Pharmacology pretest

(1)

(2)

Notice

Medi ci ne i s a n ever-cha ngi ng s ci ence. As new res ea rch a nd cl i ni ca l experi ence broa den our knowl edge, cha nges i n trea tment a nd drug thera py a re requi red. The a uthors a nd the publ i s her of thi s work ha ve checked wi th s ources bel i eved to be rel i a bl e i n thei r efforts to provi de i nforma ti on tha t i s compl ete a nd genera l l y i n a ccord wi th the s ta nda rds a ccepted a t the ti me of publ i ca ti on. However, i n vi ew of the pos s i bi l i ty of huma n error or cha nges i n medi ca l s ci ences , nei ther the a uthors nor the publ i s her nor a ny other pa rty who ha s been i nvol ved i n the prepa ra ti on or publ i ca ti on of thi s work wa rra nts tha t the i nforma ti on conta i ned herei n i s i n every res pect a ccura te or compl ete, a nd they di s cl a i m a l l res pons i bi l i ty for a ny errors or omi s s i ons or for the res ul ts obta i ned from us e of the i nforma ti on conta i ned i n thi s work. Rea ders a re encoura ged to confi rm the i nforma ti on conta i ned herei n wi th other s ources . For exa mpl e a nd i n pa rti cul a r, rea ders a re a dvi s ed to check the product i nforma ti on s heet i ncl uded i n the pa cka ge of ea ch drug they pl a n to a dmi ni s ter to be certa i n tha t the i nforma ti on conta i ned i n thi s work i s a ccura te a nd tha t cha nges ha ve not been ma de i n the recommended dos e or i n the contra i ndi ca ti ons for a dmi ni s tra ti on. Thi s recommenda ti on i s of pa rti cul a r i mporta nce i n connecti on wi th new or i nfrequentl y us ed drugs .

(3)

(4)

(5)

Copyri ght © 2013 by McGra w-Hi l l Educa ti on, LLC. Al l ri ghts res erved. Except a s permi tted under the Uni ted Sta tes Copyri ght Act of 1976, no pa rt of thi s publ i ca ti on ma y be reproduced or di s tri buted i n a ny form or by a ny mea ns , or s tored i n a da ta ba s e or retri eva l s ys tem, wi thout the pri or wri tten permi s s i on of the publ i s her.

ISBN: 978-0-07-179147-2 MHID: 0-07-179147-7

The ma teri a l i n thi s eBook a l s o a ppea rs i n the pri nt vers i on of thi s ti tl e: ISBN: 978-0-07-179146-5, MHID: 0-07-179146-9.

Al l tra dema rks a re tra dema rks of thei r res pecti ve owners . Ra ther tha n put a tra dema rk s ymbol a fter every occurrence of a tra dema rked na me, we us e na mes i n a n edi tori a l fa s hi on onl y, a nd to the benefi t of the tra dema rk owner, wi th no i ntenti on of i nfri ngement of the tra dema rk. Where s uch des i gna ti ons a ppea r i n thi s book, they ha ve been pri nted wi th i ni ti a l ca ps .

McGra w-Hi l l Educa ti on eBooks a re a va i l a bl e a t s peci a l qua nti ty di s counts to us e a s premi ums a nd s a l es promoti ons , or for us e i n corpora te tra i ni ng progra ms . To conta ct a repres enta ti ve pl ea s e e-ma i l us a t bul ks a l es @mcgra w-hi l l .com.

PreTes t™ i s a tra dema rk of McGra w-Hi l l Educa ti on LLC. TERMS OF USE

Thi s i s a copyri ghted work a nd McGra w-Hi l l Educa ti on a nd i ts l i cens ors res erve a l l ri ghts i n a nd to the work. Us e of thi s work i s s ubject to thes e terms . Except a s permi tted under the Copyri ght Act of 1976 a nd the ri ght to s tore a nd retri eve one copy of the work, you ma y not decompi l e, di s a s s embl e, revers e engi neer, reproduce, modi fy, crea te deri va ti ve works ba s ed upon, tra ns mi t, di s tri bute, di s s emi na te, s el l , publ i s h or s ubl i cens e the work or a ny pa rt of i t wi thout McGra w-Hi l l Educa ti on’s pri or cons ent. You ma y us e the work for your own noncommerci a l a nd pers ona l us e; a ny other us e of the work i s s tri ctl y prohi bi ted. Your ri ght to us e the work ma y be termi na ted i f you fa i l to compl y wi th thes e terms . THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGra w-Hi l l Educa ti on a nd i ts l i cens ors do not wa rra nt or gua ra ntee tha t the functi ons conta i ned i n the work wi l l meet your requi rements or tha t i ts opera ti on wi l l be uni nterrupted or error free. Nei ther McGra w-Hi l l Educa ti on nor i ts l i cens ors s ha l l be l i a bl e to you or a nyone el s e for a ny i na ccura cy, error or omi s s i on, rega rdl es s of ca us e, i n the work or for a ny da ma ges res ul ti ng therefrom. McGra w-Hi l l Educa ti on ha s no res pons i bi l i ty for the content of a ny i nforma ti on a cces s ed through the work. Under no ci rcums ta nces s ha l l McGra w-Hi l l Educa ti on a nd/or i ts l i cens ors be l i a bl e for a ny i ndi rect, i nci denta l , s peci a l , puni ti ve, cons equenti a l or s i mi l a r da ma ges tha t res ul t from the us e of or i na bi l i ty to us e the work, even i f a ny of them ha s been a dvi s ed of the pos s i bi l i ty of s uch da ma ges . Thi s l i mi ta ti on of l i a bi l i ty s ha l l a ppl y to a ny cl a i m or ca us e wha ts oever whether s uch cl a i m or ca us e a ri s es i n contra ct, tort or otherwi s e.

(6)

Reviewers

David Jonathan Kadouri

Uni vers i ty of Medi ci ne a nd Hea l th Sci ences —St. Ki tts Medi ca l Student

Cl a s s of 2013 Matthew Klairmont Rus h Medi ca l Col l ege

Medi ca l Student Cl a s s of 2013 Nikul Patel, MD

Uni vers i ty of Medi ci ne a nd Denti s try of New Jers ey School of Medi ci ne

(7)

Preface

Wel come to thi s , the 14th edi ti on, of Pharmacology: PreTest™ Self-Assessment and Review. I’m pl ea s ed to ha ve been i nvi ted ba ck to wri te thi s edi ti on a fter doi ng the previ ous three. Whether you’re s tudyi ng for Step 1 of the USMLE, or for a cours e exa m tha t i ncl udes pha rma col ogy content, I thi nk you’l l fi nd thi s hel pful .

I bel i eve thi s PreTest™ Self-Assessment and Review wi l l hel p you eva l ua te a nd revi ew your i ntens i ve a nd extens i ve knowl edge of pha rma col ogy a nd thera peuti cs —your knowl edge of ba s i c fa cts a nd pri nci pl es , a nd your a bi l i ty to a ppl y tha t knowl edge to s ome common cl i ni ca l s i tua ti ons .

Among the cha nges here you’l l fi nd i n “14/e” for pha rma col ogy a re:

• Ma ny new or extens i vel y revi s ed ques ti ons , mos t ba s ed on cl i ni ca l vi gnettes or s cena ri os , mos t a l rea dy tes ted on hundreds of fi rs t- a nd s econd-yea r medi ca l s tudents , a nd a l l but a s el ect few i n a forma t you’l l l i kel y s ee on Step 1. Ma ny cha nges were neces s i ta ted by the a pprova l of new drugs tha t you need to know a bout i n s ome wa y. Ma ny were ma de i n res pons e to excel l ent comments from medi ca l s tudent a nd hous e offi cer revi ewers .

• More i ntegra ti on of content between the va ri ous a rea s of pha rma col ogy a nd thera peuti cs , wi th ma ny ques ti ons tha t encoura ge you to i ntegra te new ma teri a l wi th content pres ented ea rl i er.

• A better bl end of ques ti ons tha t i ntegra te ba s i c pha rma col ogy content wi th ba s i c i nforma ti on from other precl i ni ca l di s ci pl i nes . • Cl ea rer a nd more compl ete expl a na ti ons for why correct a ns wers a re correct, a nd the others a re not.

• Upda ted cros s -references to the l a tes t edi ti ons of two wi del y us ed pha rma col ogy texts , i n the a ns wers , s o you ca n fi nd a ddi ti ona l i nforma ti on or expl a na ti ons i f you wi s h.

• An upda ted res ource tha t l ets you l ook a t s uffi xes of generi c drug na mes a nd deduce wi th rea s ona bl e (or better) certa i nty the chemi ca l or pha rma col ogi c group or cl a s s to whi ch a drug bel ongs .

(9)

Introduction

Even though your profs may tell you otherwise, pharmacology is pure memorization … the ultimate challenge in medical memorization … some remedy to dull the pain of the subject is needed.

Tha t wa s the a dmoni ti on to s tudents i n a popul a r exa m s tudy a i d.

“Baloney,” I s a y. Bei ng a rea l i s t, there ma y be s ome truth to tha t. But, rea d on, a nd you’l l s ee why I don’t thi nk tha t’s a n a bs ol ute truth, a nd certa i nl y i s n’t the bes t wa y to l ea rn pha rma col ogy.

My Perspectives on and Approaches to Learning “Pharm”

Before you get on wi th your s tudyi ng, I thought I’d gi ve you a l i ttl e i ns i ght i nto who a nother otherwi s e fa cel es s a uthor mi ght be, beca us e i t mi ght expl a i n where I’m “comi ng from” when I prepa red the ques ti ons , a ns wers , a nd expl a na ti ons you’l l fi nd here. I’ve ha d a bout 35 yea rs of tea chi ng ma ny a rea s of pha rma col ogy to more Uni vers i ty of Mi chi ga n Medi ca l School s tudents tha n I ca n count, a nd i t’s a l l been a grea t pl ea s ure a nd pri vi l ege for me. (Yup, I’m a n “ol d guy,” but for wha t i t’s worth I dri ve a bri ght yel l ow 2012 Ca ma ro converti bl e wi th a s i x-s peed ma nua l tra ns mi s s i on! Chronol ogi c a ge i s a rel a ti ve thi ng.)

I know tha t thi ngs perta i ni ng to pha rma col ogy a nd thera peuti cs a re overwhel mi ng i n terms of brea dth, deta i l , number, a nd cons equences . A genera ti on or s o a go the pha rma col ogi c a rma menta ri um (a nd wha t you os tens i bl y needed to know) wa s a s ma l l fra cti on of wha t i t i s now. We’ve pa s s ed the 10,000 drug ma rk, wi th new drugs comi ng a t a mi nd-boggl i ng frequency. Do you need to know a bout them a l l ? Ca n you pos s i bl y be ta ught a bout, or be expected to l ea rn, everythi ng?

In my opi ni on, no.

There’s s i mpl y too much i nforma ti on pres ented to you i n the precl i ni ca l yea rs , a nd even though a hos t of drugs “exi s t” there’s l i ttl e poi nt i n knowi ng a bout them a l l expl i ci tl y. Tryi ng to do s o woul d be a futi l e a nd needl es s ta s k. But no ma tter how wel l you thi nk you know your i nforma ti on (pha rma col ogi c or otherwi s e), no ma tter how compl etel y or comprehens i vel y you’ve been ta ught, a l l the content tends to become jumbl ed a nd i ncomprehens i bl e when you’re fa ced wi th the ta s k of “knowi ng i t a l l ” a l l a t once; tha t i s , when you hi t your fi rs t of s evera l “Step” exa ms , a nd get on the wa rds . You ma y l os e s i ght of the proverbi a l fores t. Knowi ng too much a bout trees a nd too l i ttl e a bout the fores t they’re i n ma y not be s uffi ci ent once you get i nto a cl i ni ca l s i tua ti on. It’s good to know ma ny i mporta nt fa cts , a nd even to be tes ted on them, but fa ct-ba s ed knowl edge a l one i s n’t s uffi ci ent. You ca n’t put yours el f i n the pos i ti on of knowi ng s o much a bout the deta i l s tha t you ca n’t thi nk i n broa der terms .

Borrowi ng from the l i tera ture, you a re expected to be l i ke the cheerful Ma jor Genera l i n Gi l bert a nd Sul l i va n’s Pirates of Penzance. You s eemi ngl y need to know “a l l the fa cts ” a nd be a bl e to s pi t them ba ck a l mos t wi thout ha vi ng to s tra i n to thi nk.

It i s rewa rdi ng to a ns wer a n os tens i bl y compl i ca ted or deta i l ed ques ti on correctl y (you pos s es s the ma i n pos i ti ve a ttri butes of Gi l bert a nd Sul l i va n’s ha ppy Ma jor Genera l ), but you don’t wa nt to fi nd yours el f s o bogged down i n knowi ng the deta i l s tha t you mi s s s eei ng the more i mporta nt bi g pi cture, or how the fa cts a ppl y or rel a te to one a nother (the Ma jor Genera l ’s ma i n fl a w). The s i mpl es t or mos t ba s i c concepts ca n be overl ooked wi th tea chi ng or l ea rni ng tha t i s too deta i l ed i n terms of fa ct a nd focus . You ha ve ha d a n a bunda nt (i f not exces s i ve) a mount of i nforma ti on a bout pha rma col ogy pres ented to you, but tha t’s onl y the founda ti on of a broa d knowl edge a nd experi ence ba s e upon whi ch you’l l bui l d over the comi ng yea rs . (I’l l a l s o go out on a l i mb a nd s ta te tha t you’ve a l s o been ta ught, a nd expected to l ea rn, a ton of i nforma ti on tha t i s tri vi a l or, a t bes t, not neces s a ry for your unders ta ndi ng a nd ul ti ma te a ppl i ca ti on of ba s i c pha rma col ogy to cl i ni ca l rea l i ty.)

One exa mpl e tha t comes to mi nd (i n fa ct, i t’s i ndel i bl y etched i n my memory) i nvol ves a fa i rl y common cl i ni ca l probl em, gout. A doc i n the ER, where I s howed up one hot s ummer da y wi th a ba d gout a tta ck, a s ked me wha t I di d for a l i vi ng. He then went on, a fter hea ri ng I ta ught pha rm, to ci te every meta bol i c i ntermedi a te a nd enzyme i n the bi os ynthes i s of uri c a ci d by the s o-ca l l ed puri ne (ATP) degra da ti on pa thwa y. Thi s i s , of cours e, the meta bol i c crux of the probl ems i n hyperuri cemi a a nd gout. Thi s new doc (he jus t gra dua ted from medi ca l s chool , wi th a Ph.D. degree to boot) correctl y s ta ted tha t a l l opuri nol i nhi bi ts the “l a s t two s teps ” i n uri c a ci d s ynthes i s by i nhi bi ti ng xa nthi ne oxi da s e. He a l s o correctl y s ta ted tha t xa nthi ne oxi da s e genera tes oxygen free ra di ca l s a nd H2O2, whi ch contri buted to the pa thophys i ol ogy. Inhi bi t xa nthi ne oxi da s e, a nd none of thos e na s ty oxi da nts a re produced, he s a i d. Tha t’s grea t. I ga ve hi m a n A for hi s i ntens i ve knowl edge.

Unfortuna tel y, tha t young phys i ci a n then dogma ti ca l l y s ta ted wha t s eemed s o mecha ni s ti ca l l y ra ti ona l but i n a ctua l i ty wa s tota l l y wrong: Gi ven the rol e of uri c a ci d i n the pa thophys i ol ogy of gout, a nd the a bi l i ty to i nhi bi t ura te s ynthes i s wi th a l l opuri nol , hi s fi rs t choi ce thera py for my a cute gout woul d be a l l opuri nol . (Now, of cours e, we ha ve the new a l l opuri nol -l i ke drug, febuxos ta t.) Oops . Wrong choi ce. He fl unked my cri ti ca l tes t. I knew he ma de a s eri ous error, a nd I pol i tel y decl i ned hi s pres cri pti on a s I checked mys el f out of the hos pi ta l AMA (Aga i ns t Medi ca l Advi ce) a s he hea ded off to fetch a pol a ri zi ng mi cros cope tha t he’d us e a fter a s pi ra ti ng my “hot toe.” But wha t i f I di dn’t know a nythi ng a bout gout, or

pha rma col ogy? I’d be getti ng a deci dedl y i na ppropri a te trea tment from a deci dedl y s ma rt phys i ci a n, but a fter da ys on hi s s el ected drug I’d proba bl y be hurti ng a nd l i mpi ng wors e tha n when I ca me to the ER. Knowi ng too much does n’t mea n knowi ng the ri ght s tuff. Si tua ti ons s uch a s thi s , whether they a ppl y to gout or to a ny of hundreds of common cl i ni ca l s cena ri os , wi l l a ppl y to your pa ti ents … a nd to your fa mi l y, fri ends , a nd even to you!

What Does Epinephrine Do to Blood Pressure?

Ma ny yea rs a go I l ea rned a bout a utonomi c pha rma col ogy from Profes s or Ra ymond P. Ahl qui s t. You proba bl y ha ven’t hea rd a bout hi m. He i s the pers on who “i nvented” the concept of a drenergi c receptors , wa y ba ck i n 1948, a nd coi ned the terms a l pha - a nd beta - a s prefi xes to a drenergi c receptors tha t we now s o gl i bl y refer to a nd ha ve eventua l l y cha ra cteri zed on the mol ecul a r l evel . Tha t La s ker Awa rd wi nner (oh, s o cl os e to a Nobel Pri ze) ha s proba bl y ca us ed more cons terna ti on for medi ca l a nd other hea l th ca re profes s i ons s tudents , gi ven the fa ct tha t now we ha ve mul ti pl e a l pha - a nd beta -a drenergi c receptors , a nd you need to l ea rn a bout them, the drugs tha t a cti va te them, a nd the i ncrea s i ng number of drugs tha t bl ock them. Dr Ahl qui s t us ed to l a ugh l oudl y, not onl y a bout how hi s concept devel oped, but a l s o a bout how there wa s (a nd s ti l l i s ) s o much more for you to l ea rn a bout, unders ta nd, a nd a ppl y. If he were s ti l l a l i ve he’d s ti l l be chuckl i ng.

Ahl qui s t ta ught ma ny s tudents a bout a utonomi c pha rma col ogy, a nd there i s much to be ta ken a wa y a nd a ppl i ed to the ba s i c yet es s enti a l knowl edge ba s e more tha n 70 yea rs l a ter; wha t YOU need to know a bout.

Wha t i s the effect of epi nephri ne on bl ood pres s ure? he woul d a s k. Hi s s tudents woul d a ns wer tha t epi nephri ne ra i s es bl ood pres s ure. Tha t a ns wer wa s i ncorrect. Next we’d s a y tha t epi nephri ne l owers bl ood pres s ure. Tha t, too, wa s wrong. Ahl qui s t’s a ns wer wa s tha t the effects of epi nephri ne on bl ood pres s ure—a nd i ndeed the res pons es to a ny other drug—“depends .” It depends on the dos e, the a dmi ni s tra ti on route, the condi ti on of the pa ti ent (eg, whether he or s he ha s a ny other condi ti ons , or i s ta ki ng a ny other drugs ), a nd a whol e bunch of other fa ctors .

Lea rn thi s “i t depends ” a ns wer when you l ea rn a bout a l l drugs . But remember, the ques ti ons i n thi s text, a nd thos e you’l l rea d on your med s chool a nd Step exa ms , a re wri tten to el i ci t the “mos t l i kel y” correct a ns wer.

(10)

Your experi ences from the cours es a nd exa ms you’ve ta ken ma y be qui te di fferent from thos e of s tudents i n other medi ca l s chool s , the medi ca l

s tudents I’ve ta ught, or the very s a me s tudents here or el s ewhere ta ught by s omeone el s e. And s o the focus of ques ti ons you’l l s ee here ma y be di fferent from thos e you’ve encountered on your exa ms , a nd the expl a na ti ons ma y di ffer too. There i s no one “s ta nda rd” pha rma col ogy curri cul um for a l l medi ca l s chool s . Some ha ve s epa ra te precl i ni ca l cours es for the ba s i c s ci ences (a na tomy, phys i ol ogy, pha rm, a nd s o on). Others , s uch a s ours , ha ve a di s ci pl i ne-ba s ed curri cul um i n whi ch, for exa mpl e, ba s i c s ci ence i nforma ti on a ppl i ca bl e to ca rdi ova s cul a r di s ea s es a re a l l i n one s ecti on (we ca l l them “s equences ”).

And when we thi nk a bout i ndi vi dua l fa cul ty i t’s obvi ous tha t poi nts empha s i zed by a pa rti cul a r i ns tructor ma y di ffer (s ometi mes ma rkedl y) i n s cope a nd ori enta ti on from thos e ma de by others . Some fa cul ty pl a ce cons i dera bl e empha s i s on deta i l ed or compl ex mecha ni s ms of a cti on, perha ps repl ete wi th s uch thi ngs a s s peci fi c pa thwa ys of drug meta bol i s m; chemi ca l s tructures , a nd perha ps s tructure–a cti vi ty rel a ti ons hi ps ; ma thema ti ca l a pproa ches to pha rma coki neti cs ; a nd s o on. Students s ometi mes l ea ve l ecture wonderi ng wha t the cl i ni ca l i mpl i ca ti ons a re. Convers el y, other fa cul ty a ddres s the cl i ni ca l “rel eva nce” of certa i n drugs , but do l i ttl e more tha n s a y “Your 50-yea r-ol d ma l e pa ti ent ha s recentl y been di a gnos ed wi th Type 2 di a betes mel l i tus . Metformi n i s a good s ta rti ng drug.” As Homer Si mps on mi ght s a y, “duh-oh, ok.” But why? When? How does i t work?

The s a me a ppl i es to pha rma col ogy texts . Some ma y devote a pa ge or more to a pa rti cul a r drug or topi c, a nd i n others tha t i nforma ti on ma y not a ppea r a t a l l .

Next there i s the i s s ue of “newnes s ” or ti mel i nes s . Drugs come a nd go a l l the ti me—a l though i t’s cl ea r tha t new drugs a re bei ng a pproved a t a fa s ter ra te tha n thos e tha t a re di s a ppea ri ng. Thi s pres ents s omewha t of a predi ca ment for you, a nd s o, for me. Wha t to l ea rn, wha t to a s k ques ti ons a bout. For deca des s tudents ha ve l ea rned a bout d-tubocura ri ne (“cura re”) a s the prototype nondepol a ri zi ng s kel eta l neuromus cul a r bl ocker: a competi ti ve a nta goni s t of a cetyl chol i ne a t NM (ni coti ni c-s kel eta l mus cl e) receptors . It’s no l onger us ed i n the Uni ted Sta tes . Indeed, a rel a ti vel y new cura re-l i ke drug, metocuri ne, i s no l onger a va i l a bl e here ei ther. If you were to l ook a t not-s o-ol d edi ti ons of a pha rma col ogy text— or even the previ ous edi ti on of thi s book—you’d fi nd content rel a ted to the “gl i ta zones ” (thi a zol i di nedi ones , to be more preci s e), a nd l ea rn or be tes ted a bout a va ri ety of drugs i n thi s cl a s s of ora l drugs for Type 2 di a betes mel l i tus . How thi ngs ha ve cha nged. Owi ng to va ri ous s eri ous s i de effects a nd a dvers e res pons es , s ome fa ta l , onl y one gl i ta zone rema i ns : pi ogl i ta zone.

Then there i s the i s s ue of i ns ti tuti ona l preferences i n terms of drug us e whi ch, i nferenti a l l y, ma y a ffect wha t you’re ta ught a nd expected to l ea rn. Perha ps you’l l l ea rn the ba s i c pha rma col ogy of ephedri ne. For yea rs i t ha s been a n outmoded drug for ca us i ng modes t bronchodi l a ti on i n a s thma , a nd ha s ga i ned more of a reputa ti on a s a CNS s ti mul a nt a nd wei ght-l os s a i d tha t wa s often a bus ed or mi s pres cri bed. Nonethel es s , beca us e of a va ri ety of fa ctors ephedri ne gets rel a ti vel y l i ttl e a ttenti on, i f a ny a ttenti on a t a l l , i n ma ny pha rma col ogy l ectures a nd texts . But a t our i ns ti tuti on, ephedri ne i s us ed frequentl y i n the opera ti ng rooms when the goa l i s to ca us e a l i ttl e upwa rd “bl i p” of bl ood pres s ure tha t ma y ha ve fa l l en too much i n res pons e to certa i n a nes theti c a gents .

You’l l a l s o l ea rn a bout revers i ng s kel eta l mus cl e pa ra l ys i s ca us ed by the nondepol a ri zi ng (cura re-l i ke) drugs : revers e the bl ocka de by gi vi ng a chol i nes tera s e i nhi bi tor (ma i nl y us i ng neos ti gmi ne), but fi rs t gi ve a tropi ne to prevent unwa nted s ti mul a ti on of mus ca ri ni c receptors when the chol i nes tera s e i nhi bi tor does i ts ma ny thi ngs . Wel l , here a nd i n ma ny other i ns ti tuti ons , a tropi ne i s not us ed for tha t purpos e. Ins tea d, the a nti mus ca ri ni c a gent tha t’s us ed i s gl ycopyrrol a te—yet a nother drug tha t ma y not be menti oned i n l ecture or gi ven much, i f a ny, di s cus s i on i n a text.

Now, I wa nt to a l l a y your concerns a nd gi ve you confi dence tha t you ca n l ea rn thi s ma teri a l , a nd a ppl y wha t you proba bl y ha ve l ea rned a bout fa mi l i a r (ta ught) drugs to thos e you ha ven’t expl i ci tl y l ea rned or rea d a bout. For exa mpl e, you’l l fi nd, i n thi s book, a t l ea s t one ques ti on a bout gl ycopyrrol a te. But i t wi l l be des cri bed i n s uch a wa y i n terms of i ts a cti ons a nd us es (eg, gi ven ri ght before a n a cetyl chol i nes tera s e i nhi bi tor i s a dmi ni s tered to revers e neuromus cul a r bl ocka de, ca us es effects a nd s i de effects X, Y, a nd Z) tha t i f you “know” the ba s i cs a bout a tropi ne, you’l l be a bl e to a ns wer the ques ti on a bout gl ycopyrrol a te wi th no probl ems .

For better or wors e, I try to a i m for the mi ddl e ground i n tea chi ng a nd tes ti ng. My focus us ua l l y i s on the “whys ” of thi ngs proba bl y more tha n the “wha ts ,” a nd I try to reduce the number of wha t our s tudents refer to a s “ra t fa cts ” to a mi ni mum. I don’t s pend ti me tea chi ng a bout a l l the

a ngi otens i n-converti ng enzyme i nhi bi tors when I ca n tea ch the es s enti a l s by focus i ng on ca ptopri l . I prune the tea chi ng of β-bl ockers wi th a focus on propra nol ol a s the prototype (mos t repres enta ti ve drug), a nd then s pend s ome ti me ta l ki ng a bout the s o-ca l l ed ca rdi os el ecti ve β-bl ockers (a tenol ol , metoprol ol ), thos e tha t ha ve va s odi l a tor a cti vi ty (whether by vi rtue of α-bl ocka de, l i ke l a beta l ol , or ni tri c oxi de genera ti on, a s wi th bi s oprol ol ), a nd try to s how how or why thos e drugs a re di fferent (yet i n key wa ys , s uch a s a dvers e effects or contra i ndi ca ti ons ) a nd i mporta nt cl i ni ca l l y. No di s cus s i on or tes ti ng on the two dozen or s o other β-bl ockers .

I a l s o provi de you, i n one of the a ppendi ces , wi th a “na me recogni ti on gui de”—for exa mpl e, i f the drug’s generi c na me ends i n “-pri l ” i t’s a n a ngi otens i n-converti ng enzyme i nhi bi tor; i f the generi c na me ends i n “-ol ol ” i t’s s ome s ort of β-a drenergi c bl ocker. Us e i t! You’l l fi nd i n thi s

PreTest™ s evera l ques ti ons a bout a drug you ma y not ha ve l ea rned a bout expl i ci tl y. But i f you “know your word s tems ” you’l l be a l l s et to a ns wer

the ques ti on correctl y. As one exa mpl e: There i s a ques ti on or two a bout the mos t l i kel y s i de effects of ta ms ul os i n, a drug us ed for ma na gi ng beni gn pros ta ti c hypertrophy. Ha ven’t l ea rned a bout ta ms ul os i n expl i ci tl y? No probl em. Look a t the generi c na me: ta ms ul osin. Sa me a s pra zosin, a s el ecti ve α1-receptor bl ocker tha t I’m s ure you ha ve l ea rned a bout. Al l the s el ecti ve α-bl ockers a re l i ke pra zos i n i n mos t (but cl ea rl y a l l ) i mporta nt wa ys .

There i s no uni vers a l l y a dopted or “offi ci a l ” medi ca l pha rma col ogy cours e or cours e content (even though the Na ti ona l Boa rd of Medi ca l Exa mi ners , who prepa re your Step exa ms , ha ve rel a ti vel y focus ed l ea rni ng a nd tes ti ng objecti ves ). If you’re curi ous , l ook a t the text reference pa ge numbers i n the expl a na ti ons to a ns wers i n thi s book. For s ome drugs or rel a ted ma teri a l you ma y s ee s evera l pa ges devoted to the topi c i n one book, a nd jus t one (or perha ps jus t one fi gure or ta bl e) i n a nother. In one text the pa ge references ma y come from ea rl y pa rts of the book, a nd for the other i t wi l l be pretty obvi ous tha t the content i s put towa rd the end. It’s not tha t one text i s better tha n the other. It s i mpl y refl ects di fferent bi a s es a nd preferences by the a uthors or edi tors .

I ha ve a certa i n job to do, res pons i bi l i ti es to ful fi l l , a s I deem a ppropri a te: pi ck a nd choos e ma teri a l I thi nk i s i mporta nt; tea ch i t cl ea rl y a nd i n a ma nner tha t excl udes wha t I deem unneces s a ry (eg, drug s tructures ; a s a phys i ci a n you’l l proba bl y never ha ve to l ook a t the chemi ca l s tructure of a drug a nd fi gure out wha t i t i s , wha t i t i s us ed for, i ts s i de effects , a nd s o on). I try to s i mpl i fy tha t whi ch ca n be unneces s a ri l y compl i ca ted. I try to bri dge l ea rni ng of ba s i c fa cts a nd concepts a nd a ppl yi ng them cl i ni ca l l y, a nd l a rgel y i gnore content I thi nk i s , for l a ck of a better phra s e, too over the top or deta i l ed to be of us e for more tha n jus t s omethi ng el s e to l ea rn. My ba ckground i s l a rgel y i n s ys tems -ba s ed phys i ol ogy a nd

pa thophys i ol ogy (a s oppos ed to, s a y, bi ochem a nd mol ecul a r bi ol ogy), a nd s o ma ny of my ques ti ons a nd expl a na ti ons focus on tha t. Thi s i s wha t I do i n cl a s s a nd on exa ms , a nd i t i s refl ected i n my ma i n a pproa ch to wri ti ng ques ti ons a nd expl a i ni ng the a ns wers i n thi s book.

Breadth and Depth of Questions and Answers: Low Yield, High Yield?

Mos t s tudents who revi ewed previ ous edi ti ons of PreTest™ Pharmacology found the book to be extremel y us eful . However, s ome ques ti ons were ci ted by a few revi ewers a s bei ng “l ow-yi el d,” “too ba s i c,” “too cl i ni ca l ,” a nd the l i ke.

I’ve tri ed to a ddres s thes e cri ti ci s ms i n every edi ti on of thi s book tha t I’ve wri tten, but l et me pol i tel y opi ne tha t a t thi s poi nt i n your medi ca l educa ti on you’re not i n the bes t pos i ti on to ma ke judgment ca l l s on s uch ma tters , a nd jus t beca us e you were (or weren’t) ta ught or tes ted on a

(11)

pa rti cul a r poi nt by your profs does n’t mea n tha t other s tudents ha ve or ha ven’t ha d the s a me expecta ti ons . And wha t s tudents s ometi mes ci te a s a l ow yi el d ques ti on i s a ctua l l y ba s i c a nd “mus t know” i nforma ti on, even though the correct a ns wer ma y be ra ther obvi ous to mos t s tudents . Tha t does n’t mea n the i nforma ti on i s uni mporta nt, or tha t your a bi l i ty to recogni ze i t s houl dn’t be eva l ua ted. It coul d wel l mea n tha t you’ve l ea rned the es s enti a l ba s i cs , a nd tha t’s good. In a ddi ti on, s ome s tudents ha ve ca l l ed certa i n ques ti ons “l ow yi el d” s i mpl y beca us e they ha ven’t l ea rned a bout the fa cts or concepts a ddres s ed i n the ques ti on. It’s ea s y to a ttri bute l i ttl e i mporta nce to thi ngs one does n’t know or unders ta nd, a nd s a y the ques ti on i s tri vi a l .

For s ome of you i t’s tempti ng to vi ew s ome of my ques ti ons a s “too cl i ni ca l ”; others ma y fi nd thi ngs “too ba s i c or mecha ni s ti c.” I ha ve been chi ded for a s ki ng s ome ques ti ons a bout i n vi tro obs erva ti ons , when the res pons es deemed mos t i mporta nt a nd a ppropri a te s eemi ngl y a re thos e tha t occur i n huma ns . Tha t’s not neces s a ri l y true i n my opi ni on.

Ans weri ng a l l the ques ti ons i n thi s book i s rel a ti vel y s i mpl e i f you thi nk a bout the ba s i c i nforma ti on you s houl d ha ve a cqui red; i f you i ntegra te i t wi th wha t you s houl d ha ve l ea rned i n other cours es (eg, i n a phys i ol ogy or cel l a nd mol ecul a r bi ol ogy cours e tha t ma y i ncorpora te a l ot of knowl edge ba s ed on i n vi tro s tudi es ); a nd i f you s ta rt doi ng wha t you wi l l ha ve to do s oon—ma ke rea s oned judgments ba s ed on a ppl yi ng your knowl edge to a pos s i bl y new cl i ni ca l pi cture: whi ch i s “mos t l i kel y?”

Breadth and Depth of Questions and Answers: Empiric Data or Mechanistically Certain Information?

Some revi ewers ha ve noted tha t s ome ques ti ons focus on empi ri c i nforma ti on: fi ndi ngs , s uch a s certa i n s i de effects , for whi ch we don’t ha ve good (l et a l one defi ni ti ve) i nforma ti on on mecha ni s ms of a cti on. The premi s e of thos e cri ti ci s ms i s “Why a s k ques ti ons a bout thes e i s s ues , for whi ch [I] ca n offer no proven mecha ni s ti c expl a na ti ons , when there i s s o much other i nforma ti on to a s k ques ti ons a bout, s o much other i nforma ti on a bout whi ch we need to know?” Some exa mpl es i ncl ude the i ncrea s ed ri s k of a s thma -rel a ted dea ths from l ong-a cti ng β-a goni s ts ; the cons ti pa ti ng effect of vera pa mi l ; the fa ci a l fl us hi ng a s s oci a ted wi th i mmedi a te-a cti ng ni a ci n; the s kel eta l mus cl e da ma ge ca us ed by s ta ti ns ; a nd ma ny more. The rea s on why I i ncl ude s uch ques ti ons i s tha t thes e a nd ma ny other s o-fa r mecha ni s ti ca l l y unexpl a i ned s i de effects , a dvers e res pons es , a nd rel a ted i s s ues a re cl i ni ca l l y i mporta nt a nd s ometi mes common. We ma y not be a bl e to expl a i n a l l the “whys ” i n bi ochemi ca l terms (I ma y s pecul a te a bout s ome publ i s hed mecha ni s ms ), but when thes e untowa rd res pons es ha ppen a nd ca us e a dvers e cons equences , a s they often do, i t’s i mporta nt for you to know.

Suggestions on How to Use This Book

Prepa re yours el f to a ns wer the ques ti ons i n ea ch cha pter by fi rs t revi ewi ng the corres pondi ng ma teri a l from your l ecture notes a nd fa vori te (or, a t l ea s t, a s s i gned) text. Thi s vol ume tha t you hol d i n your ha nds i s , a fter a l l , a revi ew a nd s el f-a s s es s ment tool , not a n ori gi na l s ource of l ea rni ng i nforma ti on.

Before you work on the ques ti ons a nd your s tudyi ng overa l l , try to do the fol l owi ng:

Be able to identify main drug classes, recognizing that sometimes we use more than one classification scheme (eg, chemical; by main mechanism(s) or site(s) of action; by clinical use); and be able to cite a prototype drug for each. Conversely, given a named prototype or otherwise representative drug, be able to work backward and know the rest of the most relevant information, including the class(es) to which it belongs.

For exa mpl e, you s houl d be a bl e to i denti fy a group of drugs tha t a re ca l l ed di hydropyri di nes a s a l a rge a nd ma i n chemi ca l cl a s s of ca l ci um cha nnel bl ockers (CCBs ) tha t a re ma i nl y va s odi l a tors a nd a re us ed for s uch i ndi ca ti ons a s hypertens i on or other condi ti ons i n whi ch va s odi l a ti on i s des i red. You s houl d know tha t ni fedi pi ne ca n be cons i dered a prototype of the ra ther l a rge di hydropyri di ne CCB cl a s s .

You s houl d be a bl e to ta ke the revers e a pproa ch by i denti fyi ng ni fedi pi ne a s the prototype di hydropyri di ne CCB; i denti fyi ng the ma i n a cti ons of the drug a nd i ts overa l l cl a s s ; a nd recogni zi ng the ma i n us es a nd a dvers e effects .

And, you s houl d a l s o know how other CCBs , not cl a s s i fi ed a s di hydropyri di nes (eg, vera pa mi l , di l ti a zem), di ffer a nd work. You certa i nl y don’t need to l ook a t chemi ca l s tructures to deduce the di fferent a cti vi ty profi l es , but you certa i nl y do need to know how, for exa mpl e, the a cti ons of ni fedi pi ne di ffer from thos e of, s a y, vera pa mi l .

It’s a l s o i mporta nt to know a bout wha t mi ght be des cri bed a s “s ubprototypes ”—for exa mpl e, wha t’s s peci a l a bout a tenol ol or metoprol ol , or l a beta l ol , compa red wi th the overa l l a nd prototypi c β-a drenergi c bl ocker, propra nol ol ? In thi s book I’l l tel l you how you ca n never forget tha t l a beta l ol , a wi del y us ed drug, bl ocks both α- a nd β-a drenergi c receptors . And I’l l gi ve you l ots of other memory-enha nci ng ti ps , too.

Be able to identify the class to which a drug belongs by looking at its generic name or other name.

You s houl d ha ve s ome knowl edge of a drug’s cl a s s by l ooki ng a t i ts generi c na me—for exa mpl e, a drug tha t ends i n the s uffi x “-s ti gmi ne” i s a revers i bl e a cetyl chol i nes tera s e i nhi bi tor; one tha t ends i n “-pri l ” i s a n a ngi otens i n-converti ng enzyme i nhi bi tor; a “-s a rta n” i s a n a ngi otens i n receptor bl ocker; a nd s o on. Al though thi s “l ook a t the generi c na me a nd you’l l know the drug group” techni que does n’t a ppl y to a l l drugs , i t does a ppl y to proba bl y hundreds . To tha t end, I’ve i ncl uded a ta bl e a t the ba ck of the book to hel p you do tha t. You a l s o need to be a bl e to gi ve a rea s ona bl e worki ng defi ni ti on for certa i n drug cl a s s i fi ca ti on terms , s uch a s ca techol a mi ne, SSRI, or revers e tra ns cri pta s e i nhi bi tor. You get the poi nt, I hope. Thi s l ea rni ng tri ck does n’t work a l l the ti me, of cours e, s i nce for ma ny drugs there i s n’t a ny rhyme or rea s on behi nd the na mes .

Be able to state the main expected effects or side effects of major drugs or drug classes. This should give you a good idea of what the relevant precautions or contraindications are, even if you haven’t been taught about the latter, even if your learning focus hasn’t been too clinical.

For exa mpl e, you know tha t a l l β-a drenergi c bl ockers ca n reduce ca rdi a c ra te, contra cti l i ty, a nd el ectri ca l i mpul s e conducti on vel oci ty (es peci a l l y through the AV node), a nd s ometi mes thes e drugs a re us ed s peci fi ca l l y to ca us e one or more of thos e effects . You s houl d then rea l i ze tha t exces s i ve dos es ma y ca us e unwa nted degrees of s uppres s i on of thos e ca rdi a c pa ra meters . And you s houl d rea l i ze tha t the effects of thes e drugs wa rra nt extra ca uti on (or contra i ndi ca te a l together) the us e of a ny β-bl ocker i n pa ti ents who a l rea dy ha ve bra dyca rdi a , s i gni fi ca ntl y reduced ventri cul a r contra cti l i ty/ca rdi a c output, or s ome degree of hea rt bl ock. Ma ki ng thes e a s s oci a ti ons or extra pol a ti ons i s not rocket s ci ence tha t you mus t ha ve been ta ught a bout expl i ci tl y. You s houl d be a bl e to us e your ba s i c knowl edge of pha rma col ogy a nd drug a cti on, a nd of phys i ol ogy a nd pa thophys i ol ogy, to pi ece thi ngs together a nd get the correct (or mos t l ogi ca l or l i kel y) a ns wer.

Be able to state the most important (eg, common, serious, or life-threatening) unwanted side effects, adverse responses, and clinically relevant drug interactions for the main drugs or drug classes.

Such “mus t know” a dvers e res pons es to certa i n drugs a ren’t neces s a ri l y common ones , but you need to know a bout them. For exa mpl e, myopa thy a nd potenti a l rha bdomyol ys i s from s ta ti ns i s rel a ti vel y ra re, but you certa i nl y need to know a bout thes e ra ther uni que cl a s s -rel a ted a dvers e effects , a nd thei r cl i ni ca l cons equences . (“Ra re” i s a n i nteres ti ng word. Sta ti n-i nduced myopa thy a ffects fa r fewer tha n 1% of pa ti ents ta ki ng the drug, but when you cons i der the fa ct tha t mi l l i ons of pa ti ents a re ta ki ng thi s medi ca ti on, the i mpl i ca ti on i s tha t you’l l proba bl y

encounter the probl em a nd need to be a bl e to recogni ze a nd properl y dea l wi th i t.) The s a me a ppl i es to gi ngi va l hyperpl a s i a from phenytoi n when a dmi ni s tered to (ma i nl y) chi l dren; pa ra doxi ca l thrombocytopeni a from unfra cti ona ted hepa ri n; coa gul opa thi es (i ncl udi ng pa ra doxi ca l thrombos i s ) from l oa di ng dos es of wa rfa ri n, a nd embryopa thy when even otherwi s e proper dos es a re a dmi ni s tered duri ng the fi rs t 12 weeks of pregna ncy; a nd s o on. And, a s one fi na l exa mpl e, you need to unders ta nd the potenti a l ri s ks of gl i bl y s a yi ng “ta ke a ceta mi nophen” to your pa ti ents who a re ta ki ng wa rfa ri n.

(12)

Get a decent pharmacology book, read it, and learn what not to focus on when filling up your memory bank.

The expl a na ti ons for a l l the a ns wers I provi de a re cros s -referenced to two excel l ent texts . Goodma n a nd Gi l ma n’s The Pharmacological Basis of

Therapeutics (12th edi ti on) i s wi thout equa l a s a n a uthori ta ti ve, current, a nd compl ete book. Dr La rry Brunton ha s done a n outs ta ndi ng job a t the

edi tor’s hel m for a whi l e now, a nd the book ha s been the defi ni ti ve “bi bl e of pha rma col ogy” for deca des . The other ci ta ti ons a re for Basic and

Clinical Pharmacology, by Drs Ka tzung, Ma s ters , a nd Trevor. To me “Ka tzung” s tri kes the bes t ba l a nce between ba s i c pha rma col ogy a nd drug a cti ons

wi th current thera peuti c pri nci pl es . And you don’t ha ve to rea d a n exces s i ve number of pa ges to get the s a l i ent i nforma ti on. Thes e recommenda ti ons a re not merel y pa yi ng homa ge to thi s books ’ publ i s her, McGra w-Hi l l . They a re unbi a s ed a nd profes s i ona l l y hones t.

Ma ny drugs come a nd go. We us ed to tea ch a bout ri todri ne, a predomi na tel y β2 a goni s t, a s a uteri ne rel a xa nt drug to hel p s l ow prema ture l a bor. It’s gone, a t l ea s t here i n the Uni ted Sta tes . Cromol yn a nd nedocromi l were s ometi mes us ed (a nd your predeces s ors were tes ted a bout) a s control meds for a s thma . Gone. It wa s ea s y to des cri be a nd a s k ques ti ons a bout tubocura ri ne, the prototypi c nondepol a ri zi ng s kel eta l mus cul a r bl ocker. Gone, a nd now we a ddres s s uch drugs a s vecuroni um, mi va curi um, a nd others , a nd i t’s rea l l y i mpos s i bl e to pi ck one of thos e drugs a s a prototype. The drugs cl a s s i fi ed a s cycl ooxygena s e II (COX-2) i nhi bi tors ha ve been wi nnowed down to one drug, cel ecoxi b. The gl i ta zones , a rel a ti vel y s ma l l group of drugs for Type 2 di a betes , but i mporta nt nonethel es s , ha ve onl y one drug rema i ni ng: pi ogl i ta zone.

There a re other i s s ues I thi nk I need to poi nt out to you, a nd they rel a te to wha t you ma y or ma y ha ve not l ea rned a bout. After revi ewi ng l ots of a nonymous pa ti ent records from our i ns ti tuti on, I’ve noted the fol l owi ng, for exa mpl e. Ephedri ne, norma l l y cons i dered a “mi nor drug” a nd s o not often ta ught, i s a ma i ns ta y i n our opera ti ng rooms when the goa l i s to ca us e a l i ttl e upwa rd “bl i p” of a too l ow bl ood pres s ure. Ephedri ne i s des cri bed i n mos t texts very bri efl y, a nd the comments us ua l l y des cri be the l i mi ta ti ons of the drug a nd rel ega te i t to “s el dom us ed” s ta tus . Not s o i n the rea l worl d.

In our opera ti ng rooms , ma ny pa ti ents get pa ra l yzed wi th a nondepol a ri zi ng neuromus cul a r bl ocker (us ua l l y one of the “curi nes ,” but not our l ong-s ta ndi ng prototype, tubocura ri ne, s i nce i t’s gone), a nd of cours e thei r neuromus cul a r bl ocka de us ua l l y needs to be revers ed pos t-op. You ha ve no doubt l ea rned tha t revers a l of s uch mus cl e pa ra l ys i s i nvol ves trea tment wi th a tropi ne, then a chol i nes tera s e i nhi bi tor, us ua l l y

neos ti gmi ne. The di ffi cul ty here i s tha t, a t our i ns ti tuti on a nd a t ma ny others , a tropi ne i s n’t us ed. We us e gl ycopyrol a te i ns tea d of a tropi ne nea rl y a l l the ti me. Ha ve you been ta ught expl i ci tl y, or rea d expl i ci tl y, a bout gl ycopyrrol a te? Bet you the a ns wer i s no. But you’l l fi nd here, i n thi s edi ti on of PreTest™ Pharmacology a l l you’l l need to know to gui de you to the correct a ns wers .

Using this PreTest Book

The ma jori ty of ques ti ons a re wri tten to el i ci t the one “bes t” or “mos t l i kel y” correct res pons e. Ma rk your a ns wer by ea ch ques ti on, or downl oa d, pri nt, a nd us e the “a ns wer s heets ” I’ve pos ted on my pers ona l tea chi ng web s i te. (The URL i s www.umi ch.edu/~ms hl a fer/pha rm.html. When you get there, cl i ck the PreTes t™ button a t the top of the pa ge.) Try to a l l ow yours el f a mi nute or s o for ea ch ques ti on, but don’t rus h. There a re no pena l ti es for goi ng through thi s revi ew a nd a ns weri ng i ncorrectl y, a nd no rewa rds for s peed. Then your ti me wi l l be s pent bes t goi ng through the expl a na ti ons for the a ns wers .

Ma ny s tudents who ha ve us ed previ ous edi ti ons of PreTest™ Pharmacology ha ve s a i d tha t even though they ma y ha ve a ns wered ques ti ons correctl y, they’ve s ti l l l ea rned or fi na l l y unders tood s omethi ng va l ua bl e a nd perha ps even i ndel i bl e by rea di ng the expl a na ti ons . After you fi ni s h a l l the ques ti ons i n a cha pter, s pend a s much ti me a s you need veri fyi ng your a ns wers a nd ca reful l y rea di ng the expl a na ti ons provi ded. Thi s i s pa rti cul a rl y i mporta nt i f you chos e a wrong a ns wer, di dn’t ha ve a rea l cl ue a bout wha t the ri ght a ns wer mi ght be, or jus t ma de a l ucky gues s , perha ps beca us e of your tes t-s a vvy s ki l l s . So, try to rea d every expl a na ti on, es peci a l l y the more l engthy ones . I wrote mos t of the expl a na ti ons to rei nforce a nd s uppl ement the i nforma ti on s ought by the ques ti ons , a nd s ometi mes gentl y to encoura ge you to l ook a t (us ua l l y ea rl i er) pa rts of thi s revi ew book. Do revi s i t your cl a s s notes a nd a decent pha rma col ogy text (s ee a bove a nd the references to key texts l i s ted for ea ch a ns wer expl a na ti on) for further cl a ri fi ca ti on too.

I urge you not to do one ra ther tempti ng thi ng: rea d, or even peek, a t the a ns wers to i ndi vi dua l ques ti ons i n a cha pter before you’ve a ns wered a l l the ques ti ons . I know thi s ma y be pa i nful i n a va ri ety of wa ys (but, “no pa i n, no ga i n” they s a y). Nonethel es s , expl a na ti ons for the a ns wer to one ques ti on ma y gi ve you a ti p-off (i f not the outri ght correct a ns wer) to a nother ques ti on tha t mi ght a ddres s the s a me drug or drug cl a s s , but from a di fferent pers pecti ve. In thi s s el f-s tudy a nd revi ew proces s —for a s s es s i ng your knowl edge, unders ta ndi ng, a nd s ynthes i s —s uch ti p-offs ma y l ul l you a rri vi ng a t a correct a ns wer by a s hort-ci rcui ted a pproa ch, ha vi ng jus t rea d a s i mi l a r or rel a ted a ns wer to a nother ques ti on. There i s “pl a nned redunda ncy” i n s ome of the ques ti ons a nd the a ns wers I’ve wri tten for you.

Some Acknowledged, Up-front Caveats

As I menti oned a bove, a nd for rea s ons I bel i eve a re defens i bl e, I’ve omi tted drug s tructures , or deta i l ed chemi ca l rea cti ons tha t des cri be the s ynthes i s or degra da ti on of drugs . And, whi l e ma ny s tudents ha ve pra i s ed tha t the va ri ous cha pters hel ped them l ea rn ma teri a l for s peci fi c a rea s of pha rma col ogy a nd thera peuti cs , a nd do wel l on thei r exa ms , I do thi ngs a l i ttl e di fferentl y here.

Look a t ques ti ons i n mos t other “revi ew” books or texts , or l ook a t the ques ti ons on your own exa ms , a nd you’l l proba bl y fi nd tha t the s cope of ques ti ons i s qui te l i mi ted. Ques ti ons a s s es s i ng your knowl edge a bout, for exa mpl e, a nti hypertens i ve drugs , ha ve a ns wer choi ces tha t a re ra ther l i mi ted to knowl edge a bout a pa rti cul a r a nti hypertens i ve drug or drug cl a s s : “Wha t i s the mos t l i kel y s i de effect of thi s pa rti cul a r ca l ci um cha nnel bl ocker?” Some wi l l di vers i fy a s s es s ment of your knowl edge a bi t more: “Whi ch a nti hypertens i ve drug mos t l i kel y ca us ed thi s s ta ted a dvers e res pons e?” Goi ng further, a ques ti on’s a ns wer choi ces ma y i ncl ude drugs repres enti ng a hos t of di vers e ca rdi ova s cul a r drugs us ed, for exa mpl e, for a ngi na , hypertens i on, hyperchol es terol emi a , a nd s o on. Sti l l , tha t’s a rel a ti vel y na rrow focus .

Such ques ti ons don’t ful l y a ddres s cl i ni ca l rea l i ty—your a bi l i ty to i ntegra te a nd a ppl y knowl edge a cros s wha t mi ght s eem l i ke i ndependent a rea s of pha rma col ogy, thera peuti cs , a nd medi ci ne. For exa mpl e, certa i n “res pi ra tory” drugs ma y ha ve a nega ti ve i mpa ct on your pa ti ent’s

ca rdi ova s cul a r di s ea s e. An os tens i bl y funda menta l a utonomi c nervous s ys tem drug ma y ha ve i mporta nt i mpl i ca ti ons to your pa ti ent wi th a certa i n ca rdi ova s cul a r or ophtha l mi c di s ea s e, res pi ra tory di s ea s e, or a ny of s evera l di s ea s es of the centra l nervous s ys tem. And s o, ma ny ques ti ons i n thi s book “encoura ge” you to i ntegra te a nd a ppl y your knowl edge a cros s s evera l s eemi ngl y di s crete a rea s of drug thera py. Doi ng s o i s wha t mos t of you wi l l ha ve to do, a t l ea s t ea rl y on i n your ca reers . It’s s i mpl y good, a nd neces s a ry, hol i s ti c i ntegra ti on of your knowl edge.

And s o now, a s you turn the pa ges a nd s ta rt your s el f-a s s es s ment a nd revi ew, do a s one of my fa vori te comi cs (La rry the Ca bl e Guy) woul d encoura ge you to do: “Gi t er done!”

Good l uck!

Ma rs ha l Shl a fer

Profes s or, Depa rtment of Pha rma col ogy Uni vers i ty of Mi chi ga n Medi ca l School Ann Arbor, MI 48109-0632

(13)

(14)

Cross-References (for Answers) to Selected Pharmacology Texts

“Brunton”—Brunton L, Cha bner B, Knol l ma n B, eds . Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12th ed. McGra w-Hi l l , 2011.

“Katzung”—Ka tzung B, Ma s ters S, Trevor, A eds . Basic and Clinical Pharmacology, 12th ed. McGra w-Hi l l , 2012.

Expl a na ti ons for the a ns wers provi ded i n thi s edi ti on of PreTest™—Pharmacology a re cros s -referenced to one or both of the a bove pha rma col ogy texts .

Ea ch text excel s i n certa i n res pects , yet they di ffer i n terms of a ctua l content a nd how i t i s pres ented. Look a t the text cros s -references i n ea ch of my a ns wers a nd you’l l s ee the di fferi ng focus . One text, or a pa rti cul a r cha pter i n tha t text, ma y be more mecha ni s ti c or more deta i l ed; a nother ma y be more cl i ni ca l ; one ma y pa i nt a di s cus s i on a bout certa i n drugs or drug groups , or a pa rti cul a r medi ca l condi ti on, wi th broa der brus h s trokes tha n a nother. One text ma y a ddres s a pa rti cul a r poi nt on s evera l pa ges , the other on one or two, or ma y ha ve no s peci fi c covera ge a t a l l . Thi s i s not s urpri s i ng, a nd i t pa ra l l el s the wa y you were proba bl y ta ught pha rma col ogy: no one s ta nda rd precl i ni ca l pha rma col ogy curri cul um for a l l medi ca l s chool s , nor a ny s ta nda rd or cons i s tency i n how the content ma y be pres ented a t one s chool , or by one prof, compa red wi th a nother.

(15)

Generic Drug Name Recognition Guide

I’ve compi l ed thi s l i s t wi th the hope tha t i t ma y hel p you l ook a t a drug’s generi c na me a nd fi gure out the group or cl a s s to whi ch i t bel ongs . I a m s ure there a re s ome omi s s i ons , but the l i s t i s nonethel es s qui te compl ete. Mos t of the entri es a re a rra nged a l pha beti ca l l y by s uffi xes , but i n a coupl e of i ns ta nces the l i s ti ng i s for a prefi x (eg, ceph- for cepha l os pori ns ) or s ome s equence of l etters cons i s tentl y found i n the drugs ’ na mes (eg,

quin i n qui ni di ne, qui ni ne, chl oroqui ne). Drug names in bold a re ones I cons i der to be a prototype or mos t i mporta nt exa mpl e(s ).

Where a nd how do generi c drugs get thei r “offi ci a l ” na mes , a t l ea s t i n the Uni ted Sta tes ? They a re a s s i gned by the Uni ted Sta tes Adopted Na mes Counci l (USANC). Thei r purpos e i s to provi de “s i mpl e, i nforma ti ve, a nd uni que nonpropri eta ry na mes for drugs ”—the USAN. They do thi s by “es ta bl i s hi ng l ogi ca l nomencl a ture cl a s s i fi ca ti ons ” ba s ed on drugs ’ pha rma col ogi c rel a ti ons hi ps wi th others (of the s a me or s i mi l a r type) or ba s ed on chemi ca l s i mi l a ri ti es (eg, the core chemi ca l s tructure of drugs ). In the Uni ted Sta tes the FDA ha s the fi na l s a y on whether a drug na me i s a ccepta bl e a nd, therefore, “offi ci a l .”

A s i de note: a l though ma ny generi c na mes a re i denti ca l worl dwi de, there a re a l s o s ome gl a ri ng i ncons i s tenci es , s ome of whi ch you’re a pt to encounter. For exa mpl e, the Bri ti s h (a nd others ) ca l l a ceta mi nophen pa ra ceta mol , a nd meperi di ne i s pethi di ne.

Where ca n you get more i nforma ti on a bout drug na mes ? Poi nt your brows er to:

(16)

(17)

(18)

(19)

(20)

(21)

(22)

(23)

(24)

(25)

(26)

(27)

(28)

(29)

(30)

List of Abbreviations

Here a re s ome common a bbrevi a ti ons you a re l i kel y to encounter i n thi s edi ti on of PreTest™ Pharmacology or el s ewhere when a bbrevi a ti ons rel a ted to pha rma col ogy a nd thera peuti cs come up. I’ve tri ed to s pel l out the ful l word(s ), a nd gi ve the a bbrevi a ti on pa rentheti ca l l y, a t the fi rs t occurrence i n ea ch ques ti on or a ns wer i n thi s book. Nonethel es s , there a re other common a bbrevi a ti ons tha t don’t a ppea r i n thi s book.

I’ve omi tted s ymbol s for chemi ca l el ements or thei r ca ti oni c or a ni oni c forms (eg, Ca2+_{, Cl}–_{), chemi ca l formul a e (eg, Na Cl ), a bbrevi a ti ons of} common bi ochemi ca l s (ATP, ADP, DNA, etc), Greek l etters , mos t uni ts of mea s ure (vol ume, wei ght, ti me), a nd a bbrevi a ti ons for mos t common l a b tes ts (but there a re s ome excepti ons ).

I wa nt to note tha t by l i s ti ng a bbrevi a ti ons here I’m not condoni ng or encoura gi ng thei r us e when, for exa mpl e, enteri ng i nforma ti on i nto a pa ti ent’s cha rt or medi ca ti on order or record. Indeed, us e of ma ny of thes e a bbrevi a ti ons i n pa ti ent-rel a ted documents s houl d be a voi ded, i n l a rge pa rt to hel p a voi d errors i n i nterpreti ng them or thei r mea ni ngs or i ntent.

[X]i—i ntra cel l ul a r concentra ti on, where X i s a n a ni on or a ca ti on

[X]O—extra cel l ul a r (“outs i de”) concentra ti on, where X i s a n a ni on or a ca ti on 1°—fi rs t degree (eg, 1° hea rt bl ock)

2°—s econd degree (eg, 2° hea rt bl ock)

3°—thi rd degree (eg, 3° hea rt bl ock, a l s o ca l l ed compl ete hea rt bl ock) 5-FU—5-fl uoroura ci l

5-HT—5-hydroxytrypta mi ne; s erotoni n

6-MP—6-merca ptopuri ne (a cti ve meta bol i te of a za thi opri ne) A

A-II—a ngi otens i n II

AA—a ra chi doni c a ci d; a mi no a ci d

AAPMC—a nti bi oti c-a s s oci a ted ps eudomembra nous col i ti s Ab—a nti body

a .c.—before mea l (s ) or, s i mpl y, before ea ti ng AC—a denyl yl cycl a s e

ACE—a ngi otens i n-converti ng enzyme (a l s o known a s bra dyki ni na s e, ki ni na s e II) ACh—a cetyl chol i ne

AChE—a cetyl chol i nes tera s e

AChEI—a cetyl chol i nes tera s e i nhi bi tor ACS—a cute corona ry s yndrome

ACTH—a drenocorti cotropi c hormone; corti cotropi n ADD/ADHD—a ttenti on-defi ci t (/hypera cti vi ty) di s order

ADH—a nti di ureti c hormone (va s opres s i n [VP]); a l dehyde dehydrogena s e a d l i b—(ta ke) freel y a s des i red, a s much a s needed, a s much a s you’d l i ke ADR—a dvers e drug rea cti on(s )

AED—a nti epi l epti c (a nti convul s a nt) drug AF (or AFIB)—a tri a l fi bri l l a ti on

AFL—a tri a l fl utter Ag—a nti gen

AIDS—a cqui red i mmunodefi ci ency s yndrome ALL—a cute l ymphocyti c l eukemi a

ALS—a myotrophi c l a tera l s cl eros i s (Lou Gehri g di s ea s e) ALT—a l a ni ne a mi notra ns fera s e

AMI—a cute myoca rdi a l i nfa rcti on AML—a cute myel ogenous l eukemi a ANA—a nti nucl ea r a nti bodi es ANS—a utonomi c nervous s ys tem AP—a cti on potenti a l

APAP—N-a cetyl para-a mi nophenol (a ceta mi nophen) APD—a cti on potenti a l dura ti on

APTT—a cti va ted pa rti a l thrombopl a s ti n ti me (eg, a mea s urement of a nti coa gul a ti on, eg, a s ca us ed by unfra cti ona ted hepa ri n) ARB—a ngi otens i n receptor bl ocker

ARC—AIDS-rel a ted compl ex

ASA—a cetyl s a l i cyl i c a ci d (a s pi ri n); Anes thes i ol ogy Soci ety of Ameri ca AST—a s pa rta te a mi notra ns fera s e

AUC—a rea under the (bl ood) concentra ti on vers us ti me “curve” (of a drug) AV(N)—a tri oventri cul a r (node)

A-V—a rteri ovenous (a s i n A-V s hunt; or di fferences i n concentra ti ons of a s ubs ta nce i n a rteri a l vs . venous bl ood, a s us ed to ca l cul a te cl ea ra nce of a drug)

AZT—a zi dothymi di ne (zi dovudi ne) B

(31)

BAL—Bri ti s h a nti -Lewi s i te (di merca prol ; chel a tor, a nti dote for a rs eni c poi s oni ng) BBB—bundl e bra nch bl ock

bi d—twi ce da i l y; s pel l i ng out twi ce da i l y i s preferred

BMI—body ma s s i ndex (body wei ght/body s urfa ce a rea i n m2₎ BMR—ba s a l meta bol i c ra te

BP—bl ood pres s ure (ca rdi a c output × tota l peri phera l res i s ta nce) BPH—beni gn pros ta ti c hypertrophy

BPM—bea ts per mi nute BUN—bl ood urea ni trogen BZD—benzodi a zepi ne C

Cav—a vera ge (mea n) pl a s ma concentra ti on of a drug

Cmax—ma xi mum pl a s ma concentra ti on

Cmin—mi ni mum pl a s ma concentra ti on

Css—s tea dy-s ta te pl a s ma concentra ti on CABG—corona ry a rtery bypa s s gra ft(i ng)

CAD—corona ry a rtery di s ea s e; corona ry hea rt di s ea s e (CHD) CAI—ca rboni c a nhydra s e i nhi bi tor

CBC—compl ete bl ood count CCB—ca l ci um cha nnel bl ocker

CDC—(US) Center for Di s ea s e Control a nd Preventi on CF—cys ti c fi bros i s

CGL—chroni c gra nul ocyti c l eukemi a

CHD—corona ry hea rt di s ea s e; corona ry a rtery di s ea s e (CAD) CHF—conges ti ve hea rt fa i l ure

CHI—cl os ed hea d i njury

CI—ca rdi a c i ndex (ca rdi a c output norma l i zed to body s urfa ce a rea ) CK—crea ti ne ki na s e

Cl —cl ea ra nce (of drug)

CML—chroni c myel ogenous l eukemi a CMV—cytomega l ovi rus

CNS—centra l nervous s ys tem

CO—ca rdi a c output (hea rt ra te × s troke vol ume) COLD—chroni c obs tructi ve l ung di s ea s e

COMT—ca techol -O-methyl tra ns fera s e (ca techol a mi ne-degra di ng enzyme)

COPD—chroni c obs tructi ve pul mona ry di s ea s e (eg, emphys ema , chroni c bronchi ti s ) COX—cycl ooxygena s e(s ); COX-1 a nd/or COX-2

CPZ—chl orproma zi ne; a l s o us ed a s a bbrevi a ti on of a bra nd na me product of prochl orpera zi ne; a voi d us e of thi s a bbrevi a ti on to a voi d i mproper s ubs ti tuti on of one drug for a nother

CRE—ca rba penem-res i s ta nt enteroba cteri a cea e CRF—corti cotropi n-rel ea s i ng fa ctor

CRP—c-rea cti ve protei n CSF—cerebros pi na l fl ui d

Css—s tea dy-s ta te drug concentra ti on

CTZ—chemoreceptor tri gger zone (vomi ti ng center) i n the bra i ns tem CVA—cerebrova s cul a r a cci dent (s troke)

CVP—centra l venous pres s ure

CYP—cytochrome P450 (s ys tem or member of i t) D

D1 (D2)—dopa mi ne D1 (or D2) receptor DA—dopa mi ne

DBH—dopa mi ne β-hydroxyl a s e (enzyme i nvol ved i n ca techol a mi ne s ynthes i s ) DBP—di a s tol i c bl ood pres s ure

DC—di s conti nue (a l s o D/C) DDI—drug–drug i ntera cti on

DFX—deferoxa mi ne (chel a tor us ed ma i nl y for i ron poi s oni ng) DHT—di hydrotes tos terone

DIG (or di g)—di goxi n Di s p—di s pens e

DKA—di a beti c ketoa ci dos i s DM—di a betes mel l i tus

DMARD—di s ea s e-modi fyi ng a nti rheuma ti c drug (eg, methotrexa te, ma ny others , i ncl udi ng corti cos teroi ds ); s ometi mes referred to a s SAARD (s l ow-a cti ng ow-a nti rheumow-a ti c drug)

(32)

DOPA—di hydroxyphenyl a l a ni ne DPH—di phenyl hyda ntoi n (phenytoi n)

DPI—dry powder i nha l er a dmi ni s tra ti on s ys tem for ora l i nha l a ti on of certa i n (ma i nl y pul mona ry) drugs ; a l s o s ee MDI, SPI dP/dt—ra te of pres s ure cha nge (eg, l eft ventri cul a r pres s ure vers us ti me; δP/δt)

DPP-4—di pepti dyl pepti da s e-4, the ta rget of ora l a nti di a beti c drugs known a s the gl i pti ns (eg, s a xa gl i pti n, s i ta gl i pti n) DU—duodena l ul cer

DVT—deep venous thrombos i s Dx—di a gnos i s

E

ECG—el ectroca rdi ogra m; EKG

ED—effecti ve dos e; emergency depa rtment ED50—medi a n effecti ve dos e

EDRF—endothel i um-deri ved rel a xi ng fa ctor (ni tri c oxi de) EEG—el ectroencepha l ogra m

EKG—el ectroca rdi ogra m; ECG EPI—epi nephri ne

ERP—effecti ve refra ctory peri od (eg, of a nerve); s ee a l s o RP, RRP EtOH—etha nol (a l s o ETOH)

F

FAB—a nti body fra gment

FDA—(US) Food a nd Drug Admi ni s tra ti on

FdUMP—5-fl uoro-2′-dexoyuri di ne-5′-monophos pha te, a cti ve a nti ca ncer (a nti )meta bol i te of fl uoroura ci l FEV—forced expi ra tory vol ume; FEV1, forced expi ra tory vol ume i n 1 s econd

FFA—free fa tty a ci ds FH2—7,8-di hydrofol i c a ci d FH4—5,6,7,8-tetra hydrofol i c a ci d FSH—fol l i cl e-s ti mul a ti ng hormone Fx—functi on

G

G6PD—gl ucos e 6-phos pha te dehydrogena s e GABA—γ-a mi nobutyri c a ci d

GAD—genera l i zed a nxi ety di s order

G-CSF—gra nul ocyte col ony-s ti mul a ti ng fa ctor GERD—ga s troes opha gea l refl ux di s ea s e GFR—gl omerul a r fi l tra ti on ra te

GH—growth hormone GI—ga s troi ntes ti na l

GLP—gl uca gon-l i ke pepti de (eg, GLP-1), a n i ncreti n-l i ke a gent GCSF—gra nul ocyte col ony-s ti mul a ti ng fa ctor

GM-CSF—gra nul ocyte ma cropha ge col ony-s ti mul a ti ng fa ctor G protei n—gua ni ne nucl eoti de-bi ndi ng protei n

Gp IIb/IIIa —pl a tel et membra ne gl ycoprotei n receptor res pons i bl e for l i nki ng (vi a fi bri nogen) a cti va ted pl a tel ets GSH, GSSG—gl uta thi one (reduced, oxi di zed)

GTT—gl ucos e tol era nce tes t (i nvol vi ng ei ther ora l [OGTT] or pa rentera l gl ucos e a dmi ni s tra ti on); drop(s ) (a s i n dos e or ra te of drug i nfus i on) gX—membra ne conducta nce of a n i on, where X i s pota s s i um, ca l ci um, etc (eg, gK)

GU—geni touri na ry H

H1—hi s ta mi ne H1 receptor H2—hi s ta mi ne H2 receptor

H2RA—hi s ta mi ne H2 receptor a nta goni s t HAART—hi ghl y a cti ve a nti retrovi ra l thera py Hb—hemogl obi n (a l s o HGB)

HbA1c—gl ycos yl a ted (or gl yca ted) hemogl obi n us ed to moni tor gl ycemi c control l ong-term hCG—huma n chori oni c gona dotropi n

Hct—hema tocri t

HCTZ—hydrochl orothi a zi de

HDL—hi gh-dens i ty l i poprotei n(s ) (chol es terol )

HEENT—hea d, eyes , ea rs , nos e, a nd throa t (eg, a s pa rts of a phys i ca l exa m)

HF—hea rt fa i l ure (or CHF, hea rt fa i l ure wi th s i gns a nd s ymptoms of venous conges ti on) HGB—hemogl obi n (a l s o Hb)

HHNKS—hyperos mol a r hypergl ycemi c nonketoti c s yndrome; a l s o a bbrevi a ted HHNS HIT—hepa ri n-i nduced thrombocytopeni a

(33)

HIV—huma n i mmunodefi ci ency vi rus

H+_,K+_{,ATPa s e—proton (hydrogen)–pota s s i um ATPa s e (eg, the ga s tri c pa ri eta l cel l “proton pump”)} HLBI—Hea rt, Lung a nd Bl ood Ins ti tute (of the Na ti ona l Ins ti tutes of Hea l th)

HMG—CoA-β-hydroxy-β-methyl gl uta ryl -coenzyme A HPA—hypotha l a mi c–pi tui ta ry a xi s

h.s .—a t bedti me

HSV—herpes s i mpl ex vi rus HTN—hypertens i on Hx—hi s tory I

IBD—i nfl a mma tory bowel di s ea s e ICP—i ntra cra ni a l pres s ure

IDDM—i ns ul i n-dependent di a betes mel l i tus ; us ua l l y mea ns Type 1 di a betes mel l i tus , however ma ny pa ti ents wi th Type 2 di a betes need (a re “dependent” on) i ns ul i n, s o IDDM i s not a s ui ta bl e term nor one tha t a utoma ti ca l l y i mpl i es Type 1

IgE, G (etc)—i mmunogl obul i n E, G, etc IGF—i ns ul i n-l i ke growth fa ctor

IHSS—i di opa thi c hypertrophi c s uba orti c s tenos i s IL (-1, -2, etc)—i nterl euki n(s )

IM—i ntra mus cul a r(l y) INH—i s oni a zi d

INR—i nterna ti ona l norma l i zed ra ti o (for norma l i zi ng res ul ts of prothrombi n ti me tes ts duri ng wa rfa ri n thera py) I&O—i nta ke a nd output (eg, of foods , fl ui ds )

INR—i nterna ti ona l norma l i zed ra ti o, deri ved from a nd us ed to s ta nda rdi ze res ul ts of prothrombi n ti me mea s urements (eg, when moni tori ng wa rfa ri n thera py)

IOM—(The) Ins ti tute of Medi ci ne, a pa rt of the Na ti ona l Aca demy of Sci ences , s tudi es a nd a dvi s es on ma ny a s pects of medi ci ne a nd medi ca l ca re; publ i s hed a l a ndma rk s tudy “To Err Is Huma n,” whi ch s howed us the ma gni tude, s cope, a nd cons equences of medi ca l errors —ma ny of whi ch i nvol ve drugs .

IOP—i ntra ocul a r pres s ure IP3—i nos i tol tri s phos pha te

ISA—i ntri ns i c s ympa thomi meti c a cti vi ty; s ubcl a s s of β-a drenergi c bl ockers tha t a l s o ha ve wea k a goni s t a cti vi ty, eg, pi ndol ol ISMP—Ins ti tute for Sa fe Medi ca l Pra cti ce (hea l th ca re/s a fety a nd moni tori ng orga ni za ti on)

IT—i ntra theca l (a dmi ni s tra ti on route) ITP—i di opa thi c thrombocytopeni c purpura IV—i ntra venous (l y)

IVP—IV pus h (ra pi d, bol us i njecti on of a drug); i ntra venous pyel ogra m J

JCAHO—Joi nt Commi s s i on on Accredi ta ti on of Hea l thca re Orga ni za ti ons (now known s i mpl y a s the “Joi nt Commi s s i on”)

JNC—Joi nt Na ti ona l Commi ttee (of the Na ti ona l Ins ti tutes of Hea l th), a s i n JNC-7—more properl y known a s the Joi nt Na ti ona l Commi ttee on Preventi on, Detecti on, Eva l ua ti on, a nd Trea tment of Hi gh Bl ood Pres s ure

K

ke—el i mi na ti on ra te cons ta nt L

LA—l eft a tri um; l oca l a nes theti c L-DOPA—l evodopa

LD—l etha l dos e

LD50—medi a n l etha l dos e LDL—l ow-dens i ty l i poprotei n(s ) LE—l upus erythema tos i s (s ee a l s o SLE) LH—l utei ni zi ng hormone

LHRH—l utei ni zi ng hormone-rel ea s i ng hormone (hypotha l a mi c) LMWH—l ow mol ecul a r wei ght hepa ri n (enoxa pa ri n)

L&R—norepi nephri ne + phentol a mi ne (occa s i ona l l y us ed a s IV a l terna ti ve to dobuta mi ne for s hort-term ca rdi a c i notropi c s upport, ena bl es norepi nephri ne to s ti mul a te hea rt wi thout ca us i ng va s ocons tri cti on)

LR—l a cta ted Ri nger s ol uti on LSD—l ys ergi c a ci d di ethyl a mi de LT—l eukotri ene

LV—l eft ventri cl e/ventri cul a r

LVEDP—l eft ventri cul a r end-di a s tol i c pres s ure LVH—l eft ventri cul a r hypertrophy

M

MAC—mi ni mum a l veol a r concentra ti on (eg, of i nha l a ti on a nes theti c/a na l ges i c) expres s ed percent of a gent i n tota l ga s mi xture needed to a bol i s h res pons e to certa i n pa i nful s ti mul i i n 50% of pa ti ents

(34)

MAP—mea n a rteri a l pres s ure

MAR—medi ca ti on a dmi ni s tra ti on record MBC—mi ni mum ba cteri ci da l concentra ti on MAO—monoa mi ne oxi da s e

MAO-A, -B—monoa mi ne oxi da s e type A, type B MAOI—monoa mi ne oxi da s e i nhi bi tor

mcg—mi crogra m; noted here beca us e i t i s preferred a bbrevi a ti on, i ns tea d of μg (whi ch mi ght be mi s i nterpreted a s mg), when wri ti ng pres cri pti ons , ma ki ng notes i n the medi ca ti on a dmi ni s tra ti on or pa ti ent cha rt, etc

MDI—metered-dos e i nha l er (del i very s ys tem for s ome drugs , us ua l l y pul mona ry) MEC—mi ni mum effecti ve concentra ti on

MH—ma l i gna nt hyperthermi a

MHC—ma jor hi s tocompa ti bi l i ty compl ex MI—myoca rdi a l i nfa rcti on

MIC—mi ni mum i nhi bi tory concentra ti on (us ua l l y a ppl i ed to a nti mi crobi a l s ) mmol —mi l l i mol e

MMR—mea s l es , mumps , rubel l a

MOPP—chemothera py combi na ti on us ed to trea t Hodgki n di s ea s e, deri ved from generi c or tra de na mes of four drugs : mechl oretha mi ne, Oncovi n® (vi ncri s ti ne), predni s one, a nd proca rba zi ne

mOs mol —mi l l i os mol e MP—[6-]merca ptopuri ne

MRSA—methi ci l l i n-res i s ta nt S. aureus MS—morphi ne s ul fa te; mul ti pl e s cl eros i s MTX—methotrexa te

N

Na -K ATPa s e—the s odi um pump (eg, on nerve, mus cl e cel l s , a nd s ome other exci ta bl e cel l s ) NADH—ni coti na mi de a deni ne di nucl eoti de

NADPH—ni coti na mi de a deni ne di nucl eoti de phos pha te

Na+_,K+_{,ATPa s e—s odi um–pota s s i um–a denos i ne tri phos pha ta s e (“s odi um pump”)}

NAPA—N-a cetyl proca i na mi de, meta bol i te of proca i na mi de; type of ca bba ge tha t i s a ma i n i ngredi ent i n ki m chee NCI—Na ti ona l Ca ncer Ins ti tute

NE—norepi nephri ne

NET—norepi nephri ne tra ns porter

NIDDM—noni ns ul i n-dependent di a betes mel l i tus ; more properl y ca l l ed Type 2 di a betes mel l i tus , a l though s ome pa ti ents wi th Type 2 di a betes ma y requi re (depend on) s uppl ementa l i ns ul i n (s ee IDDM a bove)

NM—ni coti ni c-s kel eta l mus cl e receptors (i e, thos e found pos ts yna pti ca l l y a t the s kel eta l -s oma ti c neuromus cul a r juncti on)

NN—ni coti ni c-neura l receptors (thos e found pos ts yna pti ca l l y i n a utonomi c ga ngl i a a nd on cel l s of the a drena l [s upra rena l ] medul l a ) NMDA —N- methyl -D-a s pa rta te (gl uta ma te cha nnel receptor, a goni s t, a nta goni s t, etc)

NMS—neurol epti c ma l i gna nt s yndrome

NNRTI—nonnucl eos i de revers e tra ns cri pta s e i nhi bi tor NO—ni tri c oxi de

NOS—ni tri c oxi da s e s yntha s e

NPH—neutra l prota mi ne Ha gedorn (type of i ntermedi a te-a cti ng i ns ul i n); i s opha ne i ns ul i n s us pens i on NPO—nothi ng by mouth (ni l per os )

NRTI—nucl eoti de revers e tra ns cri pta s e i nhi bi tor NS—norma l s a l i ne (i e, 0.9% Na Cl i n s teri l e wa ter)

NSAID—nons teroi da l a nti -i nfl a mma tory drug. See a l s o t-NSAID NSTMI—non-ST (el eva ti on) myoca rdi a l i nfa rcti on

NTG—ni trogl yceri n O

O2 SAT—oxygen s a tura ti on (eg, of bl ood s a mpl e) OA—os teoa rthri ti s

OC—ora l contra cepti ve

OCD—obs es s i ve–compul s i ve di s order OD—overdos e; ri ght eye

OS—l eft eye

OTC—over-the-counter (nonpres cri pti on), eg, OTC drug P

P450—cytochrome P450 mi xed-functi on oxi da s e s ys tem PA—pul mona ry a rtery; phys i ci a n-a s s i s ta nt

PAO2—a rteri a l pa rti a l pres s ure of oxygen

PABA—p-a mi nobenzoi c a ci d (i ngredi ent i n s ome s uns creens , common pres erva ti ve i n s ome mul ti us e pa rentera l medi ca ti on conta i ners ) PAC—prema ture a tri a l contra cti on