Pharmacology

NBDE II Review
(Tufts)

Prepared by M.L. Thompson, Ph.D., Dept. of General Dentistry,

Tufts Dental School
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Pharmacology Board Review hypotensive shock) or to a specific agent such as prilocaine, which
causes methemoglobinemia.
2005 III. A 3rd class of questions are aimed at your knowledge of the
mechanism of action of local anesthetics: they prevent the generation
of nerve impulses by interfering with sodium transport into the neuron.
This list of questions and topics is the result of going through about 10
years worth of old Board Exams in Pharmacology, cutting out all the IV. The last most frequent type of question regarding local anesthetics
questions, categorizing them into topic areas (e.g. antibiotics, local has to do with issues regarding absorption of local anesthetics.
anesthetics, etc.), and then further grouping them into the type of Remember, only the non-ionized (or free base form) form can
information about a category of drugs that was being asked for. penetrate tissue membranes. Inflamed tissue has a lower than
When you do this, you see that many exams repeat questions normal pH, which decreases the amount of non-ionized form available
(sometimes they reword them a little bit to make them look to penetrate.
different!), but in actuality it is possible to get a feel for the various
facts that you are expected to know, and that there aren't that many V. Usually at least one question comes up asking you to calculate how
of them. As you go through this handout, you will see that I point out many mg of local anesthetic a patient has received, e.g. how many mg
to you the major facts that tend to get asked over and over again for of lidocaine in 1.8 ml of a 2% lidocaine solution? 2% lidocaine is 20
the various major drug categories, and I also give you actual gm/100 ml or 20 mg/1 ml, so 36 in 1.8 ml.
examples of questions (and the reworded versions), as well as the
correct answer. In many cases, I have written out a detailed
explanation of the answer, just to enlighten you further. So good
luck and enjoy. 1. Which of the following is a local anesthetic subject to inactivation by
plasma esterases?
The downside is that these questions are from old Board exams. Some of a. Procaine
the material is obviously dated, as drugs fall out of fashion, newer b. Lidocaine
drugs get used instead of older drugs, etc. At the beginning of each c. Prilocaine
section I will try to indicate some things that have changed and thus d. Mepivacaine
you may want to place less emphasis on some of the questions e. Bupivacaine
here.
(a) Proccaine is the only ester listed -- all the rest are amides
On a positive note, there used to be a separate pharmacology section of
100 questions. Nowadays, you might see 25-30 in some versions,
other versions less. Unfortunately, they still can draw from the realm 2. Procaine differs from lidocaine in that
of pharmacology so you gotta review it all. However, the good thing a. Procaine is a p-aminobenzoic acid ester and lidocaine is not
is that since they ask fewer questions, and since they are trying to b. Lidocaine is a meta-aminobenzoic acid ester and procaine is not
ask more clinically relevant stuff, if you really focus your efforts on c. The duration of action of procaine is longer than that of an equal
analgesics, antibiotics, and anesthetics, you should be covered for total dose of lidocaine
the majority of questions. d. Procaine hydrochloride is metabolized into diethylaminoethanol
and benzoic acid.
There are always going to be some random, unpredictable questions that
means you have to review more if you want to do really well. Maybe (a) this is basically a true-false type question. (a) is the only
you will luck out, and these will be the questions they are testing statement that is true
and they don’t count.

3. Which of the following local anesthetics would be expected to produce

a sensitization reaction in a patient allergic to lidocaine?
a. Mepivacaine
b. Tetracaine
Local Anesthetics c. Procaine
d. Prilocaine
I. The largest category of LA questions focuses on your ability to e. Dibucaine
distinguish amide LAs from esters: (This I hope is deemphasized,
since amide local anesthetics are used almost exclusively now) i. (a), (b) and (c)
ii. (a), (d) and (e)
iii. (b) and (c) only
esters = procaine, tetracaine, cocaine. All the rest are amides: lidocaine, iv. (b), (c) and (d)
mepivacaine, bupivacaine, prilocaine, dibucaine. They also require v. (b), (d) and (e)
you to know that amides are metabolized in the liver, esters mainly by
esterases in plasma. An infrequent question asks which class of
(ii) another ester vs. amide type identification question.
drugs has the most consistency in structure . LAs are the drug group
Lidoccaine is an amide, thus other amides will be cross-
most consistent in drug structure, because LAs are either amides or
allergenic - mepivacaine, prilocaine and dibucaine are the other
esters, differing only in their structure in the intermediate chain (its
amides listed. Procaine and tetracaine are esters and will not be
either an amide or an ester) that connects the aromatic group to the
cross-allergenic.
secondary or tertiary amino terminus.

II. The next category of questions has to do with toxic reactions to local
anesthetics, either due to high systemic levels of local anesthetics in 9. The hydrolysis of procaine occurs mainly in the
general (cardiovascular collapse due to myocardial depression, a. Liver

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b. Lungs
c. Plasma 14. Bupivacaine (Marcaine ) has all of the following properties relative to
d. Muscles lidocaine (Xylocaine ) EXCEPT bupivacaine
e. Kidneys a. Is more toxic
b. Is an ester-type local anesthetic
(c) procaine is an ester; esters are metabolized predominately c. Has a slower onset of action
by pseudocholinesterases in the plasma. d. Has a longer duration of action

(d) According to textbooks, local anesthetics fall into the

following classes in terms of duration of action: short: procaine;
10. Which of the following is local anesthetic subject to inactivation by
moderate: prilocaine, mepivacaine, lidocaine; long: bupivacaine,
plasma esterases?
tetracaine, etidocaine. Statements (a), 3, and 4 would be true if
a. Lidocaine
the question was comparing mepivacaine to bupivacaine, which
b. Prilocaine
are structurally similar; but the comparison is to lidocaine. The
c. Tetracaine
only difference that applies is duration of action ((d)),
d. Mepivacaine
bupivacaine is longer. (b) is wrong, both are amides.
e. Bupivacaine

(c) esters are metabolized by plasma esterases - tetracaine is

the only ester listed, all the rest are amides 15. Amide-type local anesthetics are metabolized in the
a. Serum
b. Liver
c. Spleen
11. The activity of procaine is terminated by d. Kidney
a. Elimination by the kidney e. Axoplasm
b. Storage in adipose tissue
c. Metabolism in the liver only
(b) don't forget: esters in plasma; amides in liver
d. Metabolism in the liver and by pseudocholinesterase in the
plasma
15. The duration of action of lidocaine would be increased in the presence
of which of the following medications?
(d) remember #9 above? see the word "mainly"? same a. Prazosin
question, but worded a little differently to throw you off. Again, b. Propranolol
procaine is an ester; esters are metabolized predominately by c. Hydrochlorothiazide
pseudocholinesterases in the plasma, but also to some extent d. Lisinopril
by esters in the liver. e. Digoxin

(b) this is an interaction I tested you on several times – now you

12. All of the following factors are significant determinants of the duration know why! Propranolol interacts with lidocaine in two ways.
of conduction block with amide-type local anesthetics EXCEPT the By slowing down the heart via beta receptor blockade, blood
a. pH of tissues in the area of injection delivery (and lidocaine) to the liver is reduced, thus lidocaine
b. Degree of vasodilatation caused by the local anesthetic remains in the systemic circulation longer, and can potentially
c. Blood plasma cholinesterase levels accumulate to toxic levels. Propranolol and lidocaine also
d. Blood flow through the area of conduction block compete for the same enzyme in the liver, thus metabolism of
e. Concentration of the injected anesthetic solution lidocaine can be reduced.

(c) the word "EXCEPT" should alert you that this is basically a 16. Severe liver disease least affects the biotransformation of which of
true-false type question with 4 true statements and 1 false the following?
statement; you just have to figure out which one! In this case, a. Lidocaine
you just have to remember that plasma cholinesterase levels b. Procaine
are only important for the duration of action of ester-type LAs, c. Prilocaine
not amides, which are metabolized in the liver. All the other d. Mepivacaine
statements are variables which affect duration of the block, but
apply to both esters and amides. (b) Answer is (b)- You should be able to recognize that all of
these drugs are local anesthetics. Local anesthetics are of one
of two types, either esters or amides. Ester types are subject to
hydrolysis in the plasma and thus have short half lives. Amides
13. Which of the following is contraindicated for a patient who had an are metabolized primarily in the liver and have longer half lives.
allergic reaction to procaine six months ago? Thus the biotransformation (e.g., metabolism; again, the rats are
a. Nerve block with lidocaine using a different word to confuse you, even though they are
b. Topical application of lidocaine asking the same basic question) of an amide type local
c. Topical application of tetracaine anesthetic would be the most altered in the presence of sever
d. Infiltration with an antihistamine liver disease. The key word here is "least". Of the drugs listed,
only procaine is an ester. The rest are amides.
(c) again, just another question that requires you to be able to
pick out an ester or an amide from a list. Since procaine is an
ester, only another ester LA would be cross-allergenic. In this
list the only ester listed is tetracaine. Questions regarding toxicity:

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17. A patient has been given a large volume of a certain local anesthetic
solution and subsequently develops cyanosis with 20. The first sign that your patient may be experiencing toxicity from too
methemoglobinemia. Which of the following drugs most likely was much epinephrine would be
administered? a. Cardiovascular collapse
a. Procaine b. Convulsions
b. Prilocaine c. Elevated pulse rate
c. Dibucaine d. Slurred speech
d. Lidocaine
e. Mepivacaine (c) it is a sympathomimetic after all. All the other reactions are
related to elevated lidocaine levels
(b) strictly memorization
20. Which disease condition would make the patient most sensitive to the
epinephrine in the local anesthetic?
a. Grave’s disease
18. Use of prilocaine carries the risk of which of the following adverse b. Diabetes
effects? c. HIV
a. Porphyria d. Alcoholism
b. Renal toxicity e. Schizophrenia
c. Gastric bleeding
d. Methemoglobinemia (a) Grave’s disease is an autoimmune disease that causes
hyperthyroidism – the resulting high levels of circulating thyroid
(d) same as above but asked backwards. Methemoglobinemia hormone result in a hypermetabolic state with heightened
may result from a toluidine metabolite of prilocaine, sympathetic activity, which combined with injected epinephrine
orthotoluidine. could result in a hypertensive crisis.

21. Cardiovascular collapse elicited by a high circulating dose of a local

anesthetic may be caused by
19. The most probable cause for a serious toxic reaction to a local a. Syncope
anesthetic is b. Vagal stimulation
a. Psychogenic c. Histamine release
b. Deterioration of the anesthetic agent d. Myocardial depression
c. Hypersensitivity to the vasoconstrictor e. Medullary stimulation
d. Hypersensitivity to the local anesthetic
e. Excessive blood level of the local anesthetic
(d) Cardiovascular collapse is due to a direct action of the local
anesthetic on the heart muscle itself (LA's in toxic doses
(e) Most toxic reactions of a serious nature are related to depress membrane excitability and conduction velocity), thus
excessive blood levels arising from inadvertent intravascular (d) is the correct answer. All of the other alternatives are indirect
injection. Hypersensitivity reactions (options b & c) are rare, but ways to affect the heart.
excessive blood levels will induce toxic reactions like CNS
stimulation in most everyone. This is a case where option (e) is
the "best" answer, because it is more likely than the other
alternatives, which might be true, but are not as likely (e.g, 22. The most serious consequence of systemic local anesthetic toxicity is
“most probable”) to happen. a. Vertigo
b. Hypertension
c. Hyperventilation
20. High plasma levels of local anesthetics may cause d. Post depressive central nervous system convulsions
a. Inhibition of peristalsis e. Postconvulsive central nervous system depression
b. stimulation of baroreceptors resulting in severe hypotension
c. Inhibition of the vagus nerve to the heart (e) Of the options listed, this is the one that will kill the patient,
d. Depression of inhibitory neurons in the CNS which I guess makes it the most serious.

(d) Initially LAs inhibit central inhibitory neurons, which results in

CNS stimulation, which can proceed to convulsions. At higher 23. Hypotensive shock may result from excessive blood levels of each of
doses, they inhibit both inhibitory and excitatory neurons, the following local anesthetics EXCEPT
leading to a generalized state of CNS depression which can a. Cocaine
result in respiratory depression and death. b. Procaine
c. Lidocaine
20a. Unfortunately, you injected your lidocaine intra-arterially. The first d. Tetracaine
sign of lidocaine toxicity that might be seen in the patient would be e. Mepivacaine
a. Elevated pulse rate
b. Sweating (a) All the listed local anesthetics except cocaine are
c. CNS excitation vasodilators, especially ester-ctype drugs such as proccaine
d. Cardiovascular collapse and the amide lidocaine. Cocaine is the only local anesthetic
e. CNS depression that predictably produces vasoconstriction. Cocaine is also the
only local anesthetic to block the reuptake of NE into adrenergic
(c) same question as above just worded differently. The intra- neurons, and thus potentiate the NE that has been released
arterial injection would result in the high plasma levels from nerve endings
mentioned in the previous question.

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Questions regarding pH effects on absorption of local anesthetics

24. Which of the following anesthetic drugs produces powerful
stimulation of the cerebral cortex? 30. If the pH of an area is lower than normal body pH, the membrane
a. Cocaine theory of local anesthetic action predicts that the local anesthetic
b. Procaine activity would be
c. Lidocaine a. Greater, owing to an increase in the free-base form of the drug
d. Tetracaine b. Greater, owing to an increase in the cationic form of the drug
e. Mepivacaine c. Less, owing to an increase in the free-base form of the drug
d. Less, owing to a decrease in the free-base form of the drug
(a) see explanation above e. None of the above

(d) the next three or four questions are all versions of the same
thing – see the explanation below
Questions regarding mechanism of action:

31. A local anesthetic injected into an inflamed area will NOT give
25. Local anesthetics block nerve conduction by
maximum effects because
a. Depolarizing the nerve membrane to neutrality
a. The pH of inflamed tissue inhibits the release of the free base
b. Increasing membrane permeability to K+
b. The drug will not be absorbed as rapidly because of the
c. Increasing membrane permeability to Na+
decreased blood supply
d. Preventing an increase in membrane permeability to K+
c. The chemical mediators of inflammation will present a chemical
e. Preventing an increase in membrane permeability to Na+
antagonism to the anesthetic
d. Prostaglandins stabilize the nerve membrane and diminish the
(e) didn’t I make you memorize this? You should at keast effectiveness of the local anesthetic
remember Na+ ions are involved, which limits your choices to
(c) and (e). (c) would increase or facilitate nervous impulse
(a) while some of the other alternatives sound plausible, think
conduction, which is the opposite of what you want the local
about the factoids you were taught about local anesthetics and
anesthetic to do, so pick (e).
variables that affect their action. An important one was the role
of pH and ionization factors. Remember, the free base or
nonionized form is the form that passes through membranes,
26. Which of the following is true regarding the mechanism of action of yet once inside the neuron only the ionized form is effective.
local anesthetics? Inflamed tissue has a lower pH than normal tissue and will shift
a. Usually maintain the nerve membrane in a state of the equilibrium of the LA solution such that most of it remains
hyperpolarization ionized and thus unavailable to penetrate
b. Prevent the generation of a nerve action potential
c. Maintain the nerve membrane in a state of depolarization
d. Prevent increased permeability of the nerve membrane to
32. The penetration of a local anesthetic into nervous tissue is a function
potassium ions
of the
e. Interfere with intracellular nerve metabolism
a. Length of the central alkyl chain
b. Lipid solubility of the ionized form
(b) this should be really obvious! c. Lipid solubility of the unionized form
d. Ester linkage between the aromatic nucleus and the alkyl chain
e. Amide linkage between the aromatic nucleus and the alkyl chain
27. Local anesthetic agents prevent the generation of nerve impulses by
a. Decreasing threshold for stimulation (c) only options (b) and (c) are relevant here - the others have
b. Decreasing resting membrane potential nothing to do with LA penetration into membranes. Membrane
c. Decreasing inward movement of sodium ion permeability is affected by whether or not the molecule is
d. Increasing inward movement of potassium ion “charged” or ionized or not (e.g., unionized). Only the latter form
passes readily through membranes. See, they’re asking the
(c) Answer is (c)- straight memorization- nerve impulses are same thing they asked in the previous question, just coming at it
generated by the influx of sodium resulting in depolarization. from another angle. Remember the fact and you can cover the
repolarization and inactivity occurs when potassium moves out. angles.
(sodium-potassium pump). LAs act by blocking Na+ movement.

35. At a pH of 7.8, lidocaine (pKa = 7.8) will exist in

a. the ionized form
28. Local anesthetics interfere with the transport of which of the following b. the nonionized form
ions during drug-receptor interaction c. an equal mixture of ionized and nonionized forms
a. Sodium d. a mixture 10 times more ionized than nonionized forms
b. Calcium
c. Chloride (c) the ratio of ionized to unionized forms is given by the
d. Potassium formula log A/AH= pH-pKa. In this instance the difference
e. Magnesium between pH and pKa is 0. Thus lidocaine will exist as an equal
mixture ( so (c) is correct). Most local anesthetics are weak
(a) see how many different ways they can ask the same bases with pKa ranging from 7.5 to 9.5. LA’s intended for
question? injection are usually prepared in salt form by addition of HCl.
They penetrate as the unionized form into the neuron where
they re-equilibrate to both charged and uncharged forms inside

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the neuron - the positively charged ion blocks nerve conduction. f. 600 mg. lidocaine, 0.03 mg. epinephrine

(d) 2% lidocaine = 20 mg/ml x 3 = 60 mg lidocaine

33. The more rapid onset of action of local anesthetics in small nerves is 1:100,000 epi = 0.01 mg/ml x 3 = 0.03 mg epi
due to
a. The slightly lower pH of small nerves
b. The greater surface-volume ratio of small nerves
37. The maximum allowable adult dose of mepivacaine is 300 mg. How
c. The increased rate of penetration resulting from depolarization
many milliliters of 2% mepivacaine should be injected to attain the
d. Smaller nerves usually having a higher threshold
maximal dosage in an adult patient?
a. 5
Who knows? Who cares? probably the answer is (b) - the theory b. 10
goes that there is a size dependent critical length of c. 15
anesthetic exposure necessary to block a given nerve. Small d. 20
fibers will be blocked first because the anesthetic e. 25
concentration to h critical length in a small fiber will be reached
faster than the critical length in a larger fiber. You have to
(c) 2% mepivacaine = 20 mg/ml, so 300 mg / 20 mg/ml = 15 ml
block three nodes of ranvier, and they are farther apart in
larger fibers than they are in small diameter fibers. Make
sense?
38. A recently introduced local anesthetic agent is claimed by the
manufacturer to be several times as potent as procaine. The product
is available in 0.05% buffered aqueous solution in 1.8 ml. cartridge.
34. Which of the following statements are true regarding onset, degree
The maximum amount recommended for dental anesthesia over a 4-
and duration of action of local anesthetics?
hour period is 30 mg. The amount is contained in approximately how
a. The greater the drug concentration, the faster the onset and the
many cartridges?
greater the degree of effect
a. 1-9
b. Local anesthetics block only myelinated nerve fibers at the nodes
b. 10-18
of Ranvier
c. 19-27
c. The larger the diameter of the nerve fiber, the faster the onset of
d. 28-36
effect
e. Greater than 36
d. The faster the penetrance of the drug, the faster the onset of
effect
(d) 0.05% = 0.5 mg/ml . To give 30 mg, you have to give
i. (a), (b), and (c) 30mg/0.5 mg/ml or 60 ml. 1 cartridge = 1.8 ml, thus 60ml /1.8ml
ii. (a), (b) and (d) = 33.3 cartridges. - first express the percentage of solution as a
iii. (a) and (c) only fraction of 100, then add the units gm/ml. 0.05% equals 0.5 or
iv. (b), (c) and (d) 1/2 gms per 100 ml. The cartridge is 1.8 ml which you can
round off to almost 2 mls total. In this 2 ml you would have 1 gm
of the local anesthetic. You need to give 30 gms, which would
(ii) if you knew the fact above about small nerves, then this
require 30 cartridges. The alternative that meets this answer is
question basically becomes a true false type thing, and (c) is the
(d). Don't get tricked by the placement of the decimal point-
false statement. (a) and (d) make logical sense so you are
many people read the 0.05% as being the same as 5 gms
stuck picking between (b) and (c). You have your pick of
rather than 0.5 gms.
memorizing the small nerve thing or the myelinated nerve nodes
of ranvier thing.
39. According to AHA guidelines, the maximum # of carpules of
And now, for those of you that complained in class “do we really local anesthetic containing 1:200,000 epinephrine that can be used
have to know this stuff?” in the patient with cardiovascular disease is
a. 1
35. A dentist administers 1.8 ml of a 2% solution of lidocaine. How many b. 2
mg of lidocaine did the patient receive? c. 3
a. 3.6 d. 4
b. 9 e. 11
c. 18
d. 36 (d) the AHA limit is 0.04 mg, compared to 0.2 mg in the healthy
e. 180 patient. 1:200,000 equals 0.005 mg/ml or 0.009 per 1.8 ml
carpule. 4 carpules would thus contain 0.036 mg, which is just
(d) 2% solution = 20 mg/ml X 1.8 ml = 36 mg lidocaine. And below the 0.04 mg limit
you thought you would never have to do this stuff again!

Antibiotics
36. Three ml of a local anesthetic solution consisting of 2% lidocaine with
1:100,000 epinephrine contains how many milligrams of each? 1. The most frequently asked type of question requires you to be able to
a. 6 mg. lidocaine, 0.3 mg. epinephrine compare various penicillin antibiotics in terms of potency against
b. 6 mg. lidocaine, 0.03 mg. epinephrine certain bugs, allergenicity, drug of choice against certain conditions,
c. 60 mg. lidocaine 0.3 mg. epinephrine etc. For example:
d. 60 mg. lidocaine 0.03 mg epinephrine
e. 600 mg lidocaine, 0.3 mg. epinephrine

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a. Penicillin V vs. penicillin G: the latter is more sensitive to acid Examples Of Dental Procedures That Require Prophylaxis
degradation and thus is usually injected rather than taken And Some That Don’t
orally (Certainly no one in dentistry uses Pen G, so I
would think they would not use too many of these (According to AHA 1997 Guidelines. Caveat: our clinic
questions) guidelines, should they differ from these, are also
considered correct answers)
b. Which penicillin has the best gram-negative spectrum:
ampicillin Required Not Required

c. Which drugs from a list are or are not cross-allergenic with Extractions Restorative Procedures
penicillin: most usually asked about ones are: cephalosporins
Periodontal Surgery Intracanal endodontic treatment
and ampicillin are, erythromycin isn't
d. Which penicillin is useful against penicillinase-producing bugs Implants Taking Of Impressions
such as staphylococcus: dicloxacillin
e. Which is specific for Pseudomonas infections: an extended
spectrum such as carbenicillin Common Prescription Regimens For Treating An Infection:
f. Which combination of agents should be used prophylactically Penicillin VK 250-500mg, dispense 30, take 2 tablets at once*,
for patient with heart valve to prevent bacterial endocarditis: then 1 tab every 6 hrs until gone (7 days)
ampicillin and gentamycin (1988- according to latest *some sources do not indicate loading
recommendation of AHA and ADA, although use the latest dose, so dispense 28, take 1 q6h until
guidelines that you have heard about)) (here’s a big change gone
obviously, since combinations are no longer used, and
neither are doses given before and after treatment – Kids (less than 12 yrs): 20-50 mg/kg qid
review your latest prophylaxis guidelines)
Clindamycin 150-300 mg, dispense 21, take 1 capsule every 8
hrs until gone (7 days)
Prophylaxis Regimens For SBE (AHA 1997 Guidelines)
Kids: 8-12 mg/kg tid or qid
1st choice: Amoxicillin: 2 g (4 X 500 mg), PO 1 hr before
treatment. # of pills to be dispensed depends on # of Amoxicillin 500 mg, dispense, 21, take 1 capsule every 8 hrs
appointments Children: 50 mg/kg 1 hr prior until gone (7 days)
Kids (under 20 kg): 20-40 mg/kg tid
For PCN allergic: Clindamycin: 600 mg (4 X 150 mg)
PO 1 hr before treatment. . # of pills to be dispensed
depends on # of appointments

non-oral: 2. The 2nd largest category expects you to know the mechanism of
Ampicillin IV/IM 2 g, 1/2 hr before (Kids: 50 mg/kg) action of the various antibiotics:
Clindamycin (for PCN-allergic) 600 mg IV 1/2 hr prior, a. Bactericidal agents such as penicillin kill rapidity growing cells by
kids (20 mg/kg) inhibiting cell wall synthesis

Prophylaxis for the patient with a prosthetic joint b. Bacteriostatic agents such as tetracycline limit population
growth, but do not kill bugs by interfering with protein synthesis
Keflex, 2 g, (4 X 500mg), PO 1 hr before treatment . # of on bacterial ribosomes
pills to be dispensed depends on # of appointments
c. Antifungals such as nystatin bind to ergosterol in fungal cell
walls to weaken the wall
Examples of patient cardiovascular conditions that
require prophylaxis and some that don’t d. Bacteriostatic agents such as the sulfonamides compete with
(AHA 1997 Guidelines) PABA in folic acid synthesis, thus resulting in folic acid
deficiency
Prophylaxis Prophylaxis Not Required
Required
Prosthetic valves Cardiac pacemakers
3. Many questions are asked regarding side effects or toxicities of
penicillins, tetracyclines, clindamycin, etc:

Previous Rheumatic fever without valvular a. What are symptoms seen during allergic reactions to penicillins:
endocarditis dysfunction dermatitis, stomatitis, bronchoconstriction and cardiovascular
collapse
Pulmonary Mitral valve prolapse without
shunts valvular regurgitation b. What agent produces GI upset and pseudomonas colitis:
clindamycin
c. Which agents are most likely or least likely to cause
superinfection: most: broad spectrum agents such as
tetracyclines; least: narrow spectrum agents such as penicillin G
d. Aplastic anemia is associated with chloramphenicol
e. Liver damage or hepatotoxicity is associated with tetracycline
f. Erythromycin estolate associated with allergic cholestatic

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hepatitis
8 The principal difference among potassium, procaine and benzathine
salts of penicillin G is their
a. Potency
4. Questions involving interactions between antibiotics and other drugs:
b. Toxicity
a. Tetracycline and penicillin (cidal-static interaction)cancel each c. Duration of action
other out due to opposing mechanisms of action d. Antibacterial spectrum
e. Diffusion into the cerebrospinal fluid
b. Probenecid alters the rate of renal clearance of penicillin
c. Effectiveness of tetracyclines is reduced by concurrent (c) again, just asking you to know something about the various
ingestion of antacids or dairy products forms of penicillin. Since in most cases you are going to use Pen
VK orally, this question is an old one showing its age and probably
d. Broad spectrum antibiotics enhance the action of coumarin not likely to appear anymore on board excams
anticoagulants because of the reduction of Vitamin K sources
e. Antibiotics such as ampicillin decrease the effectiveness of
oral contraceptives due to suppression of normal Gl flora
involved in the recycling of active steroids from bile conjugates, 11. Which of the following antibiotics is cross-allergenic with penicillin
leading to more rapid excretion of the steroids from the body and should NOT be administered to the penicillin-sensitive patient?
a. Ampicillin
f. Macrolides such as erythromycin inhit the metabolism of drugs b. Erythromycin
such as seldane, digoxin, etc. c. Clindamycin
d. Lincomycin
e. Tetracycline
5. More and more questions these days are being asked about
antivirals and antifungals, so review (a) ampicillin sort of sounds like penicillin so it must be the
answer
a. Acyclovir: an antiviral used for various forms of herpes
b. Fluconazole or ketoconazole: systemic-acting antifungals
useful for treating candidiasis 12. Which of the following antibiotics may be cross-allergenic with
penicillin?
a. Neomycin
Frequently asked questions on antibiotics:
b. Cephalexin
c. Clindamycin
5. For treating most oral infections, penicillin V is preferred to penicillin G
d. Erythromycin
because penicillin V
e. All of the above
a. Is less allergenic
b. Is less sensitive to acid degradation
(b) This is a memorization question, with (b) the correct
c. Has a greater gram-negative spectrum
answer. You have to remember that the cephalosporins (like
d. Has a longer duration of action
cephalexin) are chemically related to the penicillins. The others
e. Is bactericidal, whereas penicillin G is not
are not chemically related and thus cross-allergenicity is unlikely
(b) memorization: basically the only difference
13. Which of the following antibiotics shows an incidence of
approximately 8% cross-allergenicity with penicillins?
6. The sole therapeutic advantage of penicillin V over penicillin G is
a. neomycin
b. cephalexin
a. Greater resistance to penicillinase
c. bacitracin
b. Broader antibacterial spectrum
d. vancomycin
c. More reliable oral absorption
e. tetracycline
d. Slower renal excretion
e. None of the above
(b) just slightly reworded version of the above question, but with
some different alternatives thrown in. Obviously, if you can
(c) reworded version of the above
recognize whther or not a drug is a penicillin or a cephalosporin ,
and you remember that these are the classes that show cross-
7. Which of the following penicillins is administered ONLY by deep
allergenicity, then you can handle any rewording of this question.
intramuscular injection?
a. Ampicillin
b. Dicloxacillin sodium
14. Which of the following groups of antibiotics is related both structurally
c. Penicillin G procaine
and by mode of action to the penicillins?
d. Penicillin V potassium
a. Polymyxins
b. Cycloserines
(c) Answer is (c)- (a), (b) and (d) are all used orally. Penicillin G
c. Cephalosporins
is destroyed by acid in the stomach resulting in variable and
d. Chloramphenicols
irregular absorption. Penicillin V is acid stable and available for
oral use. Penicillin G procaine is typically given intramuscularly
(c) see above
in repository form, yielding a tissue depot from which the drug is
absorbed over hours. In this form, it cannot be given IV or
subcutaneously.
13. For the dentist, the most reliable method of detecting a patient's
allergy to penicillin is by

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a. Injecting penicillin intradermally (b) didn’t they just ask the same thing in the question above?
b. Taking a thorough medical history
c. Placing a drop of penicillin on the eye
d. Having the patient inhale a penicillin aerosol 18. Which of the following antibiotics should be considered the drug of
e. Injecting a small amount of penicillin intravenously choice in the treatment of infection caused by a penicillinase-
producing staphylococcus?
(b) all of the other methods involve unacceptable risk. Once a. Neomycin
sensitized, even a small amount can cause an allergic b. Ampicillin
response. Remember, it is not a dose-related response that c. Tetracycline
won’t be problematic if you only inject a little bit. d. Penicillin V
e. Dicloxacillin

14. Which of the following antibiotics is the substitute of choice for (e) that’s really the only use for dicloxacillin
penicillin in the penicillin-sensitive patient?
a. Bacitracin
b. Erythromycin 19. Oral infections caused by organisms that produce penicillinase
c. Tetracycline should be treated with
d. Chloramphenicol a. Ampicillin
b. Dicloxacillin
(b) boy, if you haven’t heard this a zillion times by now.. None of c. Erythromycin
the alternatives listed would be a problem in terms of cross- d. Any of the above
allergenicity, but the reason (b) is the right answer is that the e. Only (a) or (c) above
spectrum of activity of erthromycin is very similar to penicillin. The
others offer a much broader spectrum of coverage than we usually (b) of those listed only (b) is penicillinase resistant. Ampicillin is an
require; always use the drug with the narrowest spectrum possible extended spectrum penicillin, and is not penicillinase resistant.
that includes the microbe in question. Standards have now Erythromycin shouldn’t be affected by penicillinases, since it isn’t a
changed such that clindamycin is the drug of choice in this peniciilin, but it doesn’t work against staph for other reasons.
situation. But if they don’t include clindamycin, look for
erythromycin, or for that matter Azithromycin
20. Which of the following antibiotics is LEAST effective against
penicillinase-producing microorganisms?
15. Most anaphylactic reactions to penicillin occur a. Ampicillin
a. When the drug is administered orally b. Cephalexin
b. In patients who have already experienced an allergic reaction to c. Methicillin
the drug d. Clindamycin
c. In patients with a negative skin test to penicillin allergy e. Erythromycin
d. When the drug is administered parenterally
e. Within minutes after drug administration (a) same question asked backassward

i. (a), (b) and (d) 21. Which of the following is a bactericidal antibiotic used specifically in
ii. (b), (c) and (d) the treatment of infections caused by Pseudomonas species and
iii. (b), (d) and (e) indole-positive Proteus species?
iv. (b) and (e) only a. Ampicillin
v. (c), (d) and (e) b. Penicillin V
c. Tetracycline
(iii) memorize d. Dicloxacillin
e. Carbenicillin

16. Which of the following penicillins has a broader gram-negative (e) Wow, I bet you didn’t think they would ask something like
spectrum than penicillin G? this!. An extended spectrum agent is required. Ampicillin is
a. Nafcillin ineffective, while Pen-V is too narrow in spectrum.
b. Ampicillin
c. Cephalexin
d. Methicillin 22. Penicillin's effectiveness against rapidly growing cells is primarily due
e. Penicillin V to its effect on
a. Protein synthesis
(b) that’s why it is considered an “extended-spectrum” form of b. Cell wall synthesis
penicillin c. Nucleic acid synthesis
d. Chelation of metal ions
e. Cell membrane permeability
17. Which of the following penicillins has the best gram-negative
spectrum? (b) memorize, memorize
a. Nafcillin
b. Ampicillin
c. Methicillin 23. Chlortetracycline acts by interfering with
d. Penicillin V a. Cell wall synthesis
e. Phenethicillin b. Nuclear acid synthesis
c. Protein synthesis on bacterial but not mammalian ribosomes

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d. Protein synthesis on mammalian but not bacterial ribosomes c. Tetracycline

d. Cephalosporins
(c) that’s why it is selectively toxic. Wouldn’t you like it if your e. Amphotericin B
doctor prescribed a drug for you that did (d)?
(c) (a) streptomycin can damage the eighth nerve, affecting
both balance and hearing, but is not associated with liver
24. The probable mechanism of the bacteriostatic action of sulfonamides damage. (b) other than allergic reactions, penicillins are
involves extremely safe, with no effect on the liver. (d) the
a. Disruption of the cell membrane cephalosporins are chemically related to the penicillins and
b. Coagulation of intracellular proteins share their relatively nontoxic nature. (e) amphotericin B, is an
c. Reduction in oxygen utilization by the cells antifungal agent that produces such adverse side effects as
d. Inhibition of metabolism by binding acetyl groups nephrotoxicity and hypokalemia, but not liver toxicity. Thus (c) is
e. Competition with para-aminobenzoic acid in folic acid synthesis the correct answer. Tetracyclines have been shown to be
hepatotoxic following high doses in pregnant patients with a
(e) memorize history of renal disease.

25. The sulfonamides act by 29. Which of the following erythromycins associated with an allergic
a. Suppressing bacterial protein synthesis cholestatic hepatitis?
b. Inhibiting the formation of the cytoplasmic bacterial membrane a. Erythromycin base
c. Inducing the formation of "lethal" bacterial proteins b. Erythromycin stearate
d. Inducing a deficiency of folic acid by competition with para- c. Erythromycin estolate
aminobenzoic acid d. Erythromycin succinate

(d) same as above worded differently (c) just because

26. Which antibiotic is able to achieve a higher concentration in bone 30. Which of the following antibiotics is LEAST likely to cause
than in serum? superinfection?
a. penicillin a. Gentamicin
b. erythromycin b. Tetracycline
c. clindamycin c. Penicillin G
d. metronidazole d. Streptomycin
e. amoxicillin e. Chloramphenicol

(c) that’s why it is very useful for treating bone infections such (c) superinfections are usually seen following the use of broad
as osteomyelitis. The question might have substituted gingival spectrum agents. Of those listed, all are wide spectrum except
fluid for bone – that would make the answer tetracycline Pen-G

27. Tetracycline reduces the effectiveness of concomitantly administered 31. Gastrointestinal upset and pseudomembranous colitis has been
penicillin by prominently associated with
a. Reducing absorption of penicillin a. Nystatin
b. Increasing metabolism of penicillin b. Cephalexin
c. Increasing renal excretion of penicillin c. Clindamycin
d. Increasing binding of penicillin to serum proteins d. Polymyxin B
e. None of the above e. Erythromycin

(e) tetracycline is bacteriostatic and would slow the rapid (c) The only 2 possibilities that produce GI upset are (c) and
growth of the microbial population that a bactericidal drug such (e). As for producing colitis, (b) and (c) are associated with this
as penicillin needs to be effective, sine only when rapidly adverse side effect. (c) is the only drug which does both,
dividing are the cells making cell walls therefore it's the right answer.

37. The action of which of the following drugs will most likely be impaired
by concurrent administration of tetracycline? 32. Symptoms that may be characterized as allergic manifestations
a. Clarithromycin during penicillin therapy are
b. Erythromycin a. Deafness, dizziness and acute anemia
c. Sulfonamide b. Crystalluria, nausea, vomiting and anaphylactic shock
d. Penicillin c. Oliguria, hematuria, bronchoconstriction and cardiovascular
e. Lincomycin collapse
d. Dermatitis, stomatitis, bronchoconstriction and cardiovascular
(d) the classic cidal- static interaction! See above, since this is collapse
just a reworded version of the same fact
(d)

28. Which of the following antibiotics is most likely to cause liver

damage? 33. Aplastic anemia is a serious toxic effect that occurs particularly after
a. Streptomycin a course of treatment with which of the following antibiotics?
b. Penicillin G a. Penicillin

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b. Lincomycin the antibiotics to avoid during pregnancy.

c. Tetracycline
d. Streptomycin
e. Chloramphenicol 39. Which of the following has the broadest antimicrobial spectrum?
a. Vancomycin (Vancocin )
(e) memorize b. Clindamycin (Cleocin )
c. Erythromycin (Erythrocin )
d. Chlortetracycline (Aureomycin )
34. Each of the following is a side effect of prolonged tetracycline e. A third generation cephalosporin
hydrochloride therapy EXCEPT:
a. Suprainfection (d) Answer is (d)- remember, tetracyclines are broad spectrum
b. Photosensitivity antibiotics effective against both gram-negative and gram-
c. Vestibular disturbances positive cocci and bacilli. Clindamycin has a spectrum of activity
d. Discoloration of newly forming teeth similar to erthyromycin and vancomycin, which is less than that
e. Gastrointestinal symptoms (when administered orally) of the tetracylines, mainly affecting gram-positive
microorganisms. Ist generation cephalosporins are effective
(c) memorize against both gram-negative and gram-positive organisms, but
the third generation ones have increased activity against gram-
negative but greatly decreased activity against gram-positive
microorganisms.
36. Colitis that results following clindamycin therapy is caused by an
overgrowth of
a. C. dificile 40. Sulfonamides and trimethoprim are synergistic bacteriostatic agents
b. Staph aureus because in bacteria they
c. Pseudomonas a. Both inhibit folic acid synthesis
d. Candida albicans b. Interfere sequentially with folinic acid production
c. Are both antimetabolites of para-aminobenzoic
(a) memorize d. Are both inhibitors of dihydrofolic acid reductase
e. Are both transformed in vivo into a single active compound
Antibiotics, Miscellaneous
(b)
37. Which antibiotic is appropriate for premedication in the penicillin
allergic patient?
a. Cephalexin 41. Which of the following substances is the most effective agent against
b. Clindamycin fungus infections of the mucous membrane?
c. Erythromycin a. Nystatin ointment
d. Amoxicillin b. Undecylenic acid
e. Ampiciilin c. Polymyxin ointment
d. Saturated magnesium sulfate
(b) clindamycin is the current recommendation. Erythromycin e. 10 per cent aluminum chloride solution
used to be, so if you get a question that doesn’t include
clindamycin as an answer, look for erythromycin. Cephalexin (a)
might be a choice, but there is the issue of cross-allergencicity,
and it must certainly be avoided in the anaphylactic patient. 42. The most desirable property of an antibiotic when used to treat an
Amoxicillin and ampicillin are penicillins! odontogenic infection is
a. Rapid absorption
38. Acyclovir is useful for treating b. Little allergenicity
a. Candidiasis c. Ability to achieve and maintain adequate concentrations at the
b. Colitis site of infection
c. Herpes simplex d. Lack of significant binding to plasma proteins
d. HIV e. No effects on drug metabolism
e. ANUG
(c) if it can’t do this it isn’t going to be very effective.
(c) always think used for herpes as the first answer

14. Nystatin is of greatest clinical usefulness in treating

a. viral infections
b. fungal infections
38. A distinct advantage that tetracyclines have over penicillins is that c. spirochetal infections
tetracyclines d. Bacterroides infections
a. Have no side effects e. penicillin resistant gram positive infections
b. Do not cause superinfections
c. Are safer to use during pregnancy
d. Have a wider range of antibacterial activity (b) Nystatin is the prototypic antifungal agent, thus (b) is the
e. Produce higher blood levels faster after oral administration most obvious 1st choice, and eliminates (a). (d) & (e) require an
antibiotic, not an antifungal
(d) broad spectrum vs. narrow spectrum. Tetracyclines certainly
have more side effects than penicillin, and are certainly one of
42. Which of the following drugs chelates with calcium?

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a. Erythromycin d. alteration in the rate of renal clearance

b. Polymyxin B
c. Tetracycline Answer is (d)- penicillin is metabolized in the liver, but it rapidly
d. Penicillin G disappears from the blood due to rapid clearance by the
e. Chloramphenicol kidneys. 90% is excreted by tubular secretion. Thus patients
with renal disease will show high blood levels of penicillin.
(c) Similarly, probenicid, a uricosuric agent (a drug which tends to
enhance the excretion of uric acid by reducing renal tubular
transport mechanisms), reduces the renal clearance of
43. Which of the following is NOT characteristic of tetracycline penicillins. And you wondered why we had those lectures on
antibiotics? pharmacokinetics!
a. Absorption is impaired when taken with antacids
b. They predispose to monilial superinfection
c. They form a stable complex with the developing tooth matrix 45. When broad-spectrum antibiotics are administered with coumarin
d. They have a low tendency for sensitization, but a high anticoagulants, the anticoagulant action may be
therapeutic index a. Reduced because of enhanced hepatic drug metabolism
e. They are effective substitutes for penicillin prophylaxis against b. Reduced because of increased protein-binding
infective endocarditis c. Increased because of reduction of vitamin K sources
d. Increased because of decreased renal excretion of the
Answer is (e)- Again, the important phrase in the question is not anticoagulant
(Hey, just Wayne and Garth). Obviously the fact that you will
remember about tetracylines is that they can discolor teeth in (c)
the fetus when taken by the mother during pregnancy. But don't
circle that answer because (a) is also characteristic of
tetracyclines (they are the most likely of all the antibiotics to 46. The therapeutic effectiveness of which of the following drugs will be
cause superinfection), and is an annoying side effect in adults most affected by concomitant ingestion of antacids?
resulting from alteration of the oral, gastric and intestinal flora. a. Cephalexin
The real answer is (e). Tetracyclines are not the drug of choice b. Erythromycin
for prophylaxis against infective endocarditis. This is due to c. Tetracycline
streptococcal infection. 15-20% of group A streptococci are d. Sulfisoxazole
resistant to tetracyclines, but none are resistant to penicillin or e. Penicillin V
erythromycin. Recently a non-streptococcal induced subacute
bacterial endocarditis has been identified, especially in juvenile (c) hey, I asked you this on the exam!
periodontitis patients. The causative bacterium is not
susceptible to penicillin or erythromycin. It may be necessary to 47. Erythromycin should be avoided in the patient taking
treat predisposed patients with tetracycline for a few weeks, and a. Aspirin
then follow this with a course of penicillin or erythromycin. b. Seldane
Remember that these drugs are antagonistic to each other and c. Benadryl
thus can't be used concurrently. Penicillin is a bactericidal drug d. Ibuprofen
which kills or destroys microorganisms by interfering with the e. Propranolol
synthesis or function of the cell wall, cell membrane or both.
Thus it is most effective against bacteria that are multiplying. (b) remember the famous erythromycin –Seldane potentially
Tetracycline is a bacteriostatic antibiotic that acts by inhibiting lethal interaction, whereby erythromycin blocks the metabolism
the growth and multiplication of organisms by inhibiting protein of Seldane to its antihistamine metabolite – it stays
synthesis by binding reversibly to the 30 S subunit of the unmetabolized and causes cardiac arrthymias. Of course this
bacterial ribosome. When the two types are given together, their question could have many other options listed, since
effectiveness is negated or reduced. erythromycin decreases the metabolism of so many other
useful drugs, such as digoxin.

Antibiotics, Drug Interactions

44. The concurrent administration of penicillin G and probenecid results

in
a. Increased metabolism of penicillin G.
b. Increased renal excretion of probenecid
c. Decreased renal excretion of penicillin G
d. Decreased bactericidal effect of penicillin G
e. Increased excretion of probenecid in the feces

(c)

71. Interaction between penicillin and probenicid is best described by

which of the following mechanisms?
a. competition at the receptor site
b. acceleration of drug biotransformation
c. alteration in the acid-base balance

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Cardiovascular Drugs ACE inhibitors: Captopril blocks the enzyme which converts
angiotensin I to angiotensin II. The latter is a potent
This category covers a lot of drugs and a lot of questions. They can vasoconstrictor (administration of angiotensin will result in an
be categorized as: elevation of blood pressure).

1. Questions asking about which drug from a list might be used to Adrenergic Agents:
treat a certain condition:
a. Prazosin: selective alpa-1 blocker, inhibits binding of nerve
hypertension: induced release of NE resulting in vasodilation
b. Methyldopa: acts centrally as a false neurotransmitter
1) Diuretics such as the high ceiling or loop-acting diuretic, stimulating alpha receptors to reduce sympathetic outflow
furosemide; resulting in vasodilation
2) Beta-blockers such as propranolol or the cardioselective beta c. Clonidine: selective agonist stimulates alpha-2receptors in
blocker metoprololor atenolol the CNS to reduce sympathetic outflow to peripheral vessels
3) Alpha-1 blockers such as prazosin, resulting in vasodilation
4) Centrally acting adrenergic drugs such as methyldopa or d. Propranolol: nonselective beta blocker reduces cardiac
clonidine output and inhibits renin secretion
5) Neuronal blockers such as guanethidine (reserved for severe e. Metoprolol: selective beta-1 blocker, reduces cardiac output
hypertension)
6) Angiotensin converting enzyme inhibitors such as Captopril, Diuretics: decrease the renal absorption of sodium, thus resulting
lisinopril in fluid loss and a reduction in blood volume. This decreases
the work the heart has to pump. Also have weak dilatory
angina: Nitroglycerin, sometimes propranolol, calcium channel action. Types of diuretics which may be mentioned include:
blockers such as verapamil
a. Thiazides: chlorothiazide
arrhythmias:
1) Lidocaine (ventricular arrhythmias), b. High-ceiling or loop acting: furosemide
2) Phenytoin (to reverse digitalis induced arrhythmias),
3) Quinidine (supraventricular tachyarrhythmias, atrial c. Potassium sparing: spironolactone
fibrillation),
4) Verapamil (supraventricular tachyarrhythmias, Congestive heart failure drugs:
paroxysmal tachycardia, atrial fibrillation),
5) Digitalis (atrial fibrillation, paroxysmal tachycardia) a. Cardiac glycosides such as digitalis or digitoxin are
6) Propranolol (paroxysmal tachycardia) effective because they have a positive inotropic effect,
increasing the force of contraction of the myocardium. This is
Congestive heart failure: Glycosides such as digitalis, digoxin, achieved by an inhibition of Na+, K+ ATPASE leading to
ACE inhibitors such as captopril increased calcium influx. Digitalis therapy reduces the
compensatory changes that are associated with congestive
heart failure such as increased heart size, rate, edema, etc.
2. The second major category of questions concerns mechanism
of action of the various agents:
Drug-condition questions
Antiarrhythmics: Remember problem is that the heart beats
irregularity 1. Quinidine is principally used to treat
a. Hypertension
a. Type 1A agents such as quinidine: acts by increasing the b. Angina pectoris
refractory period of cardiac muscle c. Congestive hear failure
b. Type 1B agents such as lidocaine decrease cardiac d. Supraventricular tachyarrhythmias
excitability
c. When digitalis is used for atrial fibrillation it acts by (d) by elimination. Hypertension ((a)) is treated primarily with
decreasing the rate of A-V conduction beta blockers such as propranolol. Angina is primarily treated
with nitroglycerin, while digoxin (digitalis) is the drug of choice for
Antiangina drugs: problem is insufficient oxygen to meet demands congestive heart failure. Quinidine is classed as an antiarrthymic
of myocardium drug (Type I-blocks sodium channels). It reduces automaticity
and responsiveness and increases refractoriness. It also has an
a. Nitroglycerin increases oxygen supply to the heart by a direct antimuscarinic action preventing the bradycardia that follows
vasodilatory action on the smooth muscle in coronary vagal stimulation.
arteries
b. Propranolol reduces oxygen demand by preventing
chronotropic responses to endogenous epinephrine,
emotions and exercise. 2. Quinidine is used to treat
c. Calcium channel blockers decrease oxygen demand by a. Hypertension
reducing afterload by reducing peripheral resistance via b. Angina pectoris
vasodilation c. Atrial fibrillation
d. Ventricular fibrillation
Antihypertensives: Remember, most drugs have the ultimate e. Congestive hear failure
effect of reducing peripheral resistance via vasodilation
(c) same question as above, just gave you a different type of

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arrythmia e. Alpha-methyldopa

(d)
3. Verapamil is most efficacious in the treatment of
a. Atrial fibrillation
b. Atrial tachycardia 10. Which of the following antihypertensives are usually reserved for
c. Ventricular tachycardia treatment of severe hypertension?
d. Catecholamine-induced arrhythmias a. Sedatives and reserpine
b. Thiazide diuretics and reserpine
(a) memorize c. Sedatives and thiazide diuretics
d. Guanethidine and ganglionic blocking agents

4. Which of the following drugs is most useful in treating or preventing (d)

angina pectoris?
a. Digitalis
b. Quinidine 11. Which of the following beta-adrenergic receptor blocking agents is
c. Propranolol thought to be cardioselective?
d. Procainamide a. Nadolol
e. Pentobarbital b. Timolol
c. Metoprolol
(c) d. Propranolol

(c)
5. Each of the following drugs can be used in the prevention and
treatment of angina pectoris EXCEPT
a. Digitalis Mechanism of Action Questions
b. Propranolol
c. Nitroglycerin
d. Isosorbide dinitrate Antiarrhythmics
e. Pentaerythritol tetranitrate
12. Antiarrhythmic drugs, such as quinidine, suppress certain cardiac
(a) arrhythmias by
a. Stimulating the beta-adrenergic receptor
b. Suppressing cardiac ATP-ase activity
6. All of the following drugs are useful in the treatment of hypertension c. Increasing ectopic pacemaker activity
EXCEPT d. Increasing the refractory period of cardiac muscle
a. Ephedrine
b. Reserpine (d)
c. Methyldopa
d. Thiazide diuretics
13. Most drugs useful in the treatment of cardiac arrhythmias act
(a) primarily by
a. Blocking Purkinje fibers
b. Blocking the alpha-adrenergic receptor
7. Digitalis is useful in the treatment of which of the following conditions? c. Suppressing SA node impulse formation
a. Atrial fibrillation d. Causing a positive inotropic effect
b. Congestive heart failure e. Increasing the refractory period of cardiac muscle
c. Paroxysmal atrial tachycardia
d. All of the above (e)

(d)
14. The most important pharmacologic action of drugs that suppress
cardiac arrhythmias is
8. All of the following drugs are useful in the treatment of cardiac a. Blockade of the vagus nerve
arrhythmias EXCEPT b. Stimulation of cardiac ATP-ase activity
a. Digitalis c. Blockade of the Beta-adrenergic receptor
b. Lidocaine d. Stimulation of the beta-adrenergic receptor
c. Phenytoin e. Increased refractory period of cardiac muscle
d. Procainamide
e. Aminophylline (e)

(e)
15. Lidocaine produces its antiarrhythmic effects by
a. Increasing AV conduction
9. The drug of choice for initial therapy for mild hypertension is b. Decreasing cardiac excitability
a. Reserpine c. Increasing cardiac conduction velocity
b. Guanethidine d. Increasing spontaneous pacemaker activity
c. Phenobarbital
d. Chlorothiazide (b) arrhythmias are defined as any abnormality of the normal

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sinus rhythm of the heart due to disease or injury induced effect. Captopril also maintains lowered BP by elevating
damage to the impulse conducting systems. They also result bradykinin (which has potent vasodilatory action) in the blood by
from the development of ectopic pacemakers or abnormal blocking its metabolism. Thus (d) is wrong, bradykinin
pacemaker rhythms. Drugs such as lidocaine are used to metabolites do not accumulate.
normalize these rhythms. Lidocaine, a local anesthetic,
depresses cardiac excitability, answer (b). The refractory period
of cardiac muscle is increased, thus slowing the heart down. All
of the other alternatives given would exacerbate the arrhythmia. 21. Administration of angiotensin results in
a. A sedative effect
b. Increased heart rate
16. When digitalis is used in atrial fibrillation, the therapeutic objective is c. Increased blood pressure
to d. Antihistaminic effects
a. Abolish cardiac decompensation e. Anti-inflammatory effects
b. Inhibit vagal impulses to the heart
c. Decrease the rate of A-V conduction (c) I guess because more angiotensin II would be formed, and
d. Increase the rate of cardiac repolarization that is a potent vasoconstrictor
e. Produce a decrease in the rate of atrial contraction
Mechanism of Action
(c)

Diuretics
Antiangina Drugs
22. Which of the following is NOT characteristic of the thiazide diuretics?
a. Increase renal excretion of sodium and chloride
17. Nitroglycerin dilates the coronary arteries in angina pectoris by
b. Increase renal excretion of potassium
a. Decreasing the heart rate reflexly
c. Increase the toxicity of digitalis
b. Increasing the metabolic work of the myocardium
d. Exacerbate existing diabetes
c. Direct action on smooth muscle in the vessel walls
e. Cause hypokalemia
d. Increasing the effective refractory period in the atrium
f. Cause hypoglycemia
e. Blocking beta-adrenergic receptors
(f) first off, how can you have an option (f)?! (a) is how diuretics
(c)
lower BP, (b) is why they can cause hypokalemia, which is
conveniently option (e), and hypokalemia can potentiate digitalis
induced arrythmias option(c). Theyy apparently can also cause
18. Propranolol is of value in treating angina pectoris because it
hyperglycemia, which would relate to option (d). How the heck
a. Has a direct action on vascular smooth muscle
are you supposed to remember all of this?
b. Blocks autoregulatory mechanisms in the heart
c. Inhibits oxygen metabolism in cardiac cells
d. Provides relief within seconds of an acute anginal attack
23. The most useful diuretic drugs act by
e. Prevents chronotropic responses to endogenous epinephrine
a. Increasing the glomerular filtration rate
emotions and exercise
b. Decreasing the renal reabsorption of sodium
(e) c. Decreasing the renal excretion of chloride
d. Increasing the renal reabsorption of potassium
e. Increasing the secretion of antidiuretic hormone

ACE Inhibitors (b) people with high BP are always told to reduce salt intake,
since high sodium levels cause fluid retention which can
19. Administration of angiotensin results in increase BP, so ipso facto, reducing renal reabsorption of
a. Anti-inflammatory effects sodium makes BP go down
b. Antihistaminic effects
c. Increased blood pressure
d. Increased heart rate 24. Which of the following drugs act by inhibiting renal reabsorption of
e. A sedative effect sodium?
a. Urea
(c) b. Chlorothiazide
c. Theophylline
d. digitalis glycosides
20. The primary antihypertensive effect of captopril (Capoten) is due to e. Procainamide
accumulation of
a. Serotonin (b) same question as above, just reversed.
b. Angiotensin I
c. Angiotensin III
d. Bradykinin metabolites
Cardiac Glycosides
(b) Captopril is an angiotension-converting enzyme inhibitor that
blocks the activation of angiotension I to angiotension II. The
decreased blood concentration of angiotension II reduces blood 25. Digoxin exerts its positive inotropic effect by
pressure, because angiotension II is a potent vasoconstrictor. a. Activation of adenylcyclase
Thus (c) is wrong, accumulation of angiotension I is the usual b. Inhibition of phosphodiesterase
c. An agonist effect of beta-receptors

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d. Inhibition of Na+, K+ ATPASE leading to increased calcium b. Lithium

influx c. Calcium
e. Decreasing the amount of calcium available for excitation- d. Chloride
contraction coupling e. Magnesium

Answer is (d)- Remember, cardiac glycosides such as digoxin (c)

are used in the treatment of congestive heart failure, which is
the failure of the heart to function adequately as a pump and
thus maintain an adequate circulation. Cardiac glycosides are 31. In the treatment of congestive heart failure, digitalis glycosides
thought to act by altering calcium ion movement, with a desired generally decrease all of the following EXCEPT
effect of increasing the force of contraction of the myocardium a. Edema
(e.g. the inotropic effect). While several of the alternatives b. Urine flow
involve calcium, the way digoxin does it is via (d), inhibition of c. Heart size
Na+, K+ ATPase, resulting in an increase of calcium ion influx d. Heart rate
into the cardiac cells, and a subsequent enhancement of the e. Residual diastolic volume
contractile mechanism. (a) is the way epinephrine works.
(b)

26. Digitoxin is effective in the treatment of cardiac failure because it

a. Is primarily a diuretic Adrenergic Agents
b. Reduces the ventricular rate
c. Decreases abnormal cardiac rhythms
d. Produces peripheral vasoconstriction 32. The mechanism of action of prazosin, an antihypertensive agent is to
e. Has a positive cardiac inotropic action a. Block beta-adrenergic receptors
b. Inhibit formation of angiotensin II
(e) c. Inhibit nerve-induced release of norepinephrine
d. Stimulate central inhibitory alpha-adrenergic receptors
e. Inhibit the postsynaptic action of norepinephrine on vascular
27. The primary action of therapeutic doses of digitalis on cardiac muscle smooth muscle
is an increase in
a. Force of contraction (e)
b. Ventricular excitability
c. Refractory period of the atrial muscle
d. Refractory period of the ventricular muscle 33. Which of the following owes a significant amount of its
e. Rate of conduction of impulse to the muscle antihypertensive effect to a central action?
a. Methyldopa
(a) b. Metoprolol
c. Hydralazine
d. Propranolol
28. The beneficial effects of digitalis in congestive heart failure result in e. Guanethidine
part from the fact that digitalis causes
a. A decrease in end-diastolic volume (a) All of these drugs are used to treat hypertension, but act by
b. A decrease in end-diastolic pressure different mechanisms. (a), methyldopa, is the drug with central
c. An increase in stroke volume and cardiac output action- it alters CNS control of blood pressure by acting on
d. A decrease in central venous pressure cardioregulatory and vasomotor systems of the brain by
e. A decrease in rate of the hear where tachycardia exists stimulating alpha2 receptors in the brain stem. Clonidine is the
usual drug that is involved in this particular question. (b)
i. (a), (b) and (c) metropolol is a selectively blocks beta-1 receptors in the heart to
ii. (a) and (c) only reduce cardiac output. (c) hydralazine has a direct action on
iii. (c) and (d) vascular smooth muscle to reduce hypertension via
iv. (e) only vasodilation. (d) propranolol blocks beta receptors in the heart,
v. All of the above while (e) guanethidine prevents the release and causes
depletion of catecholamines taken up into storage vesicles and
(v) is released like a false transmitter. It does not cross the blood-
brain barrier.

29. The cardiac glycosides will increase the concentration of which ion in
an active heart muscle?
a. Sodium 34. Which of the following drugs is thought to reduce arterial blood
b. Bromide pressure by activating alpha receptors in the vasomotor center of the
c. Calcium medulla?
d. Chloride a. Prazosin
e. Potassium b. Clonidine
c. Propranolol
(c) d. Guanethidine
e. Chlorothiazide

30. Which of the following ions augments the inotropic effect of digitalis? (b)- see above explanation
a. Sodium

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39. Symptoms of digitalis toxicity include all of the following EXCEPT

a. Extrasystoles
35. Propranolol (Inderal) can be useful in the treatment of hypertension b. Nausea and vomiting
because it blocks c. Yellow-green vision
a. Alpha-1 adrenergic receptors d. A-V conduction block
b. Sodium reabsorption in the kidney e. Decreased P-R interval
c. The release of renin from juxtaglomerular cells
d. The release of norepinephrine from nerve terminals (e)
e. The reflex tachycardia seen with the use of other
antihypertensives
40. Administration of which of the following drugs increases the likelihood
i. (a) and (b) of a toxic response to digitalis?
ii. (a) and (d) a. Diazepam
iii. (b), (c) and (d) b. Lidocaine
iv. (c), (d) and (e) c. Spironolactone
v. (c) and (e) only d. Chlorothiazide
e. Acetylsalicylic acid
(v) Answer is (v)- You should immediately recognize that
propranolol is the prototypic beta-adrenergic receptor blocker, (d) Chlorthiazide is a diuretic which causes potassium loss or
thus any answer with alternative a (i and ii) is wrong. Similarly, d hypokalemia. This results in greater penetration of digitalis into
is wrong as well-propranolol is a competitive beta- receptor the myocardium, and thus potential toxicity.
blocker- it has no effect on NE release. Another drug used for
hypertension, Clonidine, acts via this mechanism by stimulating
alpha-2 autoreceptors. Thus ii, iii, and iv are wrong. This leaves 41.
(v) as the only possible right answer. Indeed, aside from
blocking beta-1 receptors, blocking of renin release is thought to
be the other mechanism whereby beta-blockers alter
hypertension.

36. One of the proposed mechanisms of the antihypertensive effect of

beta-adrenergic receptor blocking agents is
a. Sedation
b. A diuretic effect
c. An antirenin effect
d. A vagal blocking effect
e. An increase in cardiac output

(c)

37. Selective beta-1 adrenergic agonists will produce which of the

following effects?
a. Glycogenolysis
b. Increased cardiac output
c. Decreased diastolic pressure
d. Decreased peripheral resistance
e. Relaxation of bronchial smooth muscle

(b)

Miscellaneous Side Effect Questions

38. Ototoxicity with deafness may encountered occasionally in patients

taking which of the following diuretic agents?
a. Osmotic
b. Thiazide
c. Mercurial
d. High-ceiling

(d) answer is (d)- straight memorization- deafness is typically

associated with use of ethacrynic acid, a loop or high-ceiling
diuretic. How the hell are you supposed to remember all of this
stuff???

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Analgesics- NSAIDS:
(c)
1. Mechanism of action questions regarding analgesic, antipyretic and
effects on bleeding:
5. The mechanism of the antipyretic action of salicylates probably results
Analgesic effects: aspirin inhibits the synthesis of prostaglandins from
a. Inhibition of prostaglandin synthesis in the CNS affecting
Antipyretic effects: aspirin inhibits PG synthesis in the hypothalamic temperature regulation
hypothalamic temperature regulation center b. Inhibition of bradykinin in the periphery leading to sweating
c. Depression of oxidative enzymes leading to decreased heat
Bleeding time: inhibit synthesis of thromboxane A2 preventing production
platelet synthesis d. Suppression of cholinergic mediators in the hypothalamus
e. Stimulation of norepinephrine in the hypothalamus

2. A 2nd type of question has to do with pharmacological or toxic effects (a)

of aspirin: you get to pick which of the list is or is not associated
with aspirin. Therapeutic effects of aspirin include pain relief,
antipyretic effects, antirheumatic and anti-inflammatory effects. 6. The antipyretic action of salicylates is explained in part by
Adverse or toxic effects include all of the following: occult bleeding a. Analgesia leading to sedation
from the GI tract, tinnitus, nausea and vomiting, acid-base b. Increased blood flow through the hypothalamus
disturbance or metabolic acidosis, decreased tubular reabsorption c. Cutaneous vasodilation leading to increased heat loss
of uric acid, salicylism, delirium, hyperventilation, etc. d. Depression of oxidative processes leading to decreased heat
production

3. A third type of question focuses on the difference between 1) aspirin (c)

and acetaminophen, 2) aspirin and other anti-inflammatories like
prednisone, and 3) between aspirin and ibuprofen:
7. The locus of action of aspirin's central antipyretic effect is the
1) Acetaminophen lacks anti-inflammatory activity, is hepatotoxic, a. Brain stem
and does not cause GI upset b. Hypothalamus
2) Anti-inflammatories like prednisone, hydrocortisone, c. Basal ganglia
triamcinolone etc. are steroids and do not act primarily by PG d. Limbic system
inhibition e. Cerebral cortex
3) Ibuprofen causes much less GI irritation
4) Diflunisal (Dolobid) has a longer half-life than aspirin, (b) memorization question- remember antipyresis means
acetaminophen and ibuprofen antifever. Temperature regulation center is in the hypothalamus.

4. Newer versions of the boards have questions about COX-2

inhibitors like vioxx. (Which of the following is a COX-2 8. A patient who has been taking large quantities of aspirin might show
inhibitor?) increased postoperative bleeding because aspirin inhibits
a. Synthesis of thromboxane A2 and prevents platelet
5. These old questions focus a lot on aspirin. Nowadays, aggregation
acetaminophen and ibuprofen are used much more b. Synthesis of prostacyclin and prevents platelet aggregation
commonly than aspirin, because of the many side effects of c. Synthesis of prostaglandin and prevents production of blood
aspirin that turn up in these kinds of questions. So since platelets
aspirin is the comparator prototype drug, reviewing these d. Thrombin and prevents formation of the fibrin network
questions are still useful. e. G.I. absorption of vitamin K and prevents synthesis of blood
1) But expect newer questions asking you to know: clotting factors
a. Acetaminophen causes liver toxicity, especially
when combined with alcohol or taken in excess (a) The first fact you must remember is that aspirin prevents
of 4 gr/day. platelet aggregation- this limits your choices to (a) and (b). They
b. Acetaminophen is the drug of choice for the hope to confuse you by using prostacylin, but of course you
feverish child (they usually ask the reverse, know that this is wrong immediately, the right word is
which is which drug should be avoided in the prostaglandin, as in (c), but you have already eliminated that
feverish child (aspirin- increased risk of Reye’s choice because it doesn't mention prevention of platelet
syndrome) aggregation. Thus, even if you didn't remember that
thromboxane A2 induces platelet aggregation, and aspirin
blocks this action, you could get the answer by elimination. (d) is
how heparin works, while (e) is how coumarin works.
Frequently asked questions on NSAIDS

9. Anti-inflammatory agents, such as aspirin, interfere with hemostasis by

4. The therapeutic effect of the salicylates is explained on the basis of the a. Activating antithrombin
ability of the drug to b. Preventing vasoconstriction
a. Activate autonomic reflexes c. Inhibiting thrombin generation
b. Uncouple oxidative phosphorylation d. Inhibiting platelet aggregation
c. Inhibit the synthesis of prostaglandins e. Inhibiting polymerization of fibrin
d. Competitively antagonize prostaglandins at the receptor site

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(d) acetylsalicylic acid?

a. Delirium
b. Tinnitus
10. Which of the following anti-inflammatory agents does NOT act c. Hypothermia
primarily by inhibiting activity of prostaglandin synthetase? d. Hyperventilation
a. Diflunisal e. Metabolic acidosis
b. Ibuprofen
c. Triamcinolone (c) it only lowers your temperature if you have a fever,, taking
d. Oxyphenbutazone aspirin does not have any effect on body temperature in the
e. Acetylsalicylic acid non-feverish patient, but high doses can cause all the other
effects listed.
(c) triamcinolone is a corticosteroid. Corticosteroids inhibit
phospholipase A2, the enzymatic step that precedes
prostaglandin synthetase. Diflunisal is a salicylate analgesic, like 15. All of the following are pharmacologic and toxicologic properties of
aspirin. aspirin EXCEPT
a. Tinnitus
b. Analgesia
11. A nonsteroidal, anti-inflammatory agent that appears to produce fewer c. Salicylism
gastrointestinal disturbances than high does of aspirin is d. Antipyresis
a. Ibuprofen e. Suppression of the immune response
b. Probenecid
c. Pentazocine (e)
d. Acetaminophen
e. Phenylbutazone
16. Therapeutic effects of aspirin include
(a) you might be tempted to answer acetaminophen, because it a. Analgesia
doesn’t cause GI upset, but remember it is also not anti- b. Tranquilization
inflammatory. The answer is ibuprofen. Tricky – you had to sort c. Pyretic action
through two distinguishing characteristics. Good question! d. Anti-inflammatory action
e. Antirheumatic action

12. Prolonged use of which of the following drugs does NOT cause a i. (a), (b) and (c)
predisposition to gastric irritation and bleeding? ii. (a), (c) and (d)
a. Phenytoin iii. (a), (d) and (e)
b. Ibuprofen iv. (b), (c) and (d)
c. Indomethacin v. (b), (d) and (e)
d. Phenylbutazone
e. Acetylsalicylic acid (iii)

(a) This is a straight drug identification question. Answers 2-5

are all non-steroidal antiinflammatory drugs which cause gastric 17. All of the following are pharmacologic or toxicologic properties of
irritation and bleeding due to their effects on prostaglandin acetylsalicylic acid EXCEPT
synthesis in the mucosal wall of the gut. # , phenytoin, is an a. Tinnitus
anti-convulsant-its major side effect that often appears as a b. Analgesia
question on boards is the production of gingival hyperplasia. c. Antipyresis
d. Methemoglobinemia
e. Inhibition of prostaglandin synthesis

13. Each of the following agents has been associated with gastric (d)
irritation EXCEPT
a. Aspirin
b. Alcohol 18. All of the following are possible effects of aspirin EXCEPT
c. Ibuprofen a. Reduction of fever
d. Indomethacin b. Shortening of bleeding time
e. Acetaminophen c. Suppression of inflammatory response
d. Bleeding from the gastronintestinal tract
(e) note the difference in this question and #11 and 12. e. Increase in the renal excretion of uric acid at high doses
Ibuprofen was previously the answer to “shows reduced GI
irritation”, but it does cause some, which you have to remember (e)
to answer #12 and this question. So aspirin and ibuprofen are
out. Indomethacin is a very strong NSAID that causes lots of GI
irritation, so much that use is limited in humans, so it is out. 19. Of the following, aspirin does NOT cause
What about alocohol vs. acetaminophen. Well, you should really a. Occult bleeding
know that acetaminophen is usually the answer to these types b. Nausea and vomiting
of analgesics questions, but if you didn’t know that, perhaps you c. Acid-base disturbance
may know that alcohol also causes GI irritation, so it is out. d. Suppression of the cough reflex
e. Decreased tubular reabsorption of uric acid

14. Which of the following is NOT produced by excessive doses of (d) Answer is (d)- (a) & (b) are the major side effects of aspirin

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