Autacoids, NSAIDs, respiratory and GI drugs

33 NEET-PG practice questions on Autacoids, NSAIDs, respiratory and GI drugs, part of Pharmacology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 70-year-old man with COPD and benign prostatic hyperplasia is started on a once-daily inhaled bronchodilator from a dry-powder device. Two weeks later he complains of a dry mouth and is brought to casualty with acute retention of urine. Which drug was most likely started?

   1. ASalmeterol
   2. BFormoterol
   3. CTiotropium
   4. DIndacaterol

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   Answer: C · Tiotropium

   Tiotropium is a long-acting muscarinic antagonist that blocks M3 receptors on airway smooth muscle; as a quaternary compound little is absorbed, but enough can reach the circulation to cause dry mouth, urinary retention in men with prostatic enlargement, and worsening of angle-closure glaucoma. LAMAs are a first-choice maintenance bronchodilator in COPD and reduce exacerbations. Patients are taught to keep the powder or mist away from the eyes.

   • A: Salmeterol is a twice-daily beta2-agonist without anticholinergic effects.
   • B: Formoterol is a beta2-agonist without anticholinergic effects.
   • D: Indacaterol is a once-daily beta2-agonist; it causes tremor and palpitations, not retention.

2. Question 2 · Medium

   A 62-year-old man with osteoarthritis of both knees had an anterior wall MI last year. He asks for celecoxib because a neighbour told him it is 'gentle on the stomach'. Why is this drug a poor choice for him?

   1. AIt causes more gastric ulcers than ibuprofen
   2. BIt blocks cardiac hERG potassium channels
   3. CIt cuts endothelial prostacyclin but spares platelet thromboxane
   4. DIt irreversibly acetylates COX-1 in platelets

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   Answer: C · It cuts endothelial prostacyclin but spares platelet thromboxane

   Selective COX-2 inhibitors reduce prostacyclin (PGI2), which endothelial cells make largely through COX-2 and which inhibits platelets and dilates vessels. Platelets make thromboxane A2 through COX-1, which these drugs spare, so the balance tips towards thrombosis, raising the risk of MI and stroke. They also cause sodium retention and raise BP. In patients with established cardiovascular disease, paracetamol and non-drug measures are preferred, and any NSAID is used at the lowest dose for the shortest time.

   • A: Celecoxib causes fewer, not more, gastric ulcers than non-selective NSAIDs.
   • B: Celecoxib's cardiovascular risk is thrombotic, not from hERG block.
   • D: Irreversible acetylation of platelet COX-1 is aspirin's protective action.

3. Question 3 · Medium

   A 70-year-old woman has taken omeprazole every day for 6 years without a clear indication. At a review in the medicine OPD, the resident lists four possible consequences of long-term use: 1. Hypomagnesaemia. 2. Hyperkalaemia. 3. Vitamin B12 deficiency. 4. A higher risk of Clostridioides difficile infection. Which are recognised adverse effects of long-term PPI use?

   1. A2, 3 and 4 only
   2. B1 and 4 only
   3. C1, 3 and 4 only
   4. D1, 2, 3 and 4

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   Answer: C · 1, 3 and 4 only

   Statements 1, 3 and 4 are correct. Long-term PPI use reduces intestinal magnesium absorption, which can cause hypomagnesaemia with secondary hypocalcaemia and hypokalaemia; acid is needed to release cobalamin from food protein, so B12 levels can fall; and loss of the gastric acid barrier increases enteric infections, including C. difficile. Fracture risk and pneumonia have also been linked to long-term use. PPIs do not cause hyperkalaemia, and in patients without an ongoing indication they should be tapered and stopped.

   • A: Includes hyperkalaemia and leaves out hypomagnesaemia.
   • B: Leaves out vitamin B12 deficiency, a recognised effect.
   • D: Includes hyperkalaemia, which PPIs do not cause.

4. Question 4 · Medium

   A 45-year-old woman with severe asthma has needed three courses of oral prednisolone this year despite high-dose inhaled steroid plus LABA, with good technique and adherence. Blood eosinophils are 650/µL, total IgE is normal and skin prick tests to common allergens are negative. Which add-on biologic targets the main driver of her disease?

   1. AOmalizumab (anti-IgE)
   2. BMepolizumab (anti-IL-5)
   3. CInfliximab (anti-TNF)
   4. DRituximab (anti-CD20)

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   Answer: B · Mepolizumab (anti-IL-5)

   She has severe eosinophilic asthma without allergic sensitisation. IL-5 drives the production, activation and survival of eosinophils, and blocking it with mepolizumab (or its receptor with benralizumab) reduces exacerbations and the need for oral steroids. Omalizumab needs allergic asthma with a raised IgE in a set range, which she does not have. Dupilumab, which blocks the IL-4 receptor alpha chain, is another option for type 2 asthma.

   • A: Omalizumab is for allergic asthma with raised IgE and positive sensitisation.
   • C: Anti-TNF drugs have not proved useful in asthma.
   • D: Anti-CD20 therapy has no place in asthma.

5. Question 5 · Medium

   A 52-year-old man with stable angina has had migraine since his twenties. During a severe attack he takes a tablet from his wife's strip of migraine medicine and develops crushing chest pain 30 minutes later. The drug he took acts by:

   1. ABlocking beta-adrenergic receptors in the heart
   2. BBlocking calcium entry into vascular smooth muscle
   3. CBlocking 5-HT2 receptors on vascular smooth muscle
   4. DStimulating 5-HT1B/1D receptors on cranial vessels

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   Answer: D · Stimulating 5-HT1B/1D receptors on cranial vessels

   The tablet was a triptan such as sumatriptan, used to abort migraine attacks. Triptans stimulate 5-HT1B receptors on cranial blood vessels, causing vasoconstriction, and 5-HT1D receptors on trigeminal nerve endings, reducing release of CGRP and other neuropeptides. Coronary arteries also carry 5-HT1B receptors, so triptans can cause coronary vasospasm and are contraindicated in ischaemic heart disease, uncontrolled hypertension and stroke. For such patients, NSAIDs or newer agents such as gepants are used for attacks.

   • A: Beta-blockers such as propranolol prevent migraine and reduce angina.
   • B: Calcium channel blockers such as flunarizine prevent migraine and dilate vessels.
   • C: 5-HT2 blockade (as with cyproheptadine) does not cause coronary spasm.

6. Question 6 · Medium

   A 46-year-old woman receiving cisplatin-based chemotherapy for carcinoma cervix was given IV ondansetron and dexamethasone before her first cycle. She did not vomit on the day of treatment but vomited repeatedly from day 2 to day 4. Which drug should be added for the next cycle to prevent this delayed vomiting?

   1. AGranisetron
   2. BAprepitant
   3. CPromethazine
   4. DDomperidone

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7. Question 7 · Hard

   A 26-year-old woman is brought to casualty with acute severe asthma. She can speak only single words; respiratory rate is 32/min, pulse 128/min, SpO2 91% on room air and peak flow 30% of her best. Three back-to-back nebulisations of salbutamol with ipratropium, oxygen and IV hydrocortisone bring no improvement, and an ABG now shows PaCO2 44 mmHg. Senior help and the ICU have been called. Which drug should be given next?

   1. AOral montelukast tablet
   2. BSubcutaneous omalizumab
   3. CIntravenous magnesium sulphate
   4. DIntravenous aminophylline bolus

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8. Question 8 · Medium

   A day-old baby in the NICU becomes deeply cyanosed. Echocardiography shows pulmonary atresia, with blood reaching the lungs only through a narrowing ductus arteriosus. An infusion of alprostadil is started while transfer for surgery is arranged. Which adverse effect must the team be ready to manage?

   1. ABronchospasm
   2. BSevere hypertension
   3. CHyperkalaemia
   4. DApnoea

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9. Question 9 · Easy

   An 18-year-old girl is given IV metoclopramide in casualty for vomiting. A few hours later her neck twists to one side, her eyes roll upwards and her tongue protrudes. What is the mechanism of this reaction?

   1. AStimulation of 5-HT3 receptors in the gut
   2. BBlockade of D2 receptors in the striatum
   3. CExcess serotonin in the brainstem nuclei
   4. DBlockade of muscarinic receptors in the brain

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10. Question 10 · Hard

    A 58-year-old man whose hypertension is controlled on atenolol is given IV ceftriaxone in casualty. Within minutes he develops generalised urticaria, wheeze and BP 70/40 mmHg. He receives two doses of IM adrenaline 0.5 mg five minutes apart, high-flow oxygen, 2 litres of IV saline, IV chlorpheniramine and IV hydrocortisone, but his BP stays at 76/44 mmHg with a pulse of 62/min. What best explains the poor response, and what should be added?

    1. ABeta-blockade; add IV glucagon
    2. BHistamine excess; add IV ranitidine
    3. CBradykinin excess; give icatibant
    4. DLate-phase reaction; double the hydrocortisone

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11. Question 11 · Medium

    A 30-year-old man with left-sided ulcerative colitis has been in remission on sulfasalazine for 3 years. He and his wife have not conceived after 18 months of trying; his semen analysis shows a low sperm count with poor motility, and her evaluation is normal. What is the best change to his treatment?

    1. AContinue sulfasalazine and add folic acid
    2. BSwitch to long-term oral prednisolone
    3. CSwitch to mesalamine, which lacks sulfapyridine
    4. DStop all maintenance treatment

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12. Question 12 · Medium

    A 66-year-old man with Parkinson disease on levodopa-carbidopa has troublesome nausea whenever his dose is increased. Which antiemetic will relieve the nausea without worsening his parkinsonism?

    1. AHaloperidol
    2. BDomperidone
    3. CMetoclopramide
    4. DProchlorperazine

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13. Question 13 · Easy

    A 35-year-old long-distance truck driver from Nashik has seasonal sneezing, itchy eyes and watery rhinorrhoea every spring. He must stay alert at the wheel for long hours. Which oral antihistamine is most suitable for him?

    1. AHydroxyzine
    2. BChlorpheniramine
    3. CPromethazine
    4. DFexofenadine

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14. Question 14 · Medium

    A 70-year-old woman with metastatic carcinoma of the pancreas, in a palliative care unit, takes regular oral morphine that controls her pain well. She has had no bowel movement for 6 days despite regular lactulose and bisacodyl. Her abdomen is soft and an abdominal X-ray shows no obstruction. Which drug relieves the constipation without reducing her pain relief?

    1. AOral metoclopramide
    2. BIntravenous naloxone
    3. CSubcutaneous methylnaltrexone
    4. DIntravenous neostigmine

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15. Question 15 · Hard

    A 60-year-old man takes aspirin 75 mg daily after a coronary stent. He asks the physician which painkiller he can buy for low back pain. The physician reviews four statements: 1. Low-dose aspirin irreversibly inhibits platelet COX-1 for the life of the platelet. 2. Ibuprofen taken shortly before his aspirin can block aspirin's antiplatelet effect. 3. Paracetamol at usual doses has little effect on platelet function. 4. Adding a regular NSAID to aspirin raises his risk of gastrointestinal bleeding. Which statements are correct?

    1. A1, 2, 3 and 4
    2. B1 and 4 only
    3. C1, 2 and 4 only
    4. D2, 3 and 4 only

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16. Question 16 · Easy

    A 30-year-old woman with persistent asthma was started on a budesonide-formoterol inhaler a month ago. She now has a hoarse voice and white curd-like patches on her palate that scrape off, leaving a red base. What simple advice best prevents this?

    1. AUse the inhaler only at bedtime
    2. BRinse the mouth and gargle after each use
    3. CAdd oral montelukast each night
    4. DChange to oral prednisolone tablets

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17. Question 17 · Medium

    A 22-year-old college student has asthma symptoms about twice a week and wakes at night with cough once a month. He uses a salbutamol inhaler alone and admits that he forgets daily 'preventer' inhalers. According to current GINA guidance, what is the preferred treatment for him?

    1. AAs-needed low-dose budesonide-formoterol
    2. BRegular salmeterol inhaler on its own
    3. CSalbutamol as needed, continued alone
    4. DRegular oral montelukast every night

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18. Question 18 · Medium

    A 9-year-old boy with mild persistent asthma and allergic rhinitis was started by his paediatrician on a chewable tablet taken every night. Within a month his parents report nightmares, irritability and sleep-walking, which stop when the tablet is withdrawn. How does this drug act?

    1. AIt inhibits the 5-lipoxygenase enzyme
    2. BIt blocks the CysLT1 receptor for leukotrienes
    3. CIt blocks H1 receptors in the airway
    4. DIt stabilises the membranes of mast cells

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19. Question 19 · Medium

    During a follow-up visit, a man with erosive oesophagitis says omeprazole 20 mg is not helping. He takes it at night, after dinner, with his other tablets. He has no alarm symptoms and an endoscopy two months ago showed no ulcer or Barrett change. He has lost no weight and has no dysphagia. What is the best advice?

    1. ATake it 30-60 minutes before breakfast
    2. BTake it immediately after breakfast
    3. CTake it with milk to reduce irritation
    4. DTake it with an antacid for faster action

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20. Question 20 · Hard

    In the labour room of a district hospital, a woman in preterm labour at 30 weeks was given indomethacin as a tocolytic. She was kept on it for four days because contractions recurred whenever it was reduced. A scan now shows an amniotic fluid index of 4 cm, and fetal echocardiography shows tricuspid regurgitation with high flow velocity across a narrowed ductus arteriosus. Betamethasone was completed three days ago. Her BP is 116/72 mmHg, she has no fever, and the fetus is cephalic with an estimated weight of 1.4 kg. What is the best step regarding her tocolysis?

    1. AHalve the indomethacin dose
    2. BContinue indomethacin and repeat the scan in a week
    3. CStop indomethacin and change to nifedipine
    4. DAdd magnesium sulphate to indomethacin

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21. Question 21 · Medium

    After a drug-eluting stent was placed for an anterior STEMI, a man was discharged on aspirin, clopidogrel and atorvastatin. Because of a past bleeding duodenal ulcer, a gastroprotective drug is also needed. He is 58, a non-smoker, with normal renal function, and his H. pylori stool antigen was negative after eradication therapy last year. Which drug is the best choice, and why?

    1. AEsomeprazole, which has the longest action
    2. BCimetidine, which avoids PPI interactions
    3. COmeprazole, which is the most potent PPI
    4. DPantoprazole, which inhibits CYP2C19 the least

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22. Question 22 · Easy

    Which prostaglandin E1 analogue is used to prevent NSAID-induced gastric ulcers and is contraindicated in pregnancy?

    1. ADinoprostone
    2. BAlprostadil
    3. CLatanoprost
    4. DMisoprostol

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23. Question 23 · Medium

    Despite a LABA-LAMA inhaler, a man with severe COPD (FEV1 38% of predicted), chronic productive cough and two exacerbations last year is started on a once-daily oral drug that inhibits phosphodiesterase-4. He is a retired textile worker who still smokes 5 bidis a day, weighs 52 kg and has a past history of depression. Which adverse effects should he be warned about?

    1. ADiarrhoea, weight loss and low mood
    2. BTachycardia, tremor and hypokalaemia
    3. CDry mouth, urinary retention and glaucoma
    4. DOral thrush, hoarseness and bruising

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24. Question 24 · Medium

    Serum creatinine rose from 1.2 to 2.6 mg/dL (normal 0.6-1.2) over five days in a retired mason with hypertension controlled on ramipril and hydrochlorothiazide. He had started diclofenac 50 mg three times a day for knee pain the week before. Urine microscopy is bland. By which mechanism did the new drug most likely cause this?

    1. ALoss of prostaglandin-mediated afferent arteriolar dilatation
    2. BImmune-complex deposition in the glomeruli
    3. CConstriction of the efferent arteriole by excess angiotensin II
    4. DPrecipitation of drug crystals in the tubules

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25. Question 25 · Medium

    Within an hour of taking ibuprofen for a toothache, a woman with long-standing asthma and recurrent nasal polyps develops severe wheeze, nasal blockage and flushing. She had a similar episode after aspirin last year. Her asthma had been well controlled on an inhaled steroid. Her pulse is 112/min and SpO2 91% on room air. What is the mechanism of this reaction?

    1. AIgE antibodies against ibuprofen cross-link receptors on mast cells
    2. BProstaglandin E2 excess constricts the bronchi
    3. CCOX inhibition diverts arachidonic acid to cysteinyl leukotrienes
    4. DIbuprofen directly releases histamine from basophils

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