Analgesics and Anti-inflammatory Drugs Practice Questions

Q: Which drug used in treatment of rheumatoid arthritis acts by inhibition of T-cell proliferation?

Leflunomide. ***Leflunomide*** - **Leflunomide** is a **pyrimidine synthesis inhibitor** that works by inhibiting the enzyme **dihydroorotate dehydrogenase** [1]. - This inhibition leads to a decrease in **de novo pyrimidine synthesis**, which is essential for **T-cell proliferation**, thereby exerting its immunomodulatory effects in **rheumatoid arthritis** [1], [2]. *Anakinra* - **Anakinra** is an **interleukin-1 receptor antagonist** that blocks the activity of **IL-1**, a pro-inflammatory cytokine. - It does not primarily act by inhibiting **T-cell proliferation**, but rather by modulating the inflammatory response. *Infliximab* - **Infliximab** is a **monoclonal antibody** that targets and neutralizes **tumor necrosis factor-alpha (TNF-α)**, a key cytokine in inflammation. - Its mechanism of action is primarily related to blocking **TNF-α activity**, not directly inhibiting **T-cell proliferation**. *Etanercept* - **Etanercept** is a **fusion protein** that acts as a **TNF-α receptor decoy**, binding to **TNF-α** and preventing it from interacting with its natural receptors. - Similar to infliximab, its main action is to inhibit **TNF-α**, rather than directly inhibiting **T-cell proliferation**.

Q: A 50-year-old man presents with complaints of bilateral morning stiffness in his wrists and knees and painful joints on exercise. On physical examination, the joints are slightly swollen. The rest of the examination is unremarkable. His laboratory findings are also negative except for slight anemia, elevated erythrocyte sedimentation rate, and positive rheumatoid factor. The patient was started on weekly methotrexate to control the inflammation. What is the principle mechanism of action here?

Increased extracellular levels of adenosine. ***Increased extracellular levels of adenosine*** - Methotrexate, at the low doses used for rheumatoid arthritis, primarily acts by inhibiting **aminoimidazole carboxamide ribonucleotide (AICAR) transformylase**, leading to a buildup of AICAR. - This accumulation inhibits **adenosine deaminase** and **AMP deaminase**, increasing extracellular adenosine, which is an anti-inflammatory mediator. *Inhibition of assembly of microtubules in neutrophils impairing chemotaxis* - This mechanism is characteristic of **colchicine**, used in treating gout, not methotrexate in rheumatoid arthritis. - Colchicine prevents neutrophil migration and activity by disrupting **microtubule polymerization**. *Inhibition of cyclooxygenase enzyme* - This is the primary mechanism of action for **NSAIDs (Nonsteroidal Anti-inflammatory Drugs)**, which reduce inflammation and pain by blocking prostaglandin synthesis. - Methotrexate's anti-inflammatory effects are not mediated through direct cyclooxygenase inhibition. *Inhibition of Dihydrofolate reductase enzyme* - While methotrexate does inhibit **dihydrofolate reductase (DHFR)**, this mechanism is primarily responsible for its cytotoxic effects in **cancer chemotherapy** at much higher doses. - At the low doses used in rheumatoid arthritis, the primary anti-inflammatory mechanism is related to adenosine.

Q: All are opioid agonist - antagonist compounds except

Nalmefene. ***Nalmefene*** - **Nalmefene** is a **pure opioid antagonist**, meaning it blocks opioid receptors without producing any opioid agonist effects [1], [4]. - It is primarily used to reverse opioid overdose and for alcohol dependence treatment. - Unlike agonist-antagonist compounds, it has **no agonist activity** at any opioid receptor, making it the correct answer [1], [4]. *Pentazocine* - **Pentazocine** is a classic **opioid agonist-antagonist** (mixed agonist-antagonist). - It acts as an **agonist at kappa receptors** (providing analgesia) and a **weak antagonist or partial agonist at mu receptors** [2]. - This mixed action produces a ceiling effect on respiratory depression and lower abuse potential compared to pure mu agonists [2]. *Buprenorphine* - **Buprenorphine** is a **partial mu opioid agonist** with high receptor affinity and antagonist activity at kappa receptors [2]. - While sometimes grouped with agonist-antagonists due to its mixed receptor activity, it's more accurately classified as a **partial agonist** [2]. - Its partial agonist activity at mu receptors provides effective analgesia with a ceiling effect on respiratory depression, making it useful for pain management and opioid dependence treatment [3]. *Nalbuphine* - **Nalbuphine** is a classic **opioid agonist-antagonist** compound [2]. - It acts as an **agonist at kappa receptors** and an **antagonist at mu receptors** [2]. - Provides analgesia similar to morphine but with a ceiling effect on respiratory depression and lower dependence potential [2].

Q: All of the following statements are TRUE about second generation antihistaminic agents EXCEPT:

These possess high anti-motion sickness activity. ***These possess high anti-motion sickness activity*** - Second-generation antihistamines have **poor penetration** into the central nervous system (CNS), making them ineffective for treating **motion sickness**. - **First-generation antihistamines**, which readily cross the blood-brain barrier and have **anticholinergic activity**, are typically used for motion sickness. *These may possess additional antiallergic mechanisms* - Many second-generation antihistamines, such as **cetirizine** and **loratadine**, have additional anti-inflammatory and **antiallergic properties** beyond H1 receptor blockade. - These mechanisms can include inhibiting the release of inflammatory mediators and **stabilizing mast cells**. *These do not impair psychomotor performance* - Second-generation antihistamines are **non-sedating** because they have limited ability to cross the **blood-brain barrier** and thus do not significantly affect CNS function. - This characteristic makes them suitable for use without causing **drowsiness** or impairing activities like driving. *These lack anticholinergic actions* - Unlike first-generation antihistamines, second-generation agents have **minimal to no affinity** for muscarinic acetylcholine receptors. - This lack of **anticholinergic activity** means they do not cause side effects such as **dry mouth**, blurred vision, or urinary retention.

Q: Which of the following opioid antagonists can be administered orally for long-term therapy?

Naltrexone. ***Naltrexone*** - **Naltrexone** is an opioid antagonist with good oral bioavailability, making it suitable for **long-term management** of opioid or alcohol dependence. - Its long duration of action (up to 24 hours) allows for **once-daily dosing**, which improves patient adherence for chronic conditions. - It competitively blocks opioid receptors (primarily μ-receptors) and is FDA-approved for maintenance therapy in opioid use disorder. *Buprenorphine* - **Buprenorphine** is a **partial μ-opioid agonist** and κ-opioid antagonist (mixed agonist-antagonist). - While it can be used in opioid dependence treatment, it acts primarily as a **partial agonist** providing some opioid effects, not as a pure antagonist. - It is used for opioid substitution therapy and pain management, not for complete opioid receptor blockade. *Nalbuphine* - **Nalbuphine** is a **mixed agonist-antagonist** (κ-agonist and μ-antagonist) used primarily for moderate to severe pain. - It has limited use due to its ceiling effect on analgesia and potential for dysphoria at high doses. - It is not suitable for long-term oral therapy in opioid dependence management. *Naloxone* - **Naloxone** is a pure opioid antagonist used for **acute opioid overdose** reversal. - It has rapid onset but a **short half-life (30-90 minutes)**, making it impractical for long-term therapy. - Poor oral bioavailability (<3% due to extensive first-pass metabolism) makes it unsuitable for oral administration in maintenance therapy.

Q: A 45 year old male, known case of Rheumatoid arthritis is on a monotherapy since many years. Symptoms of RA are controlled but suddenly patient develops blurring of vision. Which of the following drug is responsible for sudden effect on vision?

Hydroxychloroquine. ***Hydroxychloroquine*** - **Hydroxychloroquine** [1] is known to cause **retinal toxicity** (maculopathy) as a dose-dependent, long-term side effect, leading to **blurring of vision** and other visual disturbances. - Patients on long-term hydroxychloroquine therapy require regular **ophthalmological screening** to detect and prevent irreversible vision loss. *Methotrexate* - **Methotrexate** is a common DMARD used in RA [1], but its ocular side effects are typically rare and less severe, usually involving **conjunctivitis** or **periorbital edema**. - It does not commonly cause **maculopathy** or sudden profound blurring of vision. *Sulfasalazine* - **Sulfasalazine** [1] can cause a range of side effects, including gastrointestinal issues and various hypersensitivity reactions. - Ocular side effects are infrequent and generally mild, such as **conjunctivitis** or **periorbital edema**, and not severe blurring of vision due to retinal damage. *Leflunomide* - **Leflunomide** is an immunosuppressive DMARD [1] whose common adverse effects include hepatotoxicity, gastrointestinal upset, and hypertension. - Significant **ocular toxicity** leading to blurring of vision, particularly retinal damage, is not a characteristic side effect of **leflunomide**.

Q: Drug inhibiting granulocyte migration is:-

Colchicine. ***Colchicine*** - **Colchicine** inhibits **granulocyte migration** by binding to tubulin, thereby disrupting microtubule assembly and function [2]. - This action is crucial in its use for conditions like **gout**, where it reduces the inflammatory response by preventing neutrophil chemotaxis to crystal deposits [1], [2]. *Montelukast* - **Montelukast** is a **leukotriene receptor antagonist** that primarily reduces bronchoconstriction and inflammation. - While it affects inflammatory pathways, its direct action is not inhibiting granulocyte migration but rather blocking the effects of leukotrienes. *Cromoglycate* - **Cromoglycate** (e.g., cromolyn sodium) is a **mast cell stabilizer** that prevents the release of inflammatory mediators. - Its main mechanism involves preventing mast cell degranulation, not directly inhibiting granulocyte migration. *Felbamate* - **Felbamate** is an **antiepileptic drug** used in the treatment of seizures. - Its mechanism of action involves blocking NMDA receptors and modulating GABAergic transmission; it has no known role in inhibiting granulocyte migration.

Q: A patient of biliary colic presented to hospital. Intern gave an injection and the pain worsened. Which is the most likely injection given?

Morphine. *Morphine*- **Morphine** and other opioids can cause **spasm of the sphincter of Oddi**, leading to increased pressure in the **biliary tree** and worsening of biliary colic.- This effect is mediated through **mu-opioid receptors** on the smooth muscle of the sphincter.*Diclofenac*- **Diclofenac** is a non-steroidal anti-inflammatory drug (NSAID) which is an excellent choice for **biliary colic** because it reduces inflammation and relaxes smooth muscle.- It works by inhibiting **prostaglandin synthesis**, thus reducing pain and spasm of the gallbladder.*Etoricoxib*- **Etoricoxib** is a selective COX-2 inhibitor [1], another type of NSAID, which would typically alleviate pain in biliary colic.- It reduces inflammation and pain [1] without the **sphincter of Oddi spasm** concerns associated with opioids.*Nefopam*- **Nefopam** is a non-opioid analgesic that acts as a centrally acting **serotonin-norepinephrine-dopamine reuptake inhibitor (SNDRI)**. It would typically help with pain relief.- It is not known to cause **sphincter of Oddi spasm** and would therefore not usually worsen biliary colic.

Q: Glucosamine is used in which of the following conditions?

Arthritis. ***Arthritis*** - **Glucosamine** is a naturally occurring compound found in healthy cartilage and is often used as a supplement to help with **joint pain** and inflammation associated with arthritis, particularly **osteoarthritis**. - It is believed to help in the formation and repair of **cartilage**, reducing symptoms like pain and improving joint function. *Niemann-Pick disease* - This is a rare, inherited metabolic disorder characterized by the accumulation of **fatty substances** (lipids) in cells, leading to liver, spleen, and brain damage. - **Glucosamine** has no established role in the treatment or management of Niemann-Pick disease. *Alzheimer's disease* - This is a progressive neurological disorder causing brain cells to degenerate and die, leading to memory loss and cognitive decline. - There is currently **no scientific evidence** to support the use of glucosamine in the prevention or treatment of Alzheimer's disease. *Cancer* - Cancer is a disease characterized by the uncontrolled **growth and spread of abnormal cells** in the body. - While some research explores the potential effects of various compounds on cancer cells, **glucosamine is not a recognized treatment** and may even interact with certain cancer therapies.

Q: Morphine should not be used in the treatment of:

Biliary colic. ***Biliary colic*** - Morphine can cause **spasms of the sphincter of Oddi**, leading to an increase in biliary pressure and potentially exacerbating the pain of biliary colic. - This adverse effect can worsen the patient's condition rather than alleviate it, making alternative analgesics like **pethidine (meperidine)** or **NSAIDs** more appropriate for biliary pain. *Cancer pain* - Morphine is a **first-line opioid** for managing moderate to severe cancer pain, providing effective analgesia as part of a comprehensive pain management strategy. - Its efficacy in cancer pain is well-established, and doses can be titrated to achieve optimal pain control without significant risk of addiction in this context. *Postoperative pain* - Morphine is widely used for **postoperative pain management** due to its potent analgesic effects and predictable pharmacokinetics. - It is effective in reducing acute surgical pain and can be administered via various routes, including intravenous and epidural, to suit patient needs. *Ischemic pain* - Morphine is effective in treating ischemic pain, particularly in conditions like **myocardial infarction**, where it helps to reduce pain, anxiety, and **myocardial oxygen demand**. - While it was favored historically because of its action as a **venodilator** and **anxiolytic**, it is now used with caution in acute coronary syndromes, specifically because it can delay the absorption of oral antiplatelet drugs.

Question 1

Which drug used in treatment of rheumatoid arthritis acts by inhibition of T-cell proliferation?

Accepted Answer

Leflunomide

Answer

Anakinra

Answer

Infliximab

Answer

Etanercept

Question 2

A 50-year-old man presents with complaints of bilateral morning stiffness in his wrists and knees and painful joints on exercise. On physical examination, the joints are slightly swollen. The rest of the examination is unremarkable. His laboratory findings are also negative except for slight anemia, elevated erythrocyte sedimentation rate, and positive rheumatoid factor. The patient was started on weekly methotrexate to control the inflammation. What is the principle mechanism of action here?

Accepted Answer

Increased extracellular levels of adenosine

Answer

Inhibition of assembly of microtubules in neutrophils impairing chemotaxis

Answer

Inhibition of cyclooxygenase enzyme

Answer

Inhibition of Dihydrofolate reductase enzyme

Question 3

All are opioid agonist - antagonist compounds except

Accepted Answer

Nalmefene

Answer

Pentazocine

Answer

Buprenorphine

Answer

Nalbuphine

Question 4

All of the following statements are TRUE about second generation antihistaminic agents EXCEPT:

Accepted Answer

These possess high anti-motion sickness activity

Answer

These may possess additional antiallergic mechanisms

Answer

These do not impair psychomotor performance

Answer

These lack anticholinergic actions

Question 5

Which of the following opioid antagonists can be administered orally for long-term therapy?

Accepted Answer

Naltrexone

Answer

Buprenorphine

Answer

Nalbuphine

Answer

Naloxone

Question 6

A 45 year old male, known case of Rheumatoid arthritis is on a monotherapy since many years. Symptoms of RA are controlled but suddenly patient develops blurring of vision. Which of the following drug is responsible for sudden effect on vision?

Accepted Answer

Hydroxychloroquine

Answer

Methotrexate

Answer

Sulfasalazine

Answer

Leflunomide

Question 7

Drug inhibiting granulocyte migration is:-

Accepted Answer

Colchicine

Answer

Montelukast

Answer

Cromoglycate

Answer

Felbamate

Question 8

A patient of biliary colic presented to hospital. Intern gave an injection and the pain worsened. Which is the most likely injection given?

Accepted Answer

Morphine

Answer

Diclofenac

Answer

Etoricoxib

Answer

Nefopam

Question 9

Glucosamine is used in which of the following conditions?

Accepted Answer

Arthritis

Answer

Niemann-Pick disease

Answer

Alzheimer's disease

Answer

Cancer

Question 10

Morphine should not be used in the treatment of:

Accepted Answer

Biliary colic

Answer

Cancer pain

Answer

Ischemic pain

Answer

Postoperative pain

Analgesics and Anti-inflammatory Drugs — MCQs

Analgesics and Anti-inflammatory Drugs — MCQs

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