Practical Course 1: DM PDF

Practical course 1: DM 1. Mention 3 types of insulin that can be used for basal blood glucose control and mention the administration frequency for each of them. (short+ MCQ) NPH BID (twice daily), glargine OD (once daily), or detemir OD-BID. 2. What is the functional of basal insulin injections? (s...

Practical course 1: DM 1. Mention 3 types of insulin that can be used for basal blood glucose control and mention the administration frequency for each of them. (short+ MCQ) NPH BID (twice daily), glargine OD (once daily), or detemir OD-BID. 2. What is the functional of basal insulin injections? (short+ MCQ) - To control fasting glucose and suppress overnight hepatic glucose production 3. What is the function of prandial insulin and when should it be given? (short+ MCQ) - To control post-prandial glucose spikes - It is given with each meal. - Given as a rapid-acting insulin analogue. 4. Mention 3 types of insulin for prandial blood glucose control. (short+ MCQ) Insulin lispro, insulin aspart, and insulin glulisine 5. When should insulin glulisine be given in relation to meals and how would it be administered? (short+ MCQ) - Prandial insulins such as insulin glulisine start working in 5 to 10 minutes. - It is given with each meal (SC) to control post-prandial glucose spikes 6. Why is regular insulin considered pre-prandial and not prandial insulin? (short+ MCQ) Because it takes about 30 minutes to start working. 7. What would happen if a diabetic patient took his regular insulin just before the meal? (short+ MCQ) Regular insulin is considered a pre-prandial insulin because it takes about 30 minutes to start working. Taking regular insulin just before a meal might lead to delayed insulin action, resulting in a spike in blood sugar levels after the meal. 1 8. What is the aim of giving insulin in a sliding scale and what is its disadvantage? (short+ MCQ) - Given to reduce an elevated blood glucose level to a normal range. Disadvantage: - Giving correction insulin is the worst way to manage diabetes. - Rather than maintaining normal blood glucose levels, we're actually waiting until hyperglycemia occurs, and then trying to bring it down to normal. 9. For an 80 kg diabetic patient, dependent on insulin, suggest his total daily insulin requirement and how it could be divided between two dose per day. 80 kg adult with moderate Ketones Total Insulin dose: 40 units Divide Insulin as following: give 2 parts in the morning and one part in the evening (morning= 27 U and evening= 13 U) 10. Suggest a basal-bolus regimen with glargine and lispro for a 70 kg patient. 70 kg adult with moderate Ketones Total Insulin dose: 35 units Divide Insulin as following: Insulin Glargine (Lantus): 17 units at bedtime Insulin Lispro: 18 units total divided over meals Before breakfast: 6 units, Before lunch: 6 units, Before dinner: 6 units 11. Mention factors that increase and factors that decrease insulin requirements. (short+ MCQ) Factors that INCREASE: i) Infection, operation, pregnancy and trauma ii) Treatment with counter-regulating hormones and drugs: - Thiazide diuretics and Diazoxide vasodilator - Sympathomimetics. - Oral contraceptives (and estrogens) - Corticosteroids iii) Specific antagonists e.g., insulinase enzyme and insulin antibodies. Factors that DECREASE: i) Physical exercise (Daily insulin requirements are inversely proportional to degree of physical activity). ii) Decrease in caloric intake. 2 12. Mention items you should teach your diabetic patient. (short+ MCQ) 1-Diabetes is a lifelong disease that requires lifestyle changes. 2- Early signs and symptoms of hypoglycemia and hyperglycemia. 3- Hypoglycemia is more dangerous, keep a source of sugar. 4- To wear a medical identification bracelet. 13. Mention insulin injection and insulin use instructions. Insulin syringes Insulin pen Insulin jet Insulin pump Common injection sites (short+ MCQ) Abdomen: most preferred site Other sites: Buttocks, thighs and arms. Site Rotation is essential insulin use instructions. (short+ MCQ) 1- If meal is OMITTED: Do Not Take Medication. 2- Protect insulin from Heat & Freezing. 3- Store insulin that has not been opened in the Refrigerator. 4- Do Not Shake insulin because of: a- The resulting froth prevents withdrawal of an accurate dose. b- May damage protein molecules. 14. Mention the HbA1c value at or above which oral diabetic therapy should be escalated to the next step. (short+ MCQ) (HBA1C ≥ 6.5%) 15. For a Type 2 diabetic patient who remains uncontrolled on metformin and sulfonylurea, which of the following would NOT be added as a third drug? a. Sitagliptin b. Canagliflozin c. Repaglinide d. Liraglutide 3  Case No 1 An obese female aged 42 years complained of polyuria and polydipsia. After clinical examination and laboratory investigations, her 2 hour post prandial blood glucose was found 300 mg/dl and was diagnosed as type 2 diabetes mellitus (NIDDM) Hyperglycemia persisted despite control of diet and exercise for several weeks. How to manage this case? 1- The most suitable drug treatment of diabetes mellitus in this female is to be started with: a- insulin b- glibenclamide c- metformin d- carbimazole e- thyroxine 2- The drug selected in Q1 is: a- a sulphonylurea b- a biguanide c- a meglitinide d- a glitazone e- an α-glucosidase enzyme inhibitor must convert onto insulin therapy 3- The drug selected in Q1 may produce the following adverse effect: a- hypoglycemia b- myopathy c- alopecia d- lactic acidosis e- pancreatitis 4- Hyperglycemia persisted despite the proper use of the drug selected in Q1. What drug do you like to add? a- insulin b- glibenclamide c- metformin d- carbimazole e- thyroxine 5- The drug selected in Q4 is given by the following route of administration: a- Subcutaneous b- Intramuscular c- Intravenous d- Oral e- Rectal 6- Which of the following is expected adverse effect of the drug selected in Q4: a- hypoglycemia 4 b- myopathy c- alopecia d- lactic acidosis e- pancreatitis 7- If the female got pregnant, which of the following is most appropriate? a. She can continue any sulfonylurea drugs she is taking. b. She must convert onto insulin therapy. c. She can use a combination of two oral antidiabetics. d. She will stop all treatment. e. She will convert to diet only. Case No 2 A 57-year-old obese man presented with a three-week history of polyuria and polydepsi Clinical features and laboratory findings confirmed a diagnosis of type 2 diabete mellitus. Hyperglycemia and obesity persisted despite diet control and exercise fo several weeks. How would you manage this patient? 1- Which of the following drugs would you like to start with? a- carbimazole b- glucagon c- hydrocortisone d- metformin e- hydrochlorothiazide 2- Regarding the selected drug in Q1, the following THREE statements are CORRECT: a- It is a biguanide b- It is a sulphonylurea c- It is considered as an oral euglycemic drug d- It is considered as an oral hypoglycemic drug e- It inhibits intestinal α-glucosidase enzyme f- It stimulates insulin secretion from pancreatic β-cells g- It can cause lactic acidosis especially in patients with renal impairment 3- After 4 weeks of treatment with the drug selected in Q1, hyperglycemia was not adequately controlled. Which of the following drugs would you like to add: g- furosemide b- glibenclamide c- methimazole d- bromocriptine e- ephedrine 5 4- Regarding the selected drug in Q3, the following THREE statements are CORRECT: g- It is a biguanide b- It is a sulphonylurea c- It is considered as an oral euglycemic drug d- It is considered as an oral hypoglycemic drug e- It inhibits intestinal α-glucosidase enzyme f- It stimulates insulin secretion from pancreatic β-cells g- It can cause lactic acidosis especially in patients with renal impairment 5- One day the patient took his medication but he missed his meal and played a football game. He felt very hungry, drowsy, his face was pale and sweaty and there was tachycardia. The urine was free of glucose. The most appropriate management of this situation is to give the patient: a- oral sweets b- intravenous glucose c- subcutaneous isophane insulin d- intravenous soluble insulin e- oral acarbose 6- Hyperglycemia was adequately controlled for several months. The patient is going to undergo a surgical operation. How would you like to modify the anti-diabetic medication: a- Decrease the dose of the oral anti-diabetic drugs b- Increase the dose of the oral anti-diabetic drugs c- Stop oral anti-diabetic drugs and give insulin d- Stop oral anti-diabetic drugs and give dexamethasone e- Continue oral anti-diabetic drugs but add atropine 15 c Case 1 1 c 2 b 3 d 4 b 5 d 6 a 7 b 6  Case 2 1 d 2 a-c-g 3 b 4 b-d-f 5 a 6 c Management of Diabetes Mellitus (short+ MCQ) I- Treatment Type 1 DM: - Life style Modification (Diet regulation + Exercise) + Insulin II- Treatment of Type 2 DM: Step 1 - Life style modifications = Diet + Physical activity Tried for 1 – 3 Months. - If Still Hyperglycemia (HBA1C ≥ 6.5%) → Step 2 - Life style modifications + Monotherapy: Metformin - If Still Hyperglycemia (HBA1C ≥ 6.5%) → Step 3 - Life style modifications + Dual therapy: 1- Metformin + Sulfonylurea (e.g. Glibenclamide or Glipizide) OR 2- Metformin + DPP-4 Inhibitor (Gliptins e.g., Sitagliptin) OR 3- Metformin + SGLT2 inhibitors e.g Dapagliflozin - If Still Hyperglycemia (HBA1C ≥ 6.5%) → Step 4 - Life style modifications + Triple therapy: 1- Metformin + Sulfonylurea + DPP-4 inhibitor (Gliptin) OR 2- Metformin + Sulfonylurea + GLP-1 analogs e.g. Exenatide OR 3- Metformin + Meglitinides (Glinides) + DPP-4 inhibitor OR 4- Metformin + Meglitinides (Glinides) + GLP-1 agonist. - If Still Hyperglycemia (HBA1C ≥ 6.5%) → Step 5 - Life style modifications + Insulin Selection of antidiabetic drugs according to MOA and SEs from theoretical book Microvascular long-term complications from diabetes include nephropathy (proteinuria), retinopathy and neuropathy. 7  Practical course 2: Endocrine emergencies 1. Outline the management of hypoglycemia and hypoglycemic coma. (short+ MCQ) If patient is conscious → Oral glucose or sweets If patient in Coma = Unconscious → I.V. Glucose 50 ml 25% → Life-saving. If sterile glucose is not available → Glucagon 1 mg S.C. or I.M 2. Outline the management of diabetic ketoacidosis. (short+ MCQ) 1- Soluble insulin: 0.1 U/kg/hr IV of Regular Insulin - continue IV insulin until the glucose and acidosis are corrected then switch to SC insulin. 2- Saline [0.9 % NaCl] IV infusion: Rehydration 3- Glucose 5% IV infusion when blood glucose is < 250 mg/dl to avoid hypoglycemia 4- NaHCO3 for severe metabolic acidosis (pH < 7.1; HCO3 < 5). 5- KCl added to IV fluids to avoid hypokalemia during insulin therapy. 6- Antibiotics for infection. 3. Which of the following is a difference between the management of diabetic ketoacidosis and HyperOsmolar Non Ketotic Hyperglycemia (HONK)? a. Because the presence of ketone bodies is not a feature of HONK, we do not classically need to give NaHCO3. b. In HONK, no need to worry about hypoglycemia even with prolonged insulin infusion. c. In HONK, there will always be an excess of potassium in the blood we don’t usually need to supplement insulin with KCl. d. Subcutaneous Mixtard insulin can be used instead of regular insulin for the management of HONK. 4. Regarding the treatment of myxedema coma, indicate whether each of the following is True or False: a. T3 has a longer t1/2 than T4 and so a loading dose is usually needed. b. T4 is more cardiotoxic than T3. c. Hydrocortisone is needed to manage the expected unmasking of adrenocortical insufficiency. d. Antibiotics are needed in every case. e. Only intravenous thyroxine is reliable. 5. Regarding the treatment of thyroid crisis, match the following phrases in column A with the best choice of drugs from column B. 8 11. Enumerate the lines of management of acute adrenal insufficiency. (short+ MCQ) 1- Steroid replacement - Give IV bolus/I.M of 50-100 mg/m2 hydrocortisone (Solu-Cortef IM) immediately. - Follow with hydrocortisone 6 hourly IV - Once stable, 1- Reduce the IV dose, 2- Switch to oral maintenance dose 3-Mineralocorticoid replacement: fludrocortisone (0.05 - 0.1 mg daily). 2- Intravenous fluids: Indication: Shock or moderate to severe dehydration Bolus: 0.9% sodium chloride (normal saline) 10-20 mL/kg during the first hour of treatment. Maintenance: 0.9% sodium chloride and 5% glucose Monitor: RBG (Random Blood Glucose) & Electrolytes (Na+, K+) 3- To Treat hypoglycemia: Bolus: IV of 10% dextrose 2-5 mL/kg and recheck RBG (random blood glucose) after 30min Maintenance: 10% dextrose in 0.9% sodium chloride to maintain normoglycaemia 4- To Treat Hyperkalemia: monitor by ECG: If Potassium is >7.0 mmol/L + ECG changes (peaked T waves ± wide QRS) → Arrhythmia → Treat with either calcium gluconate or insulin infusion 12. Explain each of the following: (short+ MCQ) a. A patient with acute adrenal insufficiency will have hypoglycemia, yet he might need insulin infusion. Insulin may be needed to treat hyperkalemia but (Insulin + glucose/dextrose) may be needed to avoid hypoglycemia b. Patient with moderate hypercalcemia is given NaCl solution for fluid replacement. Because it helps to facilitate urinary calcium excretion. c. Combined treatment of moderate hypercalcemia with calcitonin and pamidronate. - Because both the bisphosphonates and denosumab are not immediately acting a standard of many practitioners faced with this situation is to use combination therapy with calcitonin and either a bisphosphonate (pamidronate) or denosumab. - In this way one takes advantage of the rapid but weak effects of calcitonin while waiting for the more delayed but more powerful anticalcemic effects of pamidronate, zoledronic acid, or denosumab to manifest themselves. d. Caution with vitamin D3 therapy with elderly patients. hypercalcemia can occur rather quickly especially when taken with Ca supplement 9 13. Regarding the treatment of hypercalcemia, match the following phrases in column A with the best choice of drugs from column B. 18. A patient with acute adrenal insufficiency might need supplementation with all of the following EXCEPT: a. Ca b. Glucose c. K d. Na 19. Describe precautions with calcium infusion. (short+ MCQ) 1-Slow infusion 2-Clinical Monitoring: pulse and cardiac auscultation to detect early tachycardia 3-ECG: continuous ECG monitoring, as rapid replacement can elicit cardiac arrythmias. 4-Magnesium levels should also be checked Hypomagnesemia (serum magnesium level is below 1.7 mEq/L) and corrected 3 a 4.a F 14 c b F 15 g c T 16 a d F 17 d e T 18 c 6 b 7 a 8 e g 9 b? 10 c 10  Treatment of Thyroid Emergencies (short+ MCQ) Myxedema Coma Thyroid crisis (storm) Severe long-standing hypothyroidism a- Loading dose of I.V levothyroxine: 1. Methimazole blocks hormone synthesis while usually loading dose initially, followed propylthiouracil in addition Prevent conversion of T4 to T3 by daily maintaince. OR Liothyronine (T3) I.V: but may be more cardiotoxic 2. K Iodide to inhibit release of thyroid hormones and more difficult to monitor. N.B. Intravenous therapy is mandatory 3. Beta blockers IV without sympathomimetics activity because of impaired absorption of (propranolol): If BB is contraindicated diltiazem can be used drugs in this condition. 4. Hydrocortisone IV: Protect against shock & Prevent conversion of T4 to T3 b- Hydrocortisone: i.v. is also needed, as adrenocortical insufficiency is usually 5. Supportive therapy is essential to control fever, heart present. failure, and any underlying disease process that may have precipitated the acute storm. Calcitonin is used to treat: hypercalcemia e.g. Vitamin D-induced hypercalcemia. Hypocalcemia (tetany) signs include Chvostek’s and Trousseau's signs 11  Practical course 3: Contraception 1. Mention advantages of the use of triphasic combination preparations as oral contraceptive method. (short+ MCQ) 1) Reduces the total amount of steroids. 2) Approximates the estrogen/ progestogen ratios that occur during the menstrual cycle to give better control of conception with minimal adverse effects as: - Minimize spotting and breakthrough bleeding. - Thromboembolic manifestation is less. 2. Compare the mechanism of action of oral combined and progestin only contraceptive pills(short+ MCQ) Oral combined contraceptive pill Progestin only contraceptive pills 1. Estrogen inhibits the release of FSH and so suppresses the 1) Increases viscosity of development of the ovarian follicle. cervical mucus so 2. The progestogen inhibits the release of LH and thus prevents impair penetration of ovulation and it also increases viscosity of cervical mucus so impair sperms. penetration of sperms 2) Hinder implantation 3. They both alter the endometrium in such a way as to discourage through effect on implantation. endometrium & on When administration ceases it is the withdrawal of progestogen motility and secretions which causes bleeding. of the fallopian tubes 3. Enumerate advantages and disadvantages of subcutaneous implant as a contraceptive method Advantages: 1) The implant is cheaper than oral contraceptives. 2) Nearly reliable as sterilization. 3) Totally reversible if the implants are surgically removed. 4) Once implantation occurs, the method does not depend on patient compliance. SO lower rates of new pregnancies compared to oral contraceptives. Disadvantages: Irregular menstrual bleeding& headaches. 4. Enumerate adverse effect of hormonal contraceptive method (short+ MCQ) The most common adverse effects: 1) Headache, and nausea 2) Fluid retention → Weight gain & Increased blood pressure may also occur 3) Breast fullness & mastalgia. 4) Progestins may be associated with: depression, changes in libido, hirsutism, and acne. Also, Break-through bleeding (common with progestogens alone or low dose combination method). 12 Severe adverse effects: Although rare 1) Thromboembolism, myocardial infarction, and stroke (most common among women who are over 35 years and smoke). 2) Increased incidence of cervical cancer and breast cancer 3) cholecystitis, gall stones & jaundice 5. Enumerate 5 clinical problems that can induced or aggravated by estrogen when used to induce contraception (short+ MCQ) 1. History of thromboembolic disease or varicose veins. 2. Breast Cancer 3. Liver disease. 4. Diabetes 5. Cardiovascular diseases e.g. hypertension, coronary heart disease 6. Uterine fibromyomata (may increase). 7. Migraine. 8. Women over 35 years. 9. Undiagnosed vaginal bleeding. 6. A 35-year-old woman on regular hormonal contraception method. She smokes about 10 cigarette per day since 3 years. 3 weeks ago, she developed severe resistant chest infection and treated with combined antibiotics. Recently she came pregnant despite regular use of her contraceptive method. (short+ MCQ) a. Explain failure of her contraceptive method 1. Missed Pills 2. Drug Interactions: Certain medications used for treatment of chest infection, including antibiotics e.g. Rifampicin are hepatic microsomal enzyme inducers increasing metabolism of hormonal contraception. 3. Smoking: is a hepatic microsomal enzyme inducer increasing metabolism of hormonal contraception. 4. Recent Illness: Severe illness, especially if accompanied by fever, vomiting, or diarrhea, can also reduce the effectiveness of hormonal contraception. b. Enumerate 2 drugs can be antagonized by co-administration with oral contraceptive pills 1. Oral anticoagulants: oral contraceptives increased level of blood clotting factors. 2. Some antihypertensive: oral contraceptives may increase Bl. pr. 3. Antihypercholesterolemic drugs: oral contraceptives increase level of blood cholesterol & triglycerides. c. Explain the interaction between tobacco smoking and oral contraceptive pills Smoking increases the incidence of thromboembolism. Smoking is a hepatic microsomal enzyme inducer increasing metabolism of hormonal contraception. 13 7. A 27-year-old woman with amenorrhea, infertility, and galactorrhea was treated with a drug that successfully restored ovulation and menstruation. Before being given the drug, the woman was carefully questioned about previous mental health problems, which she did not have. She was advised to take the drug orally. Which of the following is most likely to be the drug that was used to treat this patient? a) Clomiphene citrate b) Letrozole c) Bromocriptine d) Human chorionic gonadotropin 8. 24 years old female is coming seeking for contraception. She is lactating and not known to have any comorbidities. What will you prescribe for her? a) Oral progestin only pills b) Oral monophasic contraceptive pills c) Combined contraceptive monthly injection d) Danazol 9. A 25-year-old woman complaining of infertility with history of OHSS from previous induction with clomiphene citrate. Which inducing ovulation drug will you start a) Clomiphene citrate b) Letrozole c) Bromocriptine d) Metformin 10. You have been asked to prescribe a combined oral contraceptive pill to a 30-yr-old woman. All of the following conditions are absolute contraindications to the combined oral contraceptive pills EXCEPT a) History of deep venous thrombosis b) Previous history cholestatic jaundice c) Diabetes mellitus d) Weight gain and mastalgia 11. A 29-year-old woman comes to the clinic to discuss contraceptive options. She recently got married and wanted to opt for a more convenient method of contraception. Past medical history is significant for seizures managed on phenytoin for the past 2 years. Usage of combined oral contraceptive pills and their potential risks are explained in detail to the patient. Patient is on cetirizine, montelukast and famotidine The patient agrees to take combined oral contraceptives. After 2 months, she comes to the office with a positive pregnancy test. What is the most likely reason for the failure of contraception? a) Cetirizine b) Phenytoin c) Famotidine d) Montelukast 14 12. Minipill hormonal contraception is composed of: a-High dose estrogen + high dose progestin b-Low dose estrogen + low dose progestin c-Low dose estrogen alone d-Low dose progestin alone 13.Combined oral contraceptive pills are contraindicated in women suffering from: a-Carcinoma of breast. b-Peptic ulcer. c-Hyperthyroidism. d-Heart failure. 14. The estrogen that is used in most combined hormonal contraceptives is: a-Clomiphene b-Ethinyl estradiol c-Estrone d-Norgestrel 15. Mechanism of action of minipill oral contraceptives include: a. Inhibits FSH release b. Inhibits Ovulation c. Make the cervical mucus more thick d. Stimulate aromatase enzyme 16. One of the following conditions is NOT a contraindication to oral contraceptive use: a) History of thromboembolic disease or varicose veins b) Breast Cancer c) Uterine fibromyoma d) Women over 20 years 17. Progestogen minipill will do which of the following to inhibit pregnancy? a) Induce endometrial changes b) Inhibit ovulation c) Regulate the cycle e) Liquefy cervical mucous 7 c 13 a 8 a 14 b 9 b 15 c 10 d 16 d 11 b 17 a 12 d B) Progestin only contraceptives: Advantages Disadvantages ▪ Does not inhibit ovulation 1) Break-through bleeding is common ▪ Does not inhibit the cycle 2) Irregular menstrual cycles. ▪ Does not inhibit lactation 3) Less effective than the combined method. Missing a dose: conception. 15  Practical course 4: Obesity 1. Mention indications of pharmacotherapy in obesity. (short+ MCQ) For patients who have failed to achieve clinically significant weight loss, defined as ≥ 5% of baseline weight after 6 months of lifestyle interventions for individuals with: - BMI ≥ 30 kg/m: Drug therapy is adjunctive to lifestyle intervention. - BMI ≥ 27 kg/m in presence of concomitant obesity-related diseases and for whom dietary and physical activity therapy has not been successful. 2. For each of the following anti-obesity drugs mention the mechanism of action and one important side effect: (short+ MCQ) Orlistat Gastric and pancreatic lipase inhibitor: decrease fat Oily rectal leakage absorption NE agonist: an indirect sympathomimetic Elevation in heart rate Phenteramine GABA agonist, glutamate antagonist: antiepileptic that /Topiramate increase satiety Opioid receptor antagonist/ sleep disorder DA and NE reuptake inhibitor: work synergistically in Naltrexone the hypothalamus and the mesolimbic dopamine /Buproprion circuit to promote satiety, reduce food intake and enhance energy expenditure Liraglutide GLP-1 analogue Increased heart rate, Nausea, vomiting, diarrhea Semaglutide GLP-1 analogue Nausea, vomiting, diarrhea, abdominal pain Setmelanotide MC4R agonist: reverse hyperphagia and promote Injection site reactions, weight loss through decreased caloric intake and hyperpigmentation increase energy expenditure 3. Within the context of obesity treatment, explain the term, undeclared ingredients. Many products in market are sold for being pure herbs yet to make them effective they may be adulterated by adding medicines. 4. Mention the effect of morbid obesity on drug: absorption and distribution. Effects on absorption: The gastrointestinal transit is accelerated, and the gastric empty time is shortened, that can reduce the solubilization and absorption of some oral drugs. Absorption from the subcutaneous tissue will be slowed due to poor blood flow to subcutaneous fat. Effects on distribution: The drug distribution is probably the most impacted by the obesity-related changes because the fat mass (FM) increases leading to an important increase of the volume of distribution for lipophilic drugs. 16 5. Explain the pharmacological basis of each of the following observations after bariatric surgery: (short+ MCQ) a- Impaired absorption of extended -release preparations - It is better to give liquid formulation after bariatric surgeries. Extended-release drugs may have reduced bioavailability as a result of a significant portion of the gastric tract being bypassed. This can be important in critical drugs such as anti-epileptics. Possibly, switch oral solid medications doses to: liquid formulation - using non-oral dose forms – immediate release formulations. b- Decreased absorption of acetyl salicylic acid Acetyl salicylic acid is more soluble at an acidic pH and absorbed in the stomach, Bariatric procedures such as gastric bypass or sleeve gastrectomy, lead to decreased production of HCl and an increase in gastric pH. c- Increased absorption of allopurinol Allopurinol (basic drug) is soluble in an alkaline environment and absorbed in the small intestine. Bariatric procedures such as gastric bypass or sleeve gastrectomy, lead to decreased production of HCl and an increase in gastric pH. d- More rapid onset of orally administered morphine and midazolam - Caution is necessary when prescribing an oral opioid or midazolam. After bariatric surgery, patients may be more prone to rapid gastric emptying time, higher absorption rates and, consequently, higher and earlier peak concentrations (Cmax) (resulting from lower Vd) which causes a quicker drug onset. This may be of relevance for sedatives or opioids such as midazolam and morphine. 6. In general, what supplements are usually needed after bariatric surgery? (short+ MCQ) Should include 1–2 adult multivitamin-plus-mineral supplements: 1200–2400 mg elemental calcium 3000 IU vitamin D (titrated to therapeutic amounts), and 250–350 mg vitamin B-12/d or 1000 mg vitamin B-12/wk Thiamin: Thiamin deficiency may appear due to a combination of rapid weight loss, decrease in consumption, and persistent vomiting postoperatively Zinc: Zinc deficiency induces hair loss, impaired sense of taste, and sexual dysfunction Selenium is absorbed primarily in the duodenum; therefore, patients after malabsorptive procedures such as RYGB and BPD are at risk of selenium deficiency The separation of calcium and iron supplements is recommended & If iron concentrations continue to remain low with oral supplementation, intravenous iron is recommended. Vit A and Folic acid are also supplied. 7. How can bariatric surgery affect drug distribution. (short+ MCQ) Decrease in fat decreases the Vd of fat-soluble drugs Many patients experience hypoalbuminemia after bariatric surgery, with decreased plasma protein binding of drugs and this increases the free plasma fraction and causes decrease in the volume of distribution (Vd). 17  Practical course 5: Nutrition 1. Match each of the following nutraceuticals with its action: 1. Curcumin a) Improve insulin sensitivity and regulate blood sugar in type 2 diabetes 2. Ginkgo b) Herbal supplement enhances cognitive function and may help in preventing Biloba Alzheimer's disease 3. Isoflavones c) A carotenoid may reduce risk of prostate cancer d) Found in soy products, support bone density particularly in postmenopausal 4. Lycopene women 5. Omega-3s e) Fatty acids reduce risk of neurodegenerative diseases f) Has anti-inflammatory and antioxidant properties, and help inhibit the growth of 6. Polyphenols cancer cells 1-f 2-b 3-d 4-c 5-e 6-a 2. Enumerate clinical applications of probiotics. Gastrointestinal Disorders: Probiotics are used to manage conditions like irritable bowel syndrome (IBS) and antibiotic-associated diarrhea. Allergic Diseases: Probiotics might reduce the incidence and severity of allergic diseases such as atopic dermatitis, asthma, and other allergies. Metabolic Disorders: Probiotics can be used to manage metabolic conditions like obesity, type 2 diabetes, and hyperlipidemia by influencing lipid metabolism, improving insulin sensitivity, and reducing systemic inflammation. Urogenital Health: Probiotics have a role in preventing and treating recurrent urinary tract infections (UTIs) and bacterial vaginosis by maintaining the vaginal microbiota balance and producing antimicrobial substances. Mental Health: Emerging evidence suggests that probiotics may have benefits in mental health disorders, such as depression and anxiety, by influencing the gut-brain axis and modulating neurotransmitter production. 3. Classify antioxidants and mention 2 examples for each. A- Endogenous Antioxidants: produced by the body, They include: Enzymatic Antioxidants: Such as superoxide dismutase (SOD), catalase, (CAT) and glutathione peroxidase (GPx). These enzymes help convert free radicals into less harmful molecules. Non-Enzymatic Antioxidants: Such as vitamins D, reduced glutathione (GSH) , and polyphenols. These compounds directly scavenge free radicals B- Exogenous Antioxidants: obtained from the diet or supplements and include vitamins (like vitamin C and vitamin E), minerals (such as selenium), and various phytochemicals (like flavonoids and polyphenols). 18 4. Explain potential benefits of antioxidant supplementation. 1-Cardiovascular Health: Antioxidant therapy may inhibit atherosclerosis and thereby prevent the clinical complications of the disease such as CAD, and in particular, MI. 2-Cancer Prevention: Antioxidants may help prevent cancer by protecting cells from oxidative damage that can lead to mutations. However, the evidence is mixed, and while some studies show a protective effect, others do not. 3-Neuroprotection: Diseases like Alzheimer's and Parkinson's have been associated with oxidative stress. Antioxidants may help protect neural cells from damage and reduce the risk or progression of these diseases. 4-Immune System Support: Antioxidants play a role in maintaining a healthy immune system. 5-Anti-aging: Antioxidants protect cells against premature abnormal aging. 5. Explain the drug nutrient interaction between: (short+ MCQ) a. Warfarin and Vitamin K - Mechanism: Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors. High intake of vitamin K (found in green leafy vegetables like spinach and kale) can reduce warfarin's effectiveness by promoting clotting factor synthesis. - Management: Patients on warfarin are advised to maintain consistent vitamin K intake rather than avoiding it completely. Frequent monitoring of the International Normalized Ratio (INR) is necessary to adjust warfarin dosage accordingly. b. Proton Pump Inhibitors (PPIs) and Calcium, Magnesium and Vitamin B12 - Mechanism: PPIs reduce stomach acid, which is necessary for the absorption of certain nutrients like magnesium, calcium, and vitamin B12. Long-term use can lead to deficiencies and associated complications, such as bone fractures or neurological symptoms. - Management: Patients on long-term PPI therapy should be monitored for nutrient deficiencies. Supplementation or using the lowest effective PPI dose is recommended. 6. Explain: (short+ MCQ) a. Grapefruit juice can increase risk of muscle pain - Mechanism: Grapefruit juice contains compounds that inhibit cytochrome P450 3A4 (CYP3A4), an enzyme involved in metabolizing many drugs (e.g., statins, calcium channel blockers). This inhibition can lead to increased drug levels and a higher risk of toxicity. - Management: Patients taking drugs metabolized by CYP3A4 should avoid grapefruit juice or consult with their healthcare provider for guidance. For instance; Statins (Atorvastatin, Simvastatin, Lovastatin). Effect: Grapefruit juice can increase blood levels of these statins, leading to a higher risk of muscle pain, weakness (myopathy), and a rare but serious condition called rhabdomyolysis. b. Calcium can affect antibacterial activity of tetracyclines (iron/ fluoroquinolones) - Mechanism: Calcium and iron can bind to certain antibiotics (e.g., tetracyclines, fluoroquinolones) and reduce their absorption. - Management: It is generally recommended to take these antibiotics at least 2 hours before or 6 hours after consuming calcium or iron supplements. 19  Practical course 6: Sleep managment 1. Which of the following is a recommendation with the use of hypnotics? a. They can be used for as long as requested by the patient. b. Elderly patients should be warned and monitored for the risk of falls c. Hypnotics should always be combined with anti-anxiety agents to enhance effectiveness. d. Patients with hepatic disease would require higher doses because of diminished activation of hypnotics in the liver. e. Patients with respiratory disease would require higher doses because they find it more difficult to sleep. Answer: B 2. How do benzodiazepines produce CNS depression? Explain each of the following: Benzodiazepines are considered allosteric modifiers of GABA. Benzodiazepines stimulate specific Bz-receptors Benzodiazepine receptors are of 2 types Bz1 & Bz2 (Omega ω1 & ω2). They bind to GABA-A receptors at a site different from where GABA binds. The site of binding is named the “Benzodiazepine receptor-BZ", and there are BZ1 and BZ2 receptors. Binding of a benzodiazepine to its receptor site increases the affinity of GABA for the GABA- binding site This increases the frequency of the opening of the ion channel controlled by the GABA-A receptor. Opening of the central ion channel, allows chloride entry. This causes hyperpolarization of the neuron and decreases neurotransmission by inhibiting the formation of action potentials. Thus, benzodiazepines allosterically modify GABA action. 3. Explain each of the following: (short+ MCQ) A) Unsatisfactory response to benzodiazepines might be seen in patient with recent history of alcohol consumption. Due to Cross tolerance with alcohol ➔ unsatisfactory therapeutic response when standard doses are used in a patient with a recent history of excessive use of alcohol B) It is recommended to prescribe benzodiazepines for the shortest duration possible. To avoid Psychological and physical dependence that can be worse than that of opioids if large doses are given for long periods (more than a week) C) Describe withdrawal to benzodiazepines. withdrawal symptoms such as: o Anxiety, Restlessness, Confusion, Insomnia o Orthostatic hypotension o hyperactive reflexes and generalized seizures. Withdrawal is more common with the short acting 20 D) Tolerance to benzodiazepines is considered dynamic in nature. Due to changes in responsiveness of the CNS E) The anti-depressant, mirtazapine might be effective as a hypnotic. An older tricyclic antidepressant Strong antihistamine properties Used off-label for the treatment of insomnia 4. Based on kinetic properties, why would eszopiclone cause less tolerance (milder withdrawal) than that caused by zaleplon? (short+ MCQ) Eszopiclone: Half life of 6 hours, Tolerance is less than that of zaleplon (half life of 1 hour) 5. Classify the following hypnotics as either suitable to improve sleep latency or sleep duration: (short+ MCQ) Eszopiclone, lorazepam, ramelteon, Suvorexant, triazolam & zaleplon Suitable to improve sleep latency: ramelteon, triazolam, zaleplon Suitable to improve sleep duration: Eszopiclone, lorazepam, Suvorexant 6. Mention the name and the mechanism of action of an over-the-counter OTC product for insomnia. (short+ MCQ) Some antihistamines with sedating properties, such as : Diphenhydramine, Hydroxyzine & Promethazine cross BBB and cause sedation (1st generation antihistaminics) and has Anticholinergic effects. Some are marketed in over-the-counter (OTC) products. 7. Mention three cautions with writing hypnotic prescriptions. (short+ MCQ) 1.A dose that does not impair mentation or motor functions during waking hours. 2.Prescriptions should be written for short periods 3.Assess the efficacy of therapy from the patient’s subjective responses. 4.Combinations of antianxiety agents should be avoided 5.Patients should be cautioned about the consumption of alcohol and the concurrent use of over-the- counter medications containing antihistaminic or anticholinergic drugs 6.Excessive CNS effects in the elderly: “The most common reversible cause of confusional states in the elderly is overuse of sedative/hypnotics.” 7.Increased sensitivity to sedative-hypnotics is more common in patients with cardiovascular disease, respiratory disease, or hepatic impairment 8. Describe a strategy for management of jet-lag. (short+ MCQ) 1. Timed melatonin or melatonin agonist ramelton ⇨ To help advance the circadian phase after eastward travel across up to seven time zones, to be started on the evening of arrival and continued for up to 5 days. 2. Hypnotics ⇨ benzodiazepines and non-benzodiazepine, not for routine use, can cause next-day performance deficits. 21  Temazepam, midazolam, and triazolam; May cause and anterograde amnesia. The non-benzodiazepine zolpidem and zopiclone 3. Caffeine and other stimulants ⇨ Judicious use of caffeine is generally safe and can help offset daytime sleepiness associated with jet lag, but may lead to sleep disruption in some cases. N.B Benzodiazepines with anti- convulsant effect: Diazepam, Clonazepam &Lorazepam Triazolam can be used after a secondary event as A secondary short-term aid, added to psychotherapy. Which of the followings is a benzodiazepine’s members that is used as antidepressant: Alprazolam Practical course 7: Pain & Drug abuse 1. Describe the sequence of use of analgesics according the WHO’s analgesic ladder. (short+ MCQ) WHO Analgesic Ladder The original ladder mainly consisted of three steps: 1. First Step - Mild pain: non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen with or without adjuvants 2. Second Step - Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics and with or without adjuvants 3. Third Step - Severe and persistent pain: potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone) with or without non-opioid analgesics, and with or without adjuvants 2. What is the function of the opioid conversion table? (short+ MCQ) The opioid conversion table can be used to shift between different opioids or formulations of the same opioid 3. Mention three examples of analgesic adjuvants. Tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine. Anticonvulsants like gabapentin and pregabalin Topical therapies (e.g., capsaicin) 4. Mention the basic principles of the WHO analgesic ladder. (short+ MCQ) The three main principles of the WHO analgesic ladder are: “By the clock, by the mouth, by the ladder.” This means that drugs should be taken regularly and at regular intervals, orally whenever possible, and analgesics should be prescribed starting at Step 1 (nonopioid analgesics) and titrated upward as needed. 5. What is the goal for PCA (patient-controlled analgesia). (short+ MCQ) The goal of PCA is to efficiently deliver pain relief at a patient's preferred dose and schedule by allowing them to administer a predetermined bolus dose of medication on-demand at the press of a button. 6. For which type/s of pain can PCA (patient-controlled analgesia) be used? (short+ MCQ) PCA is used to treat acute, chronic, postoperative, and labor pain. 22 7. Which administration routes can be used for PCA (patient-controlled analgesia)? (short+ MCQ) Intravenously, epidurally, through a peripheral nerve catheter, or transdermally. 8. Which drugs are commonly used for PCA (patient-controlled analgesia)? (short+ MCQ) Opioids and local anesthetics 9. Why do you think does PCA (patient-controlled analgesia) increase patient satisfaction? (short+ MCQ) PCA has proven to be more effective at pain control and results in higher patient satisfaction. 10. What feelings promote compulsion on the use of opioids? The euphoria, indifference to stimuli, and sedation usually caused by the opioid analgesics, especially when injected intravenously, tend to promote their compulsive use 11. Describe the main features of opioid withdrawal. (short+ MCQ) Acute Effects: Euphoria (rush), Apathy: drowsiness & hypo activity. Risks of Chronic Abuse 1. Fatal overdose - homicide - suicide - accidents. 2. Risk of infections due to syringes (hepatitis, AIDS). Withdrawal Syndrome: 1. Craving for the drug - anxiety - insomnia - tremors. 2. Piloerection – mydriasis - lacrimation - rhinorrhea. 3. Tachycardia - hypertension - hot & cold flushes. 4. Abdominal cramps - vomiting – diarrhea 12. How to minimize problems presented by tolerance and dependence when using opioid analgesics? (short+ MCQ) Establish therapeutic goals before starting opioid therapy. The patient and his or her family should be included in this process. Once an effective dose is established, attempt to limit dosage to this level. Instead of opioid analgesics—especially in chronic management—consider using other types of analgesics or compounds exhibiting less pronounced withdrawal symptoms on discontinuance. Frequently evaluate continuing analgesic therapy and the patient’s need for opioids. 13. Outline the management of opioid addiction. (short+ MCQ) Methadone or buprenorphine: Replace heroin or morphine by methadone. Gradual withdrawal of methadone (longer-acting) is less severe. Naltrexone: Given chronically after detoxification to block opioid receptors, loss of euphoric effects of opioids, loss of desire to take the drug. Symptomatic treatment of withdrawal symptoms: Anxiolytics - antiemetics – antispasmodics & Clonidine (inhibits sympathetic discharge). 14. Chronic bronchitis and airway injury is a feature of the heavy consumption of which of the following? a. Cannabis 23  b. Clonidine c. Fentanyl d. Morphine Answer: A 15. Match each of the following drugs used in the management of opioid addiction with its most likely function: 1. Clonidine a. Control vomiting 2. Methadone b. Decrease withdrawal manifestations 3. Naltrexone c. Maintain abstinence d. Prevent tachycardia 1-d 2-b 3-c 16. Describe the effects of cannabis on mood and perception. Euphoria and relaxation. Feelings of well-being, grandiosity, and altered perception of passage of time. Dose-dependent perceptual changes (e.g., visual distortions), drowsiness, diminished coordination, and memory impairment may occur. 17. Describe physical and psychological changes with cannabis withdrawal. (short+ MCQ) Irritability, anger, aggression, insomnia, depressed mood, weight loss, loss of appetite, difficulty in concentration and headache. Symptoms of cannabis withdrawal appear after 24 hr of abstinence, reach their peak around 2-6 days and remit within 2 weeks but impaired sleep pattern may persist for longer periods. 18. Outline the management of cannabis addiction. (short+ MCQ) Psychosocial treatment Pharmacotherapy: (Potential treatments) Cannabinoid agonist as dronabinol and nabilone, reduce withdrawal manifestations Gabapentin and naltrexone also show promise 19. Some countries legalize cannabis and approve it for some indications. Mention three examples of such indications. (short+ MCQ) Biological Effect Approved Therapeutic Prescription Inhibition of nausea and vomiting Co-adjuvant in antitumoral therapy in cancer patients Stimulation of appetite Co-adjuvant in anorexia-cachexia syndrome in AIDS patients Treatment of chronic pain in multiple sclerosis patients (also Analgesic action oncologic and neuropathic pain) Reduction of spasticity Treatment of spasticity in multiple sclerosis patients (also tremor) Anticonvulsant action Reduction of seizures in pediatric refractory epileptic syndromes N.B.The dopamine hypothesis of addiction involves: Dopaminergic stimulation is responsible for the reward sensation after drug administration. 24  Practical course 8: CNS Emergencies 1. Status epilepticus is classified depending on how long status epilepticus lasts and how it responds to treatment. In the table below suggest one drug for each stage: (short+ MCQ) Stage 1: time period t1, Benzodiazepines Early SE prolonged seizure 5′–10′ IV Lorazepam Stage 2: −10′–30′ Non-sedating IV Anti-Epileptic Drugs Established Phenytoin OR Fosphenytoin OR Valproate SE OR Levetiracetam Stage 3: −30′–60′ EEG monitoring—IV anesthetic agents refractory SE Propofol: (can be repeated if necessary) OR Midazolam OR Thiopental OR Pentobarbital Stage 4: super- (>24 h) EEG monitoring—IV anesthetic agents refractory SE (propofol/midazolam) + IV ketamine 2. Match each of the following drugs in column A with their relation to serotonin in column B 2,8,11: f 1  serotonin synthesis L-Tryptophan (dietary supplement) 2 Serotonin receptor agonists - Triptans (TEB) - Ergot derivatives - Buspirone 3 Increase serotonin release - Amphetamines - Cocaine 4 Inhibit serotonin uptake - Amphetamines - Cocaine - Antidepressants (SSRIs, TCSs, atypical- duloxetine, venlafaxine) - Dextromethorphan - Meperidine & tramadol - St. John’s wort 25  5 Inhibit serotonin - MAO inhibitors metabolism - Linezolid 3. Outline serotonin syndrome management. (short+ MCQ) Prompt Recognition Supportive Care: to control agitation, hyperthermia, and autonomic dysfunction. Discontinuation of Serotonergic Agents Intensive Care Unit Monitoring if needed External Cooling Muscular Paralysis with neuromuscular blocking agents may be necessary. Mechanical Ventilation Sedation and Muscle Relaxation: with IV Benzodiazepines Nonspecific Serotonin Receptor Blockers: such as Cyproheptadine, chlorpromazine and methysergide. Pharmacological Interventions: 1- Benzodiazepines, such as lorazepam or diazepam, are integral to the treatment of mild-to-moderate serotonin syndrome. 2- Oral Cyproheptadine: an antihistamine with nonselective antiserotonergic effects, may be considered in patients with moderate or severe symptoms 3- Paralysis with nondepolarizing agents, immediately followed by orotracheal intubation and mechanical ventilation, should be considered for patients with hyperthermia (temperature >38.5 °C), severe truncal rigidity 4. Mention two examples of drugs or drug classes that can cause neurolept malignant syndrome. (short+ MCQ) 1- Typical neuroleptics: e.g. haloperidol, chlorpromazine. 2- Atypical neuroleptics: e.g. olanzapine, clozapine, risperidone 3 Anti-dopaminergic antiemetics: e.g. metoclopramide 4- Withdrawal of dopaminergic agents: e.g. levodopa 5. Outline the treatment of neurolept malignant syndrome. (short+ MCQ) 1- Discontinue, switch or reduce antipsychotics depending on severity 2- Anticholinergics are contraindicated in NMS, unless very mild with only rigidity. 3- Lorazepam for stupor or confusion 4- Fluids and cooling 5- Bromocriptine and amantadine may be used in moderate case 6- Dantrolene for sever cases (blocker of ryanodine receptor, preventing Ca release from the sarcoplasmic reticulum) 26 5- Explain the mechanism of action of IVIG in the treatment of Guillain-Barré Syndrome. (short+ MCQ) the mechanism of action of IVIG is not understood fully, proposed mechanisms include: suppression of IgG production, accelerated catabolism of IgG, neutralization of complement-mediated reactions, neutralization of pathogenic antibodies, down-regulation of inflammatory cytokines and inhibition of autoreactive T lymphocytes N.B. Plasma exchange can be a management strategy for: Guillain-Barré Syndrome Practical course 9: IV Fluids 1. Hypertonic electrolyte solutions… a. Mainly distribute intracellularly b. Are considered plasma expanders as they contain proteins. c. Replace lost interstitial fluid. d. Exert osmotic power on interstitial water. 2. Giving which of the following solutions is equivalent to giving pure water? a. D5W b. Lactated Ringer c. Saline 0.45% d. Saline 0.9% 3. Enumerate indications of isotonic saline. (short+ MCQ) 1. To expand ECF volume in a hypovolemic patient. 2. To treat hyponatremia in a hypovolemic patient. 3. To treat hypernatremia in a patient with hypotension. 4. To treat saline-responsive metabolic alkalosis. 5. Preferred solution in a patient requiring contrast study. 6. Second preferred solution in critically ill patients with shock, ARDS, and at times burned patient. 7. Use cautiously in patients with Na+ overload such as CHF and liver failure. 4. Ensuring a gradual rise in plasma concentration of NaCl is important to avoid Osmotic Demyelination syndrome. (short+ MCQ) 5. Explain the following: (short+ MCQ) a- Hypertonic saline may be preferred over mannitol in head trauma. ❑ Greater magnitude of ICP reduction. ❑ Longer duration of action. ❑ No rebound increase in ICP b- Lactated Ringer will not act as a buffer in hypoxia. Lactate is converted into HCO3 - in the liver but needs oxygen to be converted into HCO3 27 c- We use lactated Ringer cautiously in hepatic impairment. As hepatic failure impairs lactate metabolism with a risk of lactate accumlation d- We use lactated Ringer cautiously in renal impairment. Because of potential development of hyperkalemia. e- We use lactated Ringer cautiously in calcium or potassium deficiency. Ringer's Solution for Infusion contains insufficient concentration of potassium and calcium to be used for maintenance of these ions or to correct their deficits. f- Lactated Ringer may lead to cerebral edema in cases of closed head injury. Being slightly hypotonic (avoid in Closed Head Injury due to Increased Intracranial Pressure risk → cerebral edema). g- Lactated Ringer cannot be used to dilute blood products. Calcium in RL can bind the citrated anticoagulant in blood product. h- D5W cannot be used as a plasma expander. D5W primary expands the intracellular volume (hypotonic) i- We cannot directly give pure water intravenously. Pure water causes hemolysis, if given IV; therefore, D5W is given to provide pure water. 6. Mention adverse effects of giving NaCl solution. (short+ MCQ) Hyperchloremic Metabolic Acidosis and DEATH due to increasing chloride levels. Does not provide free water or calories. Interstitial edema Possible Acute renal injury (Cl causes renal vessel Vasoconstriction). 7. Which of the following is regarded as a balanced electrolyte solution? a. Dextran b. D5W c. Isotonic saline d. Lactated Ringer solution 8. Enumerate indications of lactated Ringer solution. (short+ MCQ) Used instead of isotonic sodium chloride solution during or after surgery. In the initial management of the injured, burned or wounded. It may reduce the risk of hyperchloraemic acidosis. To correct metabolic acidosis with hypokalemia (infrequently)- contains potassium 28 9. Mention 3 medications that can’t be used with lactated Ringer. (short+ MCQ) Ceftriaxone- Amphotericin B- Cortisone. 10. How would excess D5W change the following in plasma? (short+ MCQ) a. Na, K, Mg, P Dilution of serum electrolytes causing electrolyte disturbances such as: Hyponatremia, Hypokalemia, Hypophosphataemia and Hypomagnesaemia. b. Osmolarity Hypoosmolality c. Lactate Enhance lactate production, more in tissue hypo-perfusion. d. Glucose Hyperglycemia. For each phrase in column A, choose a suitable solution from column B. 1 d 17 d 2 a 18 e 7 d 19 b 11 a 20 c 12 b 21 b 13 f 22 c 14 b 23 b 15 c 24 c 29  16 e 25 e Practical course 10: Treatment of selected infectons (Typhoid, UTIs, Rheumatic fever) Case 1 1) A 54-year-old woman with type 2 diabetes presents with burning sensation during urination, loin angle tenderness, chills, and nausea. Urinalysis was remarkable for WBC ≥ 103 CFU/mL. Which of the following is an appropriate initial treatment option to treat the urinary tract infection in this patient.? a) Carbapenems b) Vancomycin c) Ciprofloxacin d) Gentamicin 2) If the cultures reveal P. aeruginosa, which of the following is the most appropriate choice to treat the urinary tract infection in this patient? a) Vancomycin b) Carbapenems c) Nafcillin d) Clindamycin Case 2 3) A 13-year-old child came to the clinic complaining of high-grade fever, headache, cough, abdominal distension and maculopapular rash. He was suspected to have typhoid fever. The decision to start an empiric therapy was taken till the results of culture & sensitivity are received. The doctor will probably prescribe this oral drug as an empirical therapy: a) Ceftriaxone b) Azithromycin c) Piperacillin d) Vancomycin 4) If this patient was 25 years old with no contraindications, what would be the doctor’s first choice for treatment of this patient? a) Ciprofloxacin b) Amoxicillin c) Cotrimoxazole d) Chloramphenicol Case 3 5) Adel is a 9-year-old boy who complains of fever above 39, headache, malaise. Diagnosis of acute rheumatic fever was made; he should be treated with: a) Benzathine Penicillin orally in a dose of 1,200,000 units b) Benzathine Penicillin i.m in a dose of 1,200,000 units c) Benzathine Penicillin orally in a dose of 200,000 units 30 d) Levofloxacin orally 750 mg/day e) Ceftriaxone i.m 1-2 g/day 6) After 24 days, he noticed painful swollen joints. For this, the patient will be treated with: a) Aspirin b) Azithromycin c) Prednisolone d) Clindamycin e) Haloperidol 7) The beneficial effect of the drug given is: a) Treatment of the acute inflammatory manifestations of the disease b) Providing prophylaxis against bacterial endocarditis c) Supportive treatment of congestive heart failure d) Reduction in mortality rate e) Treatment of streptococcal pharyngitis 1C, 2B, 3B, 4A, 5B, 6A, 7A 1- Outline general measures of UTI treatment. (short+ MCQ) A) Culture Sensitivity test. B) High fluid intake: to induce diuresis. C) Alteration of Urinary pH: 1- To increase efficacy of Anti-Microbials: a- Acid urine (pH < 5.5 by Ammonium chloride, Ascorbic acid, Sodium acid phosphate, Methionine & Mandelic acid) increases activity of Penicillins, Tetracyclines, Methenamine & Nitrofurantoin. b- Alkaline urine (By Na or K Acetate, Bicarbonate, Citrate & Lactate) increases activity of Sulfa, Streptomycin, Gentamicin & Erythromycin. 2- To decrease Growth of some organisms: Alkaline urine decreases the growth of E. coli. 3- Alkalinization of urine Relieves dysuria. 2. Which of the following agents will NOT require acidification of urine to enhance its action? a. Amoxicillin b. Methenamine c. Nalidixic acid d. Nitrofurantoin 3. Which of the following antibiotics for UTI treatment would not be given orally? a. Amoxicillin b. Ciprofloxacin c. Ceftriaxone d. Trimethoprim/sulphamethoxazole 31 4-Tick to choose the correct role of each antibiotic in the following matrix. first line in typhoid fever (short+ MCQ) Fully susceptible Fully susceptible Multi-drug Fluoroquinolone ` Empirical first line second line resistant resistant Amoxicillin ✓ Azithromycin ✓ ✓ ✓ Ceftriaxone ✓ ✓ ✓ Ciprofloxacin ✓ ✓ ✓ (high dose) 5. Mention three alternative antibiotics for typhoid carrier, with duration of treatment, no doses required. (short+ MCQ) Treatment Duration Amoxicillin or Ampicillin + probenecid 6 weeks TMP-SMZ 6 weeks Ciprofloxacin OR Norfloxacin 28 days 6. List antimicrobials for eradication of Group A beta Hemolytic Streptococci (GAS) for penicillin allergic and non-allergic patients. (short+ MCQ) A. Penicillins (drug of choice): 1. Benzathine penicillin G (IM 0.6-1.2 million - single dose) Or 2. Penicillin V (Oral for 10 days) B. For patients allergic to penicillin: 1. Azithromycin Or 2. Clarithromycin Or 3. Clindamycin 7. Outline treatment for rheumatic arthritis and carditis. (short+ MCQ) A. Analgesics (until diagnosis is confirmed) 1. Paracetamol (till relief or NSAIDs start) 2. Codeine (till relief or NSAIDs start) B. Anti-inflammatory 1. Aspirin (relieves all inflammtion except chorea), for 3-6 wks after improvent Or 2. Naproxen (if intolerant to aspirin) 3. Steroids: prednisone or prednisolone (plus aspirin in severe arthritis & in carditis) 8. Outline the treatment of sever rheumatic chorea. (short+ MCQ) Rheumatic chorea is usually self-limiting and improves by rest Only severe persistent cases require medications Medications should be continued till chorea improve for several weeks and then a trial off medication is attempted: Haloperidol 32  Carbamazepine Valproic acid 9. Mention important education points for patients with rheumatic fever (short+ MCQ) Antibiotic prophylaxis before dental and other surgical procedures to protect against endocarditis is so important if there is a cardiac lesion. Avoid Sodium salicylates e.g. Rh heart failure and hypertension. Take aspirin with food, milk, or 1 to 2 teaspoons of antacid, and drink at least 240 m of water. Be aware of adverse effects: o Bleeding. o Hearing changes. Steroids: monitor for adverse effects: Practical course 11: Treatment of selected infections (CAP& HAP) 1. Mention two alternative antibacterial therapies that can be used for the treatment of community- acquired pneumonia in absence of comorbidities and absence of risk factors for MRSA. (no doses required) (short+ MCQ) Amoxicillin or Doxycycline or Macrolide (if local pneumococcal resistance < 25%) e.g. Azithromycin or Clarithromycin or Extended-release clarithromycin. 2. Mention two alternative antibacterial therapies that can be used for the treatment of community- acquired pneumonia for a patient with diabetes mellitus but in absence of risk factors for MRSA. (no doses required) (short+ MCQ) Monotherapy with a respiratory fluoroquinolone: Levofloxacin Moxifloxacin Gemifloxacin OR Beta-lactam plus macrolide OR beta-lactam plus doxycycline 3. Describe the recommendations for the duration of antimicrobial treatment of patients with community-acquired pneumonia. (short+ MCQ) ‫هام جدا‬ The duration of therapy for uncomplicated CAP is usually 5 days. The duration of therapy for CAP due to suspected or proven Pseudomonas or MRSA is typically 7 days. Patients should be afebrile for 48 to 72 hours and have no signs of instability before antibiotic therapy is stopped. 33  The duration of therapy may need to be increased if the initial empiric therapy has no activity against the specific pathogen or if the pneumonia is complicated by extra pulmonary infection. 4. Mention two alternative antibacterial therapies that can be used for the treatment of hospital-acquired pneumonia in the absence of risk for MRSA and for mortality. (no doses required) 5. Mention two alternative antibacterial therapies that can be used for the treatment of hospital-acquired pneumonia in the presence of risk for MRSA in the absence of mortality risk. (no doses required) 6. Mention two alternative antibacterial therapies that can be used for the treatment of hospital-acquired pneumonia in the presence of risk for MRSA and for mortality. (no doses required) (short+ MCQ) 34  Practical course 12: Treatment of selected infections (Meningitis) 7. A 25-year-old male patient came to the ER with very high fever, severe headache, and projectile vomiting. He was labeled as a case of suspected meningitis. It was decided that a CT scan is needed for this patient before he could be subjected to lumbar puncture (LP). Which of the following would be the action of choice? a. Delay both antibiotics and dexamethasone until LP is done. b. Delay antibiotics until LP is done but give dexamethasone. c. Delay dexamethasone until LP is done but give the patient antibiotics. d. Give both antibiotics and dexamethasone and don’t wait for LP. e. Give both antibiotics and dexamethasone after CT. Answer: e 8. Outline general rules for antibiotic treatment of bacterial meningitis. (short+ MCQ) NO delay Empiric Parenteral (except rifampicin) Bactericidal: CSF ➔ impaired humoral immunity Optimize antibacterial efficacy High doses for long duration Regimen modification is permitted: so start early and modify. For example: If you suspect severe penicillin or cephalosporin allergy don’t wait for a test dose result, give moxifloxacin Don’t wait for LP result if the patient needs a CT Don’t wait for LP result or culture result 9. For each of the following age groups mention a regimen for empirical treatment of meningitis: (short+ MCQ) < 1 month Ampicillin plus cefotaxime; OR ampicillin plus an aminoglycoside 1 to 23 months Vancomycin plus a third-generation cephalosporin 2 years to 50 years Vancomycin plus a third-generation cephalosporin > 50 years Vancomycin plus Ampicillin plus a third-generation cephalosporin 10. For each of the following pathogens mention a regimen for treatment of meningitis: (short+ MCQ) Microorganism Recommended therapy Streptococcus pneumoniae Vancomycin plus a third-generation cephalosporin Neisseria meningitidis Third-generation cephalosporin 35  Listeria monocytogenes Ampicillin or penicillin G Haemophilus influenzae Third-generation cephalosporin HSV (Herpes Simples Virus) Acyclovir CMV (Cytomegalovirus) Ganciclovir Mycoplasma A macrolide or a fluoroquinolone Listeria Ampicillin or TMP/SMZ Helminths Albendazole can be effective for many of them Mycobacteria (TB) A combination of 4 anti-TB drugs Fungi Fluconazole or amphotericin B According to pathogen Protozoa Variable but TM/SMZ can be effective for many of them 11. Explain the role of dexamethasone in the treatment of meningitis. (short+ MCQ) Decreases neurological complications Given before or with the first antibiotic dose Continue if Gram stain reveals Streptococcus pneumoniae 36  Practical course 13: Antimicrobial Prophylaxis 1. Classify the following antibiotics into narrow or broad-spectrum: Tetracyclines, chloramphenicol, aminoglycosides, erythromycin Narrow-Spectrum Broad-Spectrum Vancomycin Broad spectrum & antipseudomonal penicillins Erythromycin, clarithromycin, azithromycin Tetracyclines Aminoglycosides Chloramphenicols Sulfonamides Clindamycin Trimethoprim 2. Classify the following anti-microbials into bacteriostatic or bactericidal: Aminoglycosides, cephalosporins, clindamycin, erythromycin, quinolones, tetracyclines Bactericidal Bacteriostatic Bacteriostatic (low conc.) & Bactericidal (high conc.) Inhibitors of cell wall synthesis Tetracyclines Erythromycin Aminoglycosides Macrolides Chloramphenicol Co-trimoxazole Clindamycin Quinolones Sulfonamides Rifampicin Trimethoprim Metronidazole 3. Explain the following: (short+ MCQ) a- Penicillins and aminoglycosides should not be mixed together in the same syringe. They precipitate each other (inactivate each other by forming a complex) b- Bacteriostatic and bactericidal antibiotics should not be combined for the simultaneous treatment of the same organism. A bactericidal antimicrobial will not act effectively EXCEPT with actively- growing microorganisms. c- It is better not to use aminoglycosides and vancomycin together for a long time. Both are nephrotoxic and ototoxic antimicrobials d- Non antibiotic prophylaxis is usually required for neurosurgical procedures Clean wound. 4. Which of the following anti-bacterials will have neither a systemic nor a local effect when given orally? a. Neomycin b. Penicillin G c. Sulphasalazine d. Vancomycin 37 5. Give two examples of 2nd line anti-TB drugs from two different anti-microbial classes. Aminoglycosides Fluoroquinolones Streptomycin Ciprofloxacin Kanamycin Levofloxacin Amikacin Gatifloxacin, Moxifloxacin For each phrase in column A, choose a suitable antimicrobial from column B. For each operation/procedure in column A, choose a suitable form of prophylaxis column B. 4 b 12 g 6 e 13 f 7 e 14 e 8 d 15 a 9 g 16 j 10 c 17 D 11 f 18 B 19 h 38  No Justification for Antimicrobial Prophylaxis Surgical prophylaxis Non-surgical prophylaxis Neurosurgery Clean wound. Urinary catheter. Cardiac catheterization. Gynecological Diagnostic laparoscopy. Head & Neck surgery No prosthesis. Intra-uterine device. Tonsillectomy. Endometrial biopsy. Endoscopic sinus procedures. Gastrointestinal & Splenectomy Elective, low risk. Orthopedic Clean involving knee, hand, foot + No prosthesis. Collection Antimicrobials Sulfonamides Drink plenty of fluids + Urinary alkalinization HME inhibitors Chloramphenicol Quinolones Metronidazole HME inducer Rifampicin Outdated tetracyclines Fanconi syndrome Chloramphenicol in premature babies Gray baby syndrome Metronidazole Disulfiram- like effect Cross- allergy & Cross- resistance Penicillins Cephalosporins Carbapenems No systemic effect if given orally Acid- labile penicillins Vancomycin Some oral sulfonamides (Sulfasalazine) Aminoglycosides Biliary excretion Cefoperazone (3rd generation cephalosporin) Ceftriaxone (3rd generation cephalosporin) Doxycycline (Highly Lipid soluble tetracycline) Moxifloxacin (Fluoroquinolone) Broad spectrum antimicrobials can cause Inhibition of normal flora > Intestine> Pseudomembranous colitis + Vagina > Candidiasis Inhibition of vitamin B synthesis Inhibition of vitamin K synthesis 39 40