Medication Management — MCQs

10 questions

Which of the following drugs does not cause pharmacological adrenalectomy?

A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

In extraction, the best time to administer analgesics is:

Which of the following drugs need not be stopped before surgery?

A patient after valve replacement will require follow up treatment with

Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?

Which of the following is an example of placebo?

A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

Q10

What is the most appropriate perioperative management regarding the antihypertensive medication of a 55-year-old male with a history of hypertension who has been taking ACE inhibitors for the past 5 years and is scheduled for elective hernia repair surgery?

Medication Management Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following drugs does not cause pharmacological adrenalectomy?

A. Mitotane
B. Methotrexate (Correct Answer)
C. Ketoconazole
D. Aminoglutethimide

Explanation: ***Methotrexate*** - **Methotrexate** is an **antimetabolite** and **folate antagonist** primarily used in chemotherapy and for autoimmune diseases. It does not exert its primary action on the adrenal gland or steroid synthesis. - Its mechanism involves inhibiting **dihydrofolate reductase**, leading to reduced DNA synthesis and cell proliferation, which is unrelated to adrenal function. *Ketoconazole* - **Ketoconazole** is an antifungal agent that inhibits several **cytochrome P450 enzymes** involved in steroidogenesis, including 17α-hydroxylase and 11β-hydroxylase. - This inhibition leads to a decrease in **cortisol and androgen synthesis**, effectively causing a pharmacological adrenalectomy. *Mitotane* - **Mitotane** is a cytotoxic agent that causes **adrenocortical atrophy** and inhibits the synthesis of adrenal steroids. - It is specifically used in the treatment of **adrenocortical carcinoma** due to its direct destructive effect on adrenal cells. *Aminoglutethimide* - **Aminoglutethimide** inhibits the enzymatic conversion of **cholesterol to pregnenolone**, the rate-limiting step in steroid hormone synthesis. - This broad inhibition reduces the production of **all adrenal steroids**, including cortisol, thus inducing a pharmacological adrenalectomy.

Question 2: A 20-year-old woman with a family history of von Willebrand disease is found to have an activated partial thromboplastin time (aPTT) of 78 (normal = 32) on routine testing prior to cholecystectomy. Further investigation reveals a prothrombin time (PT) of 13 (normal = 12), a platelet count of 350,000/mm³, and an abnormal bleeding time. Which of the following should be administered in the perioperative period?

A. Factor VIII
B. Desmopressin (DDAVP) (Correct Answer)
C. Platelets
D. Vitamin K

Explanation: ***Desmopressin (DDAVP)*** - **Desmopressin** is the first-line treatment for **von Willebrand disease (vWD)** [1], especially for type 1, which this patient's profile suggests (prolonged aPTT, normal PT, normal platelet count, and abnormal bleeding time). - It works by stimulating the release of endogenous **von Willebrand factor (vWF)** and **factor VIII** from endothelial cells [1]. *Factor VIII* - While Factor VIII deficiency can cause prolonged aPTT, this patient's presentation with a family history of **vWD**, normal PT, and abnormal bleeding time points specifically to a **vWF** defect rather than isolated **Factor VIII** deficiency [1]. - Administration of direct **Factor VIII** is not the primary treatment for **vWD**, although vWF concentrate (which contains Factor VIII) may be used for severe cases [1]. *Platelets* - The patient's **platelet count is normal** (350,000/mm³), indicating that a platelet transfusion is not necessary. - **vWD** is a disorder of platelet adhesion, not a problem with platelet quantity. *Vitamin K* - **Vitamin K** is essential for the synthesis of coagulation factors II, VII, IX, and X, as well as proteins C and S. - A deficiency in **Vitamin K** typically results in a prolonged **PT** [2], which is normal in this patient.

Question 3: In extraction, the best time to administer analgesics is:

A. Prior to the procedure (Correct Answer)
B. After anaesthesia has worn off
C. When pain is moderate to severe
D. Just before anaesthesia wears off

Explanation: ***Prior to the procedure*** - Administering analgesics **preemptively** helps to reduce the overall perception of pain post-operatively by blocking pain pathways before they are fully activated. - This approach is known as **preemptive analgesia** and has been shown to reduce post-operative pain intensity and analgesic consumption. *After anaesthesia has worn off* - Waiting until the anesthesia has worn off means the patient will likely experience the onset of significant pain, making it harder to control effectively. - This approach is reactive rather than proactive, and does not leverage the benefits of **preemptive pain management**. *When pain is moderate to severe* - At this point, the pain is already established and may be more difficult to manage, requiring higher doses or stronger analgesics. - **Pain management** is more effective when initiated before pain becomes severe, preventing the sensitization of pain pathways. *Just before anaesthesia wears off* - While this is better than waiting until the anesthesia has completely worn off, it still misses the opportunity for **preemptive analgesia**. - The pain pathways may already be activated or becoming sensitized as the anesthetic effect diminishes, making it less effective than administering prior to the procedure.

Question 4: Which of the following drugs need not be stopped before surgery?

A. High Dose Aspirin
B. Metformin
C. Digitalis (Correct Answer)
D. Warfarin

Explanation: ***Digitalis*** - **Digitalis (digoxin)** is often continued through surgery, especially in patients with **heart failure** or **atrial fibrillation** to maintain cardiac function. - Its cessation could precipitate **cardiac decompensation** or arrhythmias, which are high-risk events during surgery. *High Dose Aspirin* - **High-dose aspirin** should generally be stopped before surgery due to its **antiplatelet effects**, increasing the risk of perioperative bleeding. - The duration of discontinuation depends on the type of surgery and individual patient risk. *Metformin* - **Metformin** should be stopped before surgery due to the risk of **lactic acidosis**, especially in situations involving **renal impairment** or hypoperfusion associated with surgery. - It's typically held on the day of surgery and for 24-48 hours post-operatively, depending on renal function. *Warfarin* - **Warfarin** is a strong oral anticoagulant that must be discontinued before most surgeries to prevent **excessive bleeding**. - It is typically stopped 5 days pre-op, and patients often receive **bridging therapy** with heparin, depending on their risk for thromboembolism.

Question 5: A patient after valve replacement will require follow up treatment with

A. ACE inhibitors
B. Beta blockers
C. Thiazide
D. Warfarin (Correct Answer)

Explanation: ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.

Question 6: Which of the following is the FIRST-LINE antiemetic drug most commonly used for post-operative nausea and vomiting (PONV) prophylaxis?

A. Lorazepam
B. Metoclopramide
C. Promethazine
D. Ondansetron (Correct Answer)

Explanation: ***Ondansetron*** - **Ondansetron** is a **5-HT3 receptor antagonist** and is considered a first-line agent due to its high efficacy and favorable side effect profile in preventing PONV. - It works by blocking serotonin receptors in the **chemoreceptor trigger zone** and the **gastrointestinal tract**, reducing the sensation of nausea and vomiting. *Lorazepam* - **Lorazepam** is a **benzodiazepine** primarily used for its **anxiolytic** and **sedative effects**, and sometimes as an adjunct for refractory nausea, but not as a first-line antiemetic for PONV prophylaxis. - While it can help indirectly by reducing anxiety, it does not directly target the key pathways involved in PONV as effectively as 5-HT3 antagonists. *Phenytoin* - **Phenytoin** is an **anticonvulsant** medication used to prevent seizures and has no role in the direct treatment or prophylaxis of PONV. - It primarily acts on voltage-gated sodium channels in neurons and does not possess antiemetic properties. *Metoclopramide* - **Metoclopramide** is a **dopamine D2 receptor antagonist** and a **prokinetic agent** that can be used for PONV, particularly when gastric stasis is a concern. - However, it is generally considered a second-line agent due to the risk of **extrapyramidal side effects**, especially with higher doses or prolonged use. *Promethazine* - **Promethazine** is a **first-generation antihistamine** with **antidopaminergic** and **anticholinergic properties** that can be effective for nausea and vomiting. - It is often used as a rescue antiemetic or in combination therapy, but its sedative effects and potential for extrapyramidal symptoms make it less preferable as a first-line prophylactic agent compared to ondansetron.

Question 7: Match the following drugs in Column A with their contraindications in Column B. | Column A | Column B | | :-- | :-- | | 1. Morphine | 1. QT prolongation | | 2. Amiodarone | 2. Thromboembolism | | 3. Vigabatrin | 3. Pregnancy | | 4. Estrogen preparations | 4. Head injury |

A. A-1, B-3, C-2, D-4
B. A-4, B-1, C-3, D-2 (Correct Answer)
C. A-3, B-2, C-4, D-1
D. A-2, B-4, C-1, D-3

Explanation: ***A-4, B-1, C-3, D-2*** - **Morphine** is contraindicated in **head injury** as it can increase intracranial pressure and mask neurological symptoms. - **Amiodarone** is contraindicated in patients with **QT prolongation** due to its risk of inducing more severe arrhythmias like Torsades de Pointes. - **Vigabatrin** is contraindicated during **pregnancy** due to its potential for teratogenicity and adverse effects on fetal development. - **Estrogen preparations** are contraindicated in patients with a history of **thromboembolism** due to their increased risk of blood clot formation. *A-1, B-3, C-2, D-4* - This option incorrectly matches **Morphine** with QT prolongation and **Estrogen preparations** with head injury, which are not their primary contraindications. - It also incorrectly links **Vigabatrin** with thromboembolism and **Amiodarone** with pregnancy. *A-3, B-2, C-4, D-1* - This choice incorrectly associates **Morphine** with pregnancy and **Vigabatrin** with head injury, which are not the most critical or direct contraindications. - It also misaligns **Amiodarone** with thromboembolism and **Estrogen preparations** with QT prolongation. *A-2, B-4, C-1, D-3* - This option incorrectly matches **Morphine** with thromboembolism and **Amiodarone** with head injury, which are not their most significant contraindications. - It also incorrectly links **Vigabatrin** with QT prolongation and **Estrogen preparations** with pregnancy.

Question 8: Which of the following is an example of placebo?

A. Cognitive behavioral therapy
B. Sugar pill given as medication
C. Physiotherapy
D. Sham surgery (Correct Answer)

Explanation: ***Sham surgery*** - Sham surgery involves a **mock surgical procedure** performed on a patient without the actual therapeutic intervention, often used as a control in clinical trials. - Its purpose is to account for the **placebo effect** of the surgical experience itself, including anesthesia and incisions, independent of the direct physiological effects of the surgery. *Cognitive behavioral therapy* - **Cognitive behavioral therapy (CBT)** is a structured psychotherapy that helps individuals identify and change negative thought patterns and behaviors [1]. - It is a **specific, active treatment** with established mechanisms of action, not merely an inert substance or procedure [1]. *Sugar pill given as medication* - While a **sugar pill** is a classic example of a placebo, the question asks for *an* example of a placebo, and sham surgery is also a valid and often more complex form. - A sugar pill's effect primarily stems from the **expectation of relief** from a medication. *Physiotherapy* - **Physiotherapy** involves physical methods (e.g., exercise, massage, heat therapy) to treat disease, injury, or deformity. - It is an **active therapeutic intervention** with direct physiological and biomechanical effects, not an inert or non-specific treatment.

Question 9: A patient on long-term high-dose steroid therapy (prednisolone 20 mg/day for 6 months) is scheduled for major abdominal surgery. What is the most essential perioperative requirement?

A. Insulin only
B. Hydrocortisone only (Correct Answer)
C. Both
D. None of the options

Explanation: ***Hydrocortisone only*** - Patients on chronic **high-dose steroid therapy** (>5 mg prednisolone daily for >3 weeks) are at risk of **adrenal insufficiency** during surgical stress due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. - **Hydrocortisone stress dose** (100 mg IV at induction, followed by 50 mg every 8 hours) is the **most essential and immediate requirement** to prevent **adrenal crisis** during major surgery. - Hydrocortisone has both glucocorticoid and mineralocorticoid activity, mimicking the body's natural cortisol response to surgical stress. *Insulin only* - While steroids can cause **hyperglycemia** requiring insulin management, this is a **secondary concern** compared to preventing life-threatening **adrenal crisis**. - Insulin addresses a metabolic complication but does not protect against **inadequate cortisol response** to surgical stress. - **Without stress-dose steroids**, the patient risks hemodynamic collapse regardless of glucose control. *Both* - Although **both** medications might eventually be needed if hyperglycemia develops, the question asks for the **most essential** requirement. - **Hydrocortisone is non-negotiable** and must be given prophylactically; insulin is only needed if blood glucose is elevated. - Prioritizing both equally misses the critical time-sensitive need for **adrenal axis support**. *None of the options* - This is incorrect because patients on chronic high-dose steroids undergoing major surgery **absolutely require stress-dose steroid coverage**. - Failure to administer hydrocortisone can result in **acute adrenal crisis** with severe hypotension, shock, and potential mortality. - Modern guidelines confirm the need for perioperative steroid supplementation in high-risk patients.

Question 10: What is the most appropriate perioperative management regarding the antihypertensive medication of a 55-year-old male with a history of hypertension who has been taking ACE inhibitors for the past 5 years and is scheduled for elective hernia repair surgery?

A. Switch to a beta-blocker 48 hours before surgery
B. Continue ACE inhibitors until the morning of surgery (Correct Answer)
C. No changes needed in his medication regimen
D. Discontinue ACE inhibitors 24 hours prior to surgery to avoid hypotension.

Explanation: ***Continue ACE inhibitors until the morning of surgery*** - While it's common practice to hold ACE inhibitors on the day of surgery to prevent **intraoperative hypotension**, continuing them until the morning of surgery is often acceptable for elective procedures as it minimizes the risk of **rebound hypertension**. - Following the most recent guidelines, for patients undergoing elective non-cardiac surgery, ACE inhibitors can be continued, but it is important to check the specific institutional guidelines as the decision to hold or continue ACE inhibitors often varies based on the patient's individual risk profile and the type of surgery. *Switch to a beta-blocker 48 hours before surgery* - Switching to a beta-blocker acutely before surgery without a clear indication could lead to **uncontrolled hypertension** or other adverse effects if the patient is not accustomed to beta-blockers. - Beta-blockers are generally continued perioperatively if the patient is already taking them, but initiating them immediately before surgery is not a standard recommendation for routine hypertension management. *No changes needed in his medication regimen* - This is incorrect as current guidelines suggest at least some modification, such as holding the ACE inhibitor on the morning of surgery due to the risk of **refractory hypotension** under anesthesia. - ACE inhibitors can interact with anesthetic agents, making blood pressure management more challenging during surgery. *Discontinue ACE inhibitors 24 hours prior to surgery to avoid hypotension.* - While recommended by some older guidelines and for certain high-risk patients, discontinuing ACE inhibitors 24 hours prior is not universally recommended for all elective surgeries as it may increase the risk of **perioperative hypertension** or rebound effects. - The risk of perioperative hypotension with ACE inhibitors is real, however, in an elective setting, the current trend is to hold the dose on the morning of the surgery rather than a day before unless institution specific guidelines explicitly mention it.

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