ ↓↓ ↓
Resistance
Coronary Vascular ↓↓↓ ↓↓ ↓↓
Resistance
Myocardial 0 or ↓ ↓↓ 0 or ↓
Contractility

📕Short
●
Acting CCBs (Nifedipine)
Recommended to not be used for hypertension since studies have reported
increased risk of MI or mortality; reflex tachycardia

Carvedilol
● Vaso-dilatory Beta blocker that is non-selective
● Blocks the alpha-1 receptors that mediates smooth muscle A contraction
PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
22 A 54 year old male, hypertensive is on Hydrochlorothiazide D
hydrochlorothiazide and amlodipine. Which of the ● Can cause Hypokalemia, hyperglycemia, and hyperuricemia
following must be regularly monitored
Amlodipine
A. Serum uric acid
● A common side effect of amlodipine is peripheral edema
B. FBS
C. Serum Na, K
D. All of the above PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
23 DT consults because his shoes are becoming Adverse reactions: C
tighter. He was seen a month ago by an internist Amlodipine
because of elevated blood pressure. On PE you ● The most common side effect of amlodipine is peripheral edema
● Indicates drug discontinuation
noted ++ bipedal edema. Which of the following is
Indapamide (diuretic)
the most likely drug given? ● Hypokalemia, hyponatremia, hypomagnesemia, hyperuricemia
A. indapamide ○ Hyperuricemia - thiazides act in DCT where there is secretion of
B. metoprolol uric acid
C. amlodipine ● Glucose intolerance (insulin resistance)
D. candesartan ○ Be careful in giving to diabetics
● Hypercholesterolemia, ↑ LDL, ↑ Triglyceride, ↑ Calcium levels (except
furosemide)
● Sexual dysfunction, weakness
● Photosensitivity, leukopenia, allergic skin rash
Metoprolol (Beta blocker)
● Bronchospasm in asthmatic
● Excessive cardiac depression, sexual dysfunction, sedation,sleep
disturbances
Candesartan (Angiotensin II receptor blocker)
● Teratogenic
● Hyperkalemia

PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
24 This antihypertensive drug acts through blockade of
alpha 1 receptor blood vessels:
A. telmisartan
B. captopril
C. amlodipine
D. prazosin
25 This drug acts on the adrenergic nervous system:
A. nebivolol
B. telmisartan
C. ramipril
D. hydrochlorothiazide
For #26-29: MATCHING TYPE
A. Nitrates
B. Betablockers
C. Non-dihydropyridine CCBs
D. Fatty Acid Oxidase Inhibitors
26 Relieve ischemia through blockade of L-type
calcium channels
27 Shift energy source to glucose metabolism
28 Relieve ischemia through an increase in cGMP
29 Anginal relief is through adrenergic blockade
30 A 50 year old male diabetic, consults because of Empagliflozin
easy fatigability. On this consult you hear
occasional bibasal crackles. The Echo reads:
“Normal LV size and preserved systolic function
with grade 2 diastolic dysfunction.” Which of the
following is the most appropriate drug to give?
A. Empagliflozin
B. Perindopril
C. Ivabradine
D. Telmisartan
31 RT consults because of palpitation. He was
admitted in your service a month ago because of
ST-elevation Myocardial Infarction. The ECG in
Prazosin D
● Blocks the alpha-1 receptors that mediates smooth muscle contraction
Telmisartan
● Angiotensin II Receptor Blockers (ARBs)
Captopril
● 1st generation ACE inhibitor
Amlodipine
● Calcium channel blocker
● CCBs affect the L-type calcium channels in the blood vessels which inhibit
Ca++ entry in cells
PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
Nebivolol A
● Beta 1 receptor
● Vasodilatory β blocker (Selective)
● Direct vasodilatory/vasorelaxant effect via NO generation
Telmisartan
● Angiotensin II Receptor Blockers (ARBs)
Ramipril
● Prodrug and a 2nd generation ACe inhibitor
Hydrochlorothiazide
● Diuretic
● Blocks Na + /Cl - transporter in distal convoluted tubule
PHARMA.S2.L02.ANTI-HYPERTENSIVE DRUGS
C
DRUG MECHANISM OF ACTION EXAMPLES
D
Nitrates Release in nitric oxide causes Nitroprusside,
increase in cGMP Nitroglycerin
A
Betablockers Adrenergic blockade of Metoprolol, Carvedilol,
beta-adrenoreceptors Labetalol (drugs ending in B
-olol)
Non-dihydropyridine Inhibits the influx of Verapamil, Diltiazem
Calcium Channel extracellular calcium ions
Blockers across the myocardial and
vascular smooth muscle cell
membranes during
depolarization
Fatty Acid Oxidase Blocks the mitochondrial Trimetazidine
Inhibitors (pFOX oxidation of fatty acids by the
Inhibitors) enzyme thiolase and similarly
shifts metabolism towards
glucose
A
● SGLT-2 Inhibitor
● Mechanism of action: Block renal glucose resorption
● Reduce the incidence of cardiovascular death and hospitalization in people
with and without diabetes and those with and without prevalent heart failure
○ Patient is said to be “diabetic”
PHARMA.S2.L05a.PHARMACOTHERAPY OF HEART FAILURE
● “In a postmarketing multinational study of 7020 type 2 patients with known
cardiovascular disease, the addition of empagliflozin was associated with a
lower primary composite outcome of death from cardiovascular
causes, nonfatal myocardial infarction, or nonfatal stroke (hazard ratio,
0.86; p = 0.04). The mechanisms regarding this benefit remain unclear.
Weight loss, lower blood pressure, and diuresis may have played a role
since there were fewer deaths from heart failure in the treated group
whereas the rates of myocardial infarction were unaltered”
Page 763. Katzung, B. G., Kruidering-Hall, M., & Trevor, A. J. (2019).
Katzung & Trevor's Pharmacology Examination & Board Review (14th ed.).
McGraw-Hill Education.
EFFECTS OF BETA-BLOCKERS B
● Attenuation of the adverse effects of high concentrations of
catecholamines
 your clinic shows multiple premature ventricular ○ Adverse effect: cardiotoxic effect of Norepinephrine
contractions. His BP is 140/90, PR 90/min. Which ● Up-regulation of beta receptors
of the following is the most appropriate drug to ○ HF patients are subjected to high concentrations of norepinephrine
because of the activation of the sympathetic nervous system →
give?
desensitization effect of high concentrations of norepinephrine → beta
A. Amiodarone receptors are downregulated
B. Metoprolol ○ If you give beta blockers, you upregulate the density of these receptors,
C. Verapamil thereby improving contractility
D. Valsartan ● Decreased heart rate
○ Increased sympathetic activity → increase in HR → higher oxygen
demand and myocardial cell death
● Reduced ventricular remodeling through inhibition of mitogenic activity
of catecholamines
○ Similar to ACEIs, ARBs, MRAs
● NOTE: By giving beta blockers, we are able to:
○ Minimize the effects of increased sympathetic outload triggered by low
cardiac output states of heart failure patients
○ Increase the survival of remaining viable myocytes

RECOMMENDATION
● Recommended for patients with asymptomatic LV systolic dysfunction
and a history of MI, in order to prevent or delay the onset of HF or prolong
life (Class IB Recommendation)

In the case:
● Patient is said to have experienced MI a month ago
● ECG findings include multiple premature ventricular contractions (PVCs);
Digitalis could be considered as the next drug in line but is not within the
choices
● Patient has elevated blood pressure and within the upper limit range of his
pulse rate, needed to decrease sympathetic activity of the heart
PHARMA.S2.L05a.PHARMACOTHERAPY OF HEART FAILURE
For #32-35: MATCHING TYPE
A. Short to medium-acting steroid
B. Intermediate-acting steroid
C. Long-acting steroid
32 Triamcinolone B

33 Cortisone A

34 Dexamethasone C

35 Prednisone A

Page 709. Katzung, B. G., Kruidering-Hall, M., & Trevor, A. J. (2019).

Katzung & Trevor's Pharmacology Examination & Board Review (14th ed.).
McGraw-Hill Education.
36 The slowest binding kinetic is demonstrated by CLASS IC BINDING KINETICS C
which antiarrhythmic drug class? ● Slow binding kinetics
A. Class IA drugs ● Markedly slow conduction
○ Due to the slow binding
B. Class IB drugs
● Minimal K-binding
C. Class IC drugs ○ Due to its class
D. Class III drugs ● Minimally prolonged action potential
○ Due to the minimal K-blocking activity of the drug
PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS
37 Which of the following drugs will decrease the
ventricular response in atrial fibrillation?
●
○ 📝
↑AV node refractory period = ↓ventricular response in AF = ↓cardiac rate
What can decrease the cardiac rate?
■ Digoxin and DHP CCBs
D
A. Digoxin
■ Cardioversion < Rate Control
B. Verapamil
 C. Diltiazem
D. All of the above PHARMA.S2.L05a. PHARMACOTHERAPY OF HEART FAILURE

For #38-41: Match the effect of the drug/drug combination with the resultant curve above when given to a patient with
orthopnea, PND, and ejection fraction of 30% on 2D Echo (refer to graph below):

38 IV furosemide A

39 IV drip of dobutamine D

40 Captopril and isosorbide mononitrate B

41 Digoxin, furosemide, spironolactone, and C

enalapril

● Inotropes increase the work but will not improve the filling pressure
○ They just increase the contractility and not alter the loading condition of the
heart
● Diuretics decrease the preload, thus decreasing filling pressure
○ However, it does not improve the output.
● Arteriolar dilators decrease afterload, thereby enhancing output (by increasing
stroke volume)
○ Venodilators decrease the preload and venous return, thus the leftward shift.
● A combination of an inotrope (e.g. digitalis) and a vasodilator (with ACEIs and
ARBs) is the most ideal regimen
PHARMA.S2.L05a. PHARMACOTHERAPY OF HEART FAILURE
Matching Type:
A. Bactericidal and time-dependent
B. Bactericidal and concentration-dependent
C. Bacteriostatic and time-dependent
D. Bacteriostatic and concentration-dependent
42 Quinolone B
Based on the Antimicrobial Activity
43 Cephalosporin DRUGS A
ANTIMICROBIAL ACTIVITY

44 Clindamycin Penicillin
C
BACTERICIDAL Cephalosporins
“Penicillin & Cephalosporin Are Very cidal Aminoglycosides
45 Aminoglycoside Vancomycin B
For Microbes”
Fluoroquinolones
Metronidazole
Erythromycin
Chloramphenicol Sulfamethoxazole
BACTERIOSTATIC Tetracyclines
“E C S Ta Ti C” Trimethoprim
Clindamycin

1. Time-dependent: Continuous IV infusion → “CLAM TV”

○ Clindamycin
○ Linezolid
○ ALL beta-lactams

46 This diuretic is excreted primarily by the biliary
system but enough of the active form is cleared
by the kidney to exert its diuretic effect:
A. Chlorthalidone
B. Indapamide
C. Chlorothiazide
D. Metolazone
47 A 50-year-old consults because of Bp OF
150/100 on several occasions, which is also
confirmed in your clinic. The doctor before you
requested a 2D Echo that reads, “concentric LV
remodeling with segmental wall hypokinesia of
the interventricular septum apex to mid, with a
preserved ejection fraction of 50%.” Which of
the following is the drug of choice?
A. An ACEi
B. An ARB
C. A betablocker
D. A diuretic
48 A patient with hyperaldosteronism will benefit
from:
A. Furosemide
B. Thiazide
C. Eplenerone
D. Acetazolamide
49 A 4-year-old male was admitted due to oliguria
and hypertension. On PE, bipedal edema and
ascites were noted. Serum creatinine was high.
An impression of post-infectious
glomerulonephritis was given. Which of the
following will you give to address the
hypertension?
A. Amlodipine
B. Enalapril
C. Thiazide
D. Furosemide
For #50-54: Write A if TRUE, B if FALSE
50 Both amiloride and triamterene do not block
aldosterone but instead directly interfere with
sodium entry through epithelial sodium
channels
51 With fixed dose combinations of K-sparing and
thiazide diuretics, the K-spring associated
adverse effects often predominate
52 The combination of amiloride with indomethacin ● Only causes mild diuresis
has been reported to cause acute renal failure
○ Macrolides
○ Tetracycline
○ Vancomycin
2. Concentration-dependent: Single large daily dose → “SAD MFKr”
○ Streptogramins (Dalfopristin, Quinupristin)
○ Aminoglycosides
○ Daptomycin
○ Metronidazole
○ Fluoroquinolones
○ Ketolides (Telithromycin)
PHARMA.S2.L05.GENERAL PRINCIPLES OF ANTIMICROBIAL THERAPY
“Although indapamide is excreted primarily by the biliary system, enough of B
the active form is cleared by the kidney to exert its diuretic effect in the DCT.”
Katzung, B. G., Kruidering-Hall, M., & Trevor, A. J. (2019). Katzung &
Trevor's Pharmacology Examination & Board Review (12th ed.). McGraw-Hill
Education.
ACE IN HEART FAILURE A
● Inhibits the Phospholipase C Signaling System
○ This system is responsible for cardiac myocyte growth, inotropy, myocyte
apoptosis, aldosterone release, NE release, fibroblast and smooth muscle
proliferation
○ By inhibition of angiotensin II, ACEIs prevent ventricular remodeling
PHARMA.S2.L05a. PHARMACOTHERAPY OF HEART FAILURE
● 📝
Aldosterone antagonists
Aldosterone will stay in the cell and will bind to intracellular receptor → gene
transcription on Na+ channel and Na+/K+ ATPase, increasing the expression.
C
● Indication- Hyperaldosteronism due to:
○ Primary hypersecretion (Conn’s syndrome)
○ Secondary hyperaldosteronism (due to CHF, cirrhosis, nephrotic syndrome)
○ Resistant hypertension (resistant to treatment with conventional drugs for
hypertension)
PHARMA.S2.L03. DIURETICS
● 📕
CLINICAL INDICATION OF LOOP DIURETICS
The most important indications for the use of loop diuretics include acute
pulmonary edema and other edematous conditions
D
○ To redistribute fluid in the body
○ Reduce pulmonary congestion and left ventricular filling pressures in heart
● 📕 failure
Many times the treatment of the fluid overload will also serve as an effective
anti-hypertensive agent, especially in the presence of renal insufficiency
● If we want to get rid of fluid overload and increase urine output, the Loop diuretics
will be the best one (i.e. emergency situations, ICU patients)
○ Commonly Prescribed: Furosemide
● If we give furosemide with someone with acute kidney injury with oliguria, we do
not only increase the urine output but also address the hyperkalemia related to the
oliguria
PHARMA.S2.L03. DIURETICS
THIAZIDES A
Toxicity
○ Hypokalemic metabolic alkalosis
■ Decreased distal delivery promotes increased H+ and K+ secretion, promoting
hypokalemia and metabolic alkalosis
■ Hypokalemia
B
POTASSIUM-SPARING DIURETICS
Renal Epithelial Na+ Channel Inhibitors
B
○
○
📝
● Amiloride and Triamterene are direct inhibitors of Na+ influx in the CT.
📝
Amiloride - pyrazinoylguanidine derivative
Triamterene- a pteridine
● Indications: Used in combination with other diuretics that cause hypokalemia
○ Offsets ↑ K+ excretion
○ 📝
○ Edema or hypertension
Liddle’s syndrome
○ Used primarily for anti-kaliuretic (inhibits potassium excretion) action
Toxicity and Contraindications
 ● Hyperkalemia
○ Most common
○ Unlike most other diuretics, K+-sparing diuretics reduce urinary excretion of K+

○ 📕
and can cause mild, moderate, or even life-threatening hyperkalemia.
Contraindicated to patients with renal disease (where K+ excretion is reduced

○ 📝
and patients with oliguria.
Too much hyperkalemia can cause arrhythmias
● Hyperchloremic Metabolic Acidosis
● Gynecomastia

53 Strong CYP3A4 inhibitors like erythromycin can POTASSIUM-SPARING DIURETICS
markedly increase blood levels of eplerenone
but not spironolactone
○ 📕
● Acute Renal Failure
The combination of triamterene with indomethacin has been reported to
cause acute renal failure. This has not been reported with other K+ sparing
diuretics.
● Kidney Stones
PHARMA.S2.L03. DIURETICS
A
Contraindications
● Chronic renal insufficiency
● Oral K+ administration should be discontinued
● Concomitant use of Beta Blockers, ACE inhibitors, and Angiotensin receptor
blockers increase the likelihood of hyperkalemia
● Liver disease may impair metabolism of triamterene and spironolactone
● Strong CYP3A4 inhibitors (ie. Erythromycin, Fluconazole, Diltiazem and Grapefruit
juice) can markedly increase blood levels of eplerenone but not spironolactone

Katzung, B. G., Kruidering-Hall, M., & Trevor, A. J. (2019). Katzung & Trevor's
Pharmacology Examination & Board Review (12th ed.). McGraw-Hill Education.
54 Mannitol administered orally is an osmotic OSMOTIC DIURETICS B
diuretic Pharmacokinetics
● Mannitol
○ Prototype
○ Poorly absorbed
■ Given parenterally
○ Inert
■ Not metabolized
○ Excreted by glomerular filtration in 30-60 minutes
PHARMA.S2.L03. DIURETICS
Matching Type:
A. Inhibitor of other metabolic processes
B. Inhibitor of cell membrane function
C. Inhibitor of cell wall synthesis
D. Inhibitor of protein synthesis
55 Cefepime C
Based on the Mechanism of Action
56 Chloramphenicol DRUGS D
MECHANISM OF ACTION

57 Colistin Penicillins
B
Cephalosporins
Inhibition of Cell Wall Synthesis Bacitracin
58 Sulfonamide Vancomycin A
Polymyxin B
Inhibition of Cell Membrane Function Colistin
30S

Aminoglycosides
Tetracyclines
50S
Inhibition of Protein Synthesis
Macrolides
Lincosamides
Streptogramins
Chloramphenicol
Quinolones
Inhibition of Nucleic Acid Synthesis Metronidazole
Rifampicin
Inhibition of Other Metabolic Sulfonamides
Processes Trimethoprim
PHARMA.S2.L05.GENERAL PRINCIPLES OF ANTIMICROBIAL THERAPY
59 For the experiment on influence on route of Expected Results C
administration, which of the following is an Latency of the drug is shorter with IV than IM
expected result? Duration of drug effect is equal with IV and IM
Actual Results
A. Shorter latency for IM, longer duration
Latency of the drug is equal with IV and IM
for IV Duration of drug effect is longer with IM than IV
B. Longer latency for IM, longer duration
 for IV
C. Shorter latency for IV, equal duration for
IV and IM
D. Equal latency for IM and IV, longer
duration for IV
60 For the experiment on influence of chemical Expected and Actual Results: C
structure, the expected result is: Heart Rate - Epinephrine > Terbutaline > Dobutamine
A. Heart rate: epinephrine > terbutaline > Contractility - Epinephrine > Dobutamine > Terbutaline
dobutamine
B. Heart rate: dobutamine > epinephrine >
terbutaline
C. Contractility: epinephrine > dobutamine
> terbutaline
D. Contractility: epinephrine > terbutaline >
dobutamine
61 For the experiment on antagonism, addition of Morphine is an opioid/narcotic analgesic whereas Naloxone is an opioid antagonist. B
naloxone to subject animals given morphine Thus, we expect that naloxone shortens the duration of action of morphine in animals.
extended the duration of action of morphine
A. True
B. False
62 A 28-year-old male is admitted at the ICU due to LOOP DIURETICS C
iodide toxicity. Which among the following ● Furosemide, Bumetanide, Torsemide, Ethacrynic acid
diuretics must be given?
A. Thiazide ● 📕
Clinical Indications
The most important indications for the use of loop diuretics include acute
pulmonary edema and other edematous conditions
B. Mannitol ● Chronic CHF, Reduce pulmonary congestion and left ventricular filling pressures in
C. Furosemide heart failure (acute pulmonary edema)
D. Spironolactone ● Acute kidney injury/Acute renal failure
● Acute Hypercalcemia
● Hyperkalemia
● Anion overdose
○ Useful in treating toxic ingestion of bromide, fluoride, and iodide which are all
reabsorbed in the TAL of loop of Henle through the NKCC transporter or its
analog
○ Overdose of those anions → Loop diuretics inhibit reabsorption of those anions

○ 📕
→ they will be excreted and not produce toxicity anymore
Saline Solution must be administered to replace urinary losses of Na+ and to
provide Cl-, so as to avoid extracellular fluid volume depletion

PHARMA.S2.L03. DIURETICS
63 A 16-year-old male is admitted due to ruptured Cefoxitin (2nd gen cephalosporin) is used for mixed anaerobic infections. During B
appendicitis. He is scheduled for emergency appendectomy, there is risk for anaerobic infections.
appendectomy. Which of the following
Indications for other choices:
antibiotics must be given 1 hour prior to the
● Cefuroxime (2nd gen cephalosporin) - against B-lactamase producing H.
procedure? influenzae or Moraxella (sinusitis, otitis, and lower respiratory tract infections such
A. Ceftriaxone as pneumonia)
B. Cefoxitin ● Ceftriaxone and Ceftazidime - 3rd generation cephalosporin for severe infections
C. Cefuroxime due to penicillin-resistant strains of pneumococci.
D. Ceftazidime PHARMA.S2.L06. SPECIFIC ANTMICROBIALS p. 4-5

64 A 35-year-oldmale diabetic, presents to your Aspirin/acetylsalicylic acid/ASA C

clinic because of chest pain occurring during ● Antiplatelet drug indicated for unstable angina, NSTEMI (in combination with other
exertion. To prevent myocardial infarction, you antiplatelets), STEMI, recent MI/stroke
will give him
Indications for the other choices:
A. Rivaroxaban ● Rivaroxaban - venous thrombosis, pulmonary embolism, prevention of stroke in
B. Warfarin patients with nonvalcular atrial fibrillation
C. ASA ● Warfarin - prevention of stroke in patients with atrial fibrillation
D. Any of the above PHARMA.S2.L04. ANTI-ANGINAL, p.9,12,22
65 RJ has been having chest pain for the last 30 Enoxaparin B
minutes when he presented in the ER. The ECG ● Anticoagulant; Low molecular weight heparin for unstable angina, NSTEMI
shows changes suggestive of NSTEMI. Which of ● Indirect thrombin inhibitor
● Prevent occlusive thrombus formation so as to not progress to STEMI
the following will best prevent the progression
STEMI? Indications for the other choices:
A. Alteplase ● Alteplase - coronary artery thrombosis, ischemic stroke, pulmonary embolism
B. Enoxaparin ● ASA & Clopidogrel - antiplatelets also used for unstable angina and NSTEMI
C. ASA
D. Clopidogrel PHARMA.S2.L04. ANTI-ANGINAL, p.2,11,17

66 Theophylline produces its bronchodilating effect Bronchodilators and MOA B

by means of? ● Theophylline - Antagonism of adenosine at A2 receptors
A. Inhibition of mediator release from mast ● Sympathomimetics - Inhibits release of bronchoconstrictor mediators from mast
cells
cells
● Steroids - anti-inflammatory and immunosuppressive
B. Antagonism of adenosine at A2
 receptors ● Beta agonists - Stimulation of B2 receptors
C. Anti-inflammatory activity on T
lymphocytes
D. Stimulation of B2 receptors
PHARMA.S2.L01-RESPIRATORY DRUGS AND CORTICOSTEROIDS
67 Long acting bronchodilator with an onset of D
Pharmacologic Characteristics of LABA
action within 5min and a half-life of 2-3 hours?
A. Oledaterol LABA Onset of Action Duration of Half Life (hours)
B. Salmeterol (Minutes) Action (hours)
C. Indacaterol Salmeterol 10-30 12 12-15 days
D. Vilanterol
Formoterol 1-3 12 10
Olodaterol 5 24 7.5
Villanterol 5.08 + 0.5 24 2.5
Indacaterol 4.0 + 0.2 24 >30
PHARMA.S2.L01-RESPIRATORY DRUGS AND CORTICOSTEROIDS
68 A 58-year-old female in the ICU is being treated ● Ceftazidime is the DOC for Pseudomonas aeruginosa infections. C
for septicemia based on a blood culture result of ● Only ceftazidime and cefoperazone have activity against Pseudomonas.
Pseudomonas aeruginosa. Which of the PHARMA.S2.L07.SPECIFIC ANTIMICROBIALS – Penicillins and Cephalosporins
following antibiotics is appropriate to use?
A. Ampicillin-sulbactam
B. Ceftriaxone
C. Ceftazidime
D. Cefpodoxime proxetil
69 TRUE OR FALSE. ● All TETRACYCLINES must be taken w/o food except doxycycline and A
Tetracycline has decreased bioavailability when minocycline.
taken with food. PHARMA.S2.L05.GENERAL PRINCIPLES OF ANTIMICROBIAL THERAPY

70 TRUE OR FALSE. ● The excretion of cefoperazone and ceftriaxone is mainly through the biliary tract, B
Ceftriaxone dose must be adiusted in patients and no dosage adjustment is required in renal insufficiency.
with acute kidney injury because it is eliminated
PHARMA.S2.L07.SPECIFIC ANTIMICROBIALS – Penicillins and Cephalosporins
via the kidneys.
Match the patient with the most appropriate therapy to give
A. Defibrillation
B. Electrical Cardioversion
C. Medical Cardioversion
D. None of the above
71 A carpenter is brought to the ER because of cold ● When do we do cardioversion: B
clammy sweats and palpitation: Vital signs - BP ○ When you see QRS complexes that are nice looking but the patient is
80/60, PR 160/min, RR 15/min; cardiac monitor: hemodynamically unstable, meaning the blood pressure is dropping.
■ Eg. If you see AFRVR and the patient’s BP is 70 palpatory, deliver a current
SVT
(50-100 J), synchronized cardioversion (press ‘SYNC’ on the monitor)
72 A bankteller is brought to the ER because of a
first episode of palpitation. BP 140/80, PR ● 📝 because it syncs the QRS then delivers the shock at the height of the QRS.
Synchronized cardioversion is used in Supraventricular Tachycardia (SVT) that
C
160/min, RR 14/min
● 📝
are hemodynamically compromised resulting to low blood pressure
Same principle as defibrillator except shock is delivered at the height of QRS

73 A 60 year old female brought to the ER because
of chest pain. BP120/80, PR 70/min, RR 13/min.
Cardiac monitor: Sinus rhythm with frequent
premature ventricular contraction
74 A professor is brought to the ER because of loss
of consciousness. Vital signs: BP=0, PR=0,
RR=0. Cardiac monitor: ventricular fibrillation
● IMPORTANT.
○ Hemodynamically unstable patients – Electrical cardioversion
○ Hemodynamically stable patients – Medical cardioversion
PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS
● None because patient is hemodynamically stable and does not meet the D
indications for either defibrillation and cardioversion. See #71 and #74.
PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS
● When do we defibrillate? A
○ Patients with Ventricular Fibrillation or Pulseless V-tach
PHARMA.S2.L05b.ANTI-ARRHYTHMIC DRUGS

75 The mechanism of hyperglycemia in patients
taking B2 selective agents is due to?
A. Increase glycogenolysis
B. Activation of receptors in adipose tissue
C. Direct stimulation of the pancreatic islets
D. Increase gluconeogenesis
76 A 21-year-old male presented with fever for 2
weeks duration. Enteric fever was entertained.
Blood culture revealed heavy growth of
Salmonella typhi. Which of the following
● Other effects of β adrenergic stimulation affected by β blockers: A
○ β1 - ↑ renin release; lipolysis; ↑ intraocular pressure
○ β2 - ↑ glucagon & insulin secretion, ↑ glycogenolysis
PHARMA.S2.L02-ANTI-HYPERTENSIVE DRUGS page 7
● Ceftriaxone (3rd generation) is the DOC for Salmonella when using cephalosporins B
○ Expanded gram negative coverage compared to earlier generations
● A. Cefuroxime is a 2nd generation cephalosporin without activity against
Salmonella typhi.
● C Cefotaxime and D. Ceftazidime are both 3rd generation, but not DOC.
 antibiotics must be administered?
A. Cefuroxime PHARMA.S2.L07.SPECIFIC ANTIMICROBIALS – Penicillins and Cephalosporins
B. Ceftriaxone
C. Cefotaxime
D. Ceftazidime
77 For experiments on graded dose response ● Efficacy - Degree to which a drug can produce the desired response C
curves, which of the following are the expected ● Potency - Amount of drug required to produce 50% of the maximal response the
results? drug is capable of inducing
● Morphine
A. Efficacy: morphine > ibuprofen > aspirin >
○ Opioid analgesic with high maximum efficacy and approximately 10 mg
paracetamol equivalent dose (Katzung, p. 555)
Potency: ibuprofen > morphine > ○ Severe, constant pain is usually relieved with opioid analgesics having high
paracetamol > aspirin intrinsic activity, whereas sharp, intermittent pain does not appear to be as
B. Efficacy: morphine > aspirin > ibuprofen > effectively controlled. (Katzung, 563)
paracetamol ● Ibuprofen
Potency: morphine > aspirin > ibuprofen > ○ Most commonly used OTC and prescribed NSAID
aspirin ○ Widely used as an analgesic, anti-inflammatory, and antipyretic
○ Used to manage mild to moderate pain related to dysmenorrhea, headache,
C. Efficacy: morphine > ibuprofen >
migraine, and postoperative dental pain
paracetamol > aspirin ○ Nonselective COX inhibitor
Potency: morphine > ibuprofen > ○ A 2400 mg daily dose is equivalent to 4 g of aspirin in antiinflammatory effect
paracetamol > aspirin ○ Analgesic dose is given at a lower dose at <1600 mg/day
D. Efficacy: morphine > ibuprofen > aspirin > ○ Decreases the anti-platelet activity of aspirin
paracetamol ○ Antagonizes the irreversible platelet inhibition induced by aspirin and can limit its
Potency: morphine > aspirin > ibuprofen > cardioprotective effects
paracetamol ○ Concomitant use with aspirin may also decrease the total antiinflammatory effect
● Paracetamol
○ Non-opioid analgesic
○ Weak COX-1 and COX-2 inhibitor in peripheral tissues
○ Evidence suggests that it may inhibit COX-3 in the CNS
○ Pharmacokinetics
■ 10-15 mg/kg dose in children
■ 325-1000 mg per dose in adults
■ Given every 4-6 hours
■ Rapidly and completely absorbed from the GI tract (duodenum)
○ Half-life: 2-4 hours

■ 📕
○ Indications
Used in the treatment of mild to moderate pain (headache, myalgia,
postpartum pain)
■ Inadequate for inflammatory conditions such as rheumatoid arthritis (RA)
● Aspirin

○ 📝
○ Analgesia, antipyretic, anti-inflammatory, and antithrombotic (in low dose)
High doses of aspirin may be effective but normally should not be given
○ Low doses of aspirin (<100 mg daily) are used widely for their cardioprotective
effects
■ Reduce thrombus potential
○ At high therapeutic doses (> 3g daily), as might be given for acute rheumatic
fever, salt and water retention can lead to an increase (up to 20%) in circulating
plasma volume and decreased hematocrit cardioprotective effects

PHARMA.S1.L02.PHARMACODYNAMICS
PHARMA.S1.L06.NSAIDs, DMARDs, ANTI-GOUT, & NON-OPIOID ANALGESICS

78 Which ACEI can be given relatively early in a ● Captopril has no prodrug compared to the other choices. It also has the shortest B
patient with acute MI? effective plasma half-life.
A. Enalapril
B. Captopril First Generation ACE Inhibitors
C. Ramipril Captopril Enalapril Lisinopril
D. Perindopril
Prodrug No Yes No
Active Drug Captopril Enalaprilat Lisinopril
Lipophilicity + ++ 0
Effective plasma 2H 11H 13H
half-life
Route of Renal Renal Renal
elimination (ratio)

Second Generation ACE Inhibitors

Cilazapril Perindopril Quinapril Ramipril Imidapril
Prodrug Yes Yes Yes Yes Yes
Active Drug Cilazaprilat Perindoprilat Quinaprilat Ramiprilat Imidaprilat
Lipophilicity + + ++ + No data
Effective 4H 9H 3H 12H 7-9H
 plasma
half-life
Route of Renal Renal Renal Renal & Renal &
elimination Hepatic Hepatic
(ratio) (70:30) (70:30)
PHARMA.S2.L02-ANTI-HYPERTENSIVE DRUGS

79 This oral anticoagulant acts through inhibition ● Heparin inhibits the activated factors (IXa, Xa, IIa/thrombin) B
of Factor Ila. ● Rivaroxaban, Apixaban, and Edoxaban are direct inhibitors of
A. Warfarin ● Factor Xa
● Dabigatran directly inhibits Factor IIa/Thrombin
B. Dabigatran
● Warfarin inhibits the synthesis of Factors VII, IX, X, and II
C. Rivaroxaban
D. Enoxaparin

PHARMA.S2.L04-ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS

80 RI, a 55-year-old male comes for a follow-up
because of headache. A week ago, you gave him
several medications for his hypertension and
anginal chest pain. Which of the following will
you discontinue or replace with another drug?
A. Clopidogrel
B. Ramipril
C. Isosorbide mononitrate
D. Losartan
● Acute adverse effect of Nitrates C
○ Orthostatic hypotension
○ Tachycardia
○ Throbbing headache and transient dizziness
PHARMA.S2.L04-ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS

MATCHING TYPE (81-84)

A. Fludrocortisone
B. Spironolactone
C. Ketoconazole
D. Aminoglutethimide
81 Mineralocorticoid antagonist Spironolactone B
● 7 alpha-acetylthiospironolactone
● Uses: Primary aldosteronism
○ Used diagnostically for detection of aldosteronism in hypokalemic patients with
82 Androgen antagonist hypertension B
○ Amelioration of signs and symptoms when surgical removal of an adenoma is
delayed
○ Androgen antagonist → treatment of hirsutism and acne in women
● Pharmacokinetics & Pharmacodynamics
○ Well-absorbed in the gut
○ Slow onset of action
○ Half-life: 2 hrs
○ Highly protein bound
○ Undergoes enterohepatic recycling
● Adverse Effects
○ Hyperkalemia, cardiac arrhythmia
○ Gynecomastia, impotence
○ Abnormal menstrual cycles
○ Sedation, headache
○ GI disturbances
83 Blocks conversion of cholesterol and Aminoglutethimide D
pregnenolone ● No longer available in the world market
● Aromatase inhibitor
○ Produces a state of medical adrenalectomy
○ Blocks conversion of cholesterol to pregnenolone
○ Inhibits synthesis of all hormonally active steroids

PHARMA.S2.L01-RESPIRATORY DRUGS AND CORTICOSTEROIDS

84 Treatment for Hypercortisolism Ketoconazole C

85 A school teacher presents in the emergency room ANTI-ANGINALS
because of severe chest pain that started an hour ECG Readings
earlier. The ECG in the ER shows ST segment
elevation in the inferior and right sided chest leads.
Which of the following should NOT be given
a. Enoxaparin
b. Aspirin
c. IV nitroglycerine
d. All of the above
NITRATES
ENOXAPARIN (LMWH)
ASPIRIN
PHARMA.S2.L04-ANTI-ANGINAL_ANTIPLATELETS_FIBRINOLYTICS_ANTICOAGUL
ANTS_ANTI-HYPERLIPIDEMIC DRUGS
86 A 64-year-old chronic stable angina patient consults
because she is still experiencing chest pain. She is
currently on a long-acting nitrate. If your goal of
therapy is more efficient energy utilization of the heart,
you will give:
A. Ranolazine
B. Trimetazidine
C. Ivabradine
D. Diltiazem
● Antifungal imidazole derivative
● Inhibits ergosterol (fungal equivalent of cholesterol) synthesis
○ Potent non-selective inhibitor of adrenal and gonadal steroid
synthesis
○ Inhibits cholesterol side-chain cleavage
○ Inhibits the cytochrome P450 enzymes necessary for cortisol
synthesis
● Commonly used for treatment of Cushing’s syndrome
PHARMA.S2.L01-RESPIRATORY DRUGS AND CORTICOSTEROIDS
C
● Contiguous limb leads shown in the hexaxial system:
○ II, III, aVF: inferior wall MI (they are contiguous)
○ I, aVL: lateral wall MI (they are contiguous)
○ V4R, V5R, V6R – right-sided leads: to see if that patient has
concomitant or right ventricular infarction in relation to the
involvement of the inferior wall
● If there is an inferior wall then you should get the right sided chest leads to
see involvement of the right ventricle.
● Inferior wall MI be careful in giving Nitrates because they are
contraindicated in inferior wall MI
● Nitroglycerine/Isosorbide Sublingual
○ Rapid relief of anginal pain
■ Caution: May cause lightheadedness due to ↓
lightheadedness
● IV isosorbide dinitrate
○ First 24-48 hours in patients with acute MI and CHF
● Isosorbide mononitrate
○ Continued beyond 48 hrs
●
○
REMEMBER: 📕
Prevention of recurrent angina
Sublingual Nitroglycerin is the most frequently used agent
for the immediate treatment of angina. (Because rapid onset of action and
short duration of action) and Clinical use of intravenous nitroglycerin is
therefore restricted to the treatment of severe, recurrent rest angina
● MOA
○ Releases nitric oxide in smooth muscle, which activates guanylyl
cyclase and increases cGMP
● Clinical Applications
○ Sublingual form for acute episodes
○ Oral and transdermal forms for prophylaxis
○ IV form for acute coronary syndrome
● MOA
○ Complexes with anti-thrombin III; irreversibly inactivates the
coagulation factors thrombin and factor Xa
■ LMW heparins (enoxaparin, dalteparin, tinzaparin more
selective anti-factor X activity, more reliable
pharmacokinetics with renal elimination, protamine
reversal only partially effective, less risk of
thrombocytopenia
● Clinical Applications
○ Venous thrombosis, pulmonary embolism, myocardial infarction,
unstable angina, adjuvant to percutaneous coronary intervention
(PCI) and thrombolytics
● MOA
○ Nonselective, irreversible COX inhibitor-reduces platelet
production of thromboxane A2, a potent stimulator of platelet
aggregation
● Clinical Applications
○ Prevention and treatment of arterial thrombosis
NEWER ANTI-ANGINAL AGENTS B
● Trimetazidine - Metabolic pathway modulator and pFOX inhibitor
○ During normal conditions, the heart uses the fatty acid oxidation pathway as the
source of energy of the myocardial cells. Free Fatty acid oxidation provides
more energy but is associated with increased oxygen consumption.
○ When oxygen is in low supply as in periods of sustained ischemia, the oxidative
processes of free fatty acid and glucose are disrupted
■ This paradoxically leads to an increased rate of free fatty acid
beta-oxidation.
■ This is associated with an even greater increase in oxygen consumption
and a decrease in glucose metabolism. Lactic acid accumulation occurs,
and in extreme cases, the development of central metabolic acidosis.
 ○ Trimetazidine works by selectively inhibiting the enzyme (long-chain
3-ketoacyl coenzyme A thiolase, LC-3KAT) which is the final enzyme in the
free fatty acid beta-oxidation pathway.
■ This increases the metabolic rate of glucose
○ Trimetazidine also increases pyruvate dehydrogenase activity which
restores homeostasis between glucose oxidation and glycolysis, an imbalance
occurring during ischemia
○ Metabolic modulation (pFOX) effects of Trimetazidine would result to:
■ FFA breakdown inhibition and glucose breakdown stimulation
■ Reduction in the amount of oxygen necessary for ATP production
■ Reduction in the cellular accumulation of lactic acid and H+
■ Reduction in the accumulation of Na+ and Ca2+
■ Reduction in ATP losses for maintaining ion homeostasis
■ Reduction of adverse effects of overloading cells with calcium
■ Anti-radical effect
■ Reduction of granulocyte infiltration to the ischemic and re-perfused area of
the myocardium, hence, preventing reperfusion injuries
■ Cardiomyocyte apoptosis inhibition
● Ranolazine - Partial inhibition of fatty acid oxidation (not achieved with the usual
dosage)
○ Blocks the late sodium current that facilitates calcium entry via the
sodium-calcium exchange
● Ivabradine - Selective If sodium channel blocker
○ It reduces the cardiac rate by inhibiting the hyperpolarization-associated
sodium channel in the SA node
○ Advantage: lack of effect on GI and bronchial smooth muscles
○ Mechanism of Action
■ By reducing heart rate
● Increases exercise capacity
● Reduces angina frequency and severity
■ Has no hemodynamic effect
● Can be given in patients with relatively low blood pressure
■ This drug is given in patients with Sinus Tachycardia
CCB
● Diltiazem – Nondihydropyridine calcium channel blocker
○ Act on the SA node to DEC HR
○ Act on the AV node to produce AV nodal blocking effect or
parasympathomimetic effect on the AV node
○ Used for Sinus Tachycardia especially to those with contraindications with
beta-blockers (greatest suppression of SA nodes).
PHARMA.S2.L04-ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
87 Sputum eosinophilia of 5% will most likely respond to? INHALED CORTICOSTEROIDS C
A. Omalizumab ● Inhibits the expression of multiple inflammatory genes in airway
B. Anti-leukotriene epithelial cells
C. Inhaled corticosteroids ● Prevents and reverses the increase in vascular permeability leading to the
D. Immunotherapy resolution of airway edema
● Has a direct inhibitory effect on mucus glycoprotein secretion from airway
submucosal glands, as well as indirect inhibitory effects by the down
regulation of inflammatory stimuli, which stimulates mucus secretion
○ Note: Corticosteroids have no direct effect on contractile
responses of airway smooth muscle
○ Improvement in the lung function after inhaled corticosteroid use is
presumably due to an effect on the chronic airway inflammation
and airway hyper-responsiveness
● ICS prevents inflammation BUT it does not cure the asthma (it just
addresses the s/s of asthma)
● The fraction of steroid that is inhaled into the lungs may be absorbed from
the airway and alveolar surfaces; may reach the systemic circulation.
Fraction that is deposited in the oropharynx may be swallowed and absorbed
from the gut
88 Patients with low Th2, FeNO level, peripheral and C
sputum eosinophilia will likely respond to? Biomarker Asthma Phenotype Predicts Response To
A. Oral steroids
B. Fluoroquinolone Periostin Th2 high Anti-IL 13 and 14
C. Tiotropium
Elevated exhaled nitric oxide
D. Immunotherapy Inhaled steroids
(>50pbb in adults and >35 pbb in Th2 high
children)
Sputum eosinophilia >3% Inhaled steroids
Th2 high

Peripheral eosinophilia (>0.3 x

109 /L or 300 uL) Th2 high Anti-IL 5

Elevated total IgE > 30 IU Allergic Omalizumab

Allergic skin tests Allergic asthma with
and elevated specific Omalizumab
atopy
IgE
 Lack of elevated
peripheral and Th2 low Tiotropium, macrolides
sputum eosinophil
and low FeNO

89 A 55-year-old professor presents in your clinic
because of lightheadedness. He is a known
hypertensive on metoprolol 100 mg daily. He tells you
that he consulted his neighbor physician and was
given a drug that he cannot recall. If his BP is 90/60,
PR is 38/min, 12 lead ECG – complete heart block,
which of the following is a possible drug that could
have been prescribed to him?
A. Losartan
B. Diltiazem
C. Ivabradine
D. Amlodipine
● Diltiazem – Nondihydropyridine calcium channel blocker B
○ CARDIOselective
○ Effect is similar to B-Blockers
○ Act on the SA node to DEC HR
○ Act on the AV node to produce AV nodal blocking effect or
parasympathomimetic effect on the AV node
○ Negative inotropic effect
● Losartan – ARBs
● Ivabradine
○ Selective Na channel blocker
○ For patients with sinus tachycardia
● Amlodipine – Dihydropyridine CCB
○ VASOselectibe

PHARMA.S2.L02-ANTI-HYPERTENSIVE DRUGS
PHARMA.S2.L04-ANTI-ANGINAL_ANTIPLATELETS_FIBRINOLYTICS_ANTICOAGUL
ANTS_ANTI-HYPERLIPIDEMIC DRUGS
90 A known diabetic and hypertensive with chronic stable ● Rosuvastatin – HMG-CoA Reductase Inhibitor B
angina shows you her lipid profile. What is the best ● Fenofibrate – Fibric acid derivatives (Fibrates)
drug to give if the LDL is 250 mg/dL? ● Niacin
A. Fenofibrate
○ Therapeutic use: heterozygous familial hypercholesterolemia
B. Rosuvastatin
C. Niacin ● Cholestyramine – Bile-acid binding resins
D. Cholestyramine
Effects of Antipild Drugs
DECREASE LDL DECREASE TG INCREASE HDL
Statins Fibric acid derivatives Niacin
Niacin Omega 3 fatty acids Fibric acid derivatives
Resins
PCSK9 inhibitors

PHARMA.S2.L04-ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS
91 A 2-year-old female was admitted due to fever with no ● Cefuroxime C
accompanying symptoms. Urinalysis revealed pyuria ○ 2nd generation cephalosporins
and bacteriuria. Urine culture was requested. What ○ Use: Against B-lactamase producing H. influenzae or Moraxella (sinusitis,
appropriate antibiotic must be started?
otitis, and lower respiratory tract Infections such as pneumonia)
A. IV cefazolin
B. IV ampicillin ● Cefazolin
C. IV cefuroxime ○ 1st generation cephalosporins
D. IV ceftazidime ○ Use: surgical prophylaxis for “clean” wounds
● Ceftazidime
○ 3rd generation cephalosporins
○ For serious infections
○ For febrile immunocompromised patients in combination with other
antibiotics
● Ampicillin
○ Broad spectrum penicillin
○ For Listeria and Shigella infections

PHARMA.S2.L07.SPECIFIC ANTIMICROBIALS – Penicillins and Cephalosporins

92 After 3 days, patient is still febrile. Urine culture ● Cefuroxime – 2nd generation cephalosporin D
showed E. coli 100,000 CFU’s/mL, ESBL (+). What will ● Ceftriaxone – 3rd generation
be your next course of action? ● Cefepime – 4th generation
A. Continue IV cefuroxime
B. Shift antibiotic to IV ceftriaxone
C. Shift antibiotic to IV cefepime GOOD FOR ESBL (+)
DRUG
D. Shift antibiotic to piperacillin-tazobactam INFECTIONS
Natural Penicillins ✗
Anti-Staph Penicillins ✗
Aminopenicillins ✗
✓
Extended Spectrum Penicillins
(+) BL inhibitor
1st Generation cephalosporins ✗
2nd Generation cephalosporins ✗
 3rd Generation cephalosporins ✗
4th Generation cephalosporins ✗
5th Generation cephalosporins ✗

Matching type: Choose the most appropriate drug to give to a patient with Vasospastic CAD
A. Amlodipine
B. Verapamil
C. Isosorbide mononitrate
D. Any of the above
93 50-year-old, with ECG showing atrial fibrillation ● Vasospastic CAD or Coronary artery vasospasm B
with an average ventricular response of 100/min. ○ Important cause of chest pain syndromes that can lead to
BP 140/90 myocardial infarction (MI), ventricular arrhythmias, and sudden
94 60-year-old with a recent history of elevations in death A
BP of 150-160/100, PR 65/min ● #93. Verapamil
95 55-year-old non-hypertensive male, with the ○ Non-dihydropyridine CCB
C
following vital signs BP 120/80, PR 70/min ○ Used for atrial fibrillation/flutter (greatest suppression of AV
nodes)
● #94. Amlodipine
○ Dihydropyridine CCB
■ Vasoselective; Tend to act more on peripheral vessels than
on cardiac tissues
■ Have highest smooth muscle relaxation (more selective
vasodilators) and have lesser cardiac depressant effect than
Verapamil and Diltiazem
○ Long acting CCB
■ Provide smoother BP control and are more appropriate for
treatment of chronic HTN
● #95. Isosorbide mononitrate
○ Continued beyond 48 hrs
○ Prevention of recurrent angina

Sources:
https://emedicine.medscape.com/article/153943-overview#:~:text=Coronary%20artery
%20vasospasm%2C%20or%20smooth,the%20development%20of%20atherosclerotic
%20lesions.
PHARMA.S2.L04-ANTI-ANGINAL/ANTIPLATELETS/FIBRINOLYTICS/ANTICOAGULA
NTS/ANTI-HYPERLIPIDEMIC DRUGS, p. 5,6
PHARMA.S2.L02-ANTI-HYPERTENSIVE DRUGS, p. 12

96 Dennis Flores, M.D.

-1 UST-Hospital
00 8 567 8912

Patient: X December 13,

2022
Age/Sex: 50 y/o M
Manila

Captopril 25 mg/ tablet

#60

Label. Take 1 tablet orally every 12 hours for 30 days

No refills.

Dennis Flores, MD
PTR No. 12345
Lic No. 67890