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Endocrine and Reproductive Pharmacology

Adrenal corticosteroids

Anabolic steroids, related drugs

Calcium-regulating drugs

Diabetes mellitus and hypoglycemia

Erectile dysfunction

Estrogens, progestins, contraceptives, fertility agents

Testosterone

Thyroid disorders

Uterine stimulants (oxytocics) and relaxants (tocolytics)

Questions

365. A 55-year-old male patient with a 20-year history of type 2 diabetes mellitus comes to your clinic for his regular check-up. He looks good, feels well. However, over the last year his HbA_1c levels hovered around 9.5% (equivalent to an average plasma glucose of around 225 mg/dL). Current diabetes medications are metformin and glyburide. The patient says he is doing “the best he can” with recommended diet and exercise plans. He has other personal and familial risk factors for coronary heart disease. He takes a statin and metformin to control his lipids, but his LDL and triglyceride levels are far too high. He is taking verapamil for Stage 1 hypertension, but his pressure is still higher than you’d like it to be. Two years ago, he had severe angina from atherosclerotic coronary disease and underwent angioplasty and placement of a stent. He has had no ischemic episodes since.

You’re thinking about adding niacin to get further control of triglyceride levels, adding another antihypertensive drug, and adjusting his diabetes treatment by adding another hypoglycemic drug (perhaps insulin). Which comorbidity or other factor would weigh against your selection of an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) as the add-on antihypertensive drug for this patient?

a. Bilateral renal artery stenosis and albuminuria

b. Bradycardia

c. Had two episodes of hyperosmolar hyperglycemic nonketotic syndrome in past 2 years

d. Has heart failure

e. Niacin will indeed be prescribed

366. A patient has an inoperable pancreatic islet cell carcinoma and is chronically hypoglycemic. Which drug would be most likely chosen for relatively long-term oral therapy that attempts to raise blood glucose levels into a more acceptable range?

a. Atenolol (or metoprolol)

b. Diazoxide

c. Glucagon

d. Octreotide (somatostatin analog)

e. Oxytocin

367. A patient with type 2 diabetes mellitus is notoriously noncompliant with medication and diet recommendations. However, he thinks he’s smart enough to fool the physician into thinking otherwise: he takes his medication and eliminates nearly all carbohydrate intake for a few days before each clinic visit, knowing he will get a finger stick for a spot check of plasma glucose levels. What would be the simplest, most cost-effective, and most informative way for the physician to assess for past drug and diet compliance and long-term glycemic control?

a. Glucose concentration in venous blood sample

b. Glucose tolerance test (oral)

c. HbA_1c

d. Plasma levels of the antidiabetic drug

e. Urine ketone levels (in a sample donated at the time of clinic visit)

f. Urine glucose levels

368. A 70-year-old man complains of progressive difficulty starting his urine stream, and having to get up several times during each night to urinate. Rectal examination reveals a generally enlarged, smooth-surfaced prostate. Prostate-specific antigen (PSA) titers are significantly elevated. You decide to start finasteride treatment. Eventually urine flow increases, nocturesis episodes decrease, and overall prostate size decreases. Which phrase best summarizes the most likely mechanism by which finasteride caused symptom relief?

a. Blocks α-adrenergic receptors

b. Blocks testosterone receptors

c. Inhibits dihydrotestosterone synthesis

d. Inhibits testosterone synthesis

e. Lowers plasma testosterone levels by increasing its renal clearance

369. A 38-year-old woman presents in the endocrinology and metabolism clinic today. One of the drugs she is taking is classified as a dipeptidyl peptidase-4 (DPP-4) inhibitor. Which statement best describes the main actions of this drug?

a. Activates hydroxylases required for cortisol and aldosterone synthesis

b. Cleaves active insulin from the proinsulin molecule

c. Enzymatically splits levothyroxine from thyroglobulin

d. Helps normalize physiologic release of estrogen and progesterone

e. Inhibits inactivation of incretins, raises glucagon-like peptide levels

370. A 54-year-old woman who has not seen a physician for several years presents with a previously undiagnosed thyroid cancer and thyrotoxicosis. One drug that is administered as part of early management, and may be lifesaving, is propranolol. Which of the following best summarizes the objective for administering this drug?

a. Block parenchymal cell receptors for thyroid hormones

b. Block thyroid hormone release by a direct effect on the gland

c. Inhibit thyroid hormone synthesis

d. Lessen dangerous cardiovascular signs and symptoms of thyroid hormone excess

e. Lower TSH levels

371. A woman deemed at high risk of postmenopausal osteoporosis is started on alendronate. What is this representative bisphosphonate’s main mechanism of action?

a. Activates vitamin D and so facilitates absorption of dietary calcium

b. Contains lots of calcium, which supplements dietary calcium intake

c. Directly forms hydroxyapatite crystals in bone

d. Provides supplemental phosphate, which indirectly elevates plasma Ca²+

e. Reduces the number and activity of osteoclasts in bone

372. Some patients who are taking high doses of a bisphosphonate for Paget disease of the bone develop an endocrine-metabolic disorder. What disorder would that be?

a. Cushing disease (cushingoid symptoms)

b. Diabetes insipidus

c. Diabetes mellitus

d. Hyperparathyroidism

e. Hyperthyroidism

373. Metyrapone is useful in testing hyper- or hypo-function of certain endocrine conditions or biological processes those glands normally control. When we administer this drug for diagnostic purposes, which structure or function are we most likely assessing?

a. α cells of pancreatic islets

b. β cells of pancreatic islets

c. Leydig cells of the testes

d. Pituitary-adrenal axis

e. Thyroid gland’s response to TSH

374. A 60-year-old man on long-term therapy with a drug develops hypertension, hyperglycemia, and decreased bone density. Blood tests indicate anemia. Some of his stool samples initially were positive for occult blood, and then the stool developed a “coffee-grounds” appearance. Which drug is most likely responsible for the patient’s symptoms?

a. Beclomethasone

b. Hydrochlorothiazide

c. Metformin

d. Pamidronate

e. Prednisone

375. A woman with atrial fibrillation is being treated long-term with amiodarone (and warfarin). This antiarrhythmic can cause biochemical changes and clinical signs and symptoms that resemble those associated with which endocrine disease/disorder?

a. Addisonian crisis

b. Cushing syndrome

c. Diabetes insipidus

d. Diabetes mellitus

e. Hypothyroidism

f. Ovarian hyperstimulation syndrome

376. A 22-year-old woman has been sexually assaulted and she wishes to have the pregnancy terminated by pharmacologic means. What is generally the most appropriate drug, assuming no contraindications?

a. Ergonovine (or methylergonovine)

b. Mifepristone

c. Raloxifene

d. Ritodrine

e. Tamoxifen

377. A patient has hyperthyroidism from a thyroid cancer, and the medical team concludes that oral radioiodine (sodium iodide 131 [¹³¹I]) is the preferred treatment. The dosage is calculated correctly, and the drug is administered. What statement about this approach is also correct?

a. A β-adrenergic blocker should not be used for symptom control if or when ¹³¹I is used

b. Hyperthyroidism symptoms resolve almost completely within 24 to 48 hours after dosing with ¹³¹I

c. Many patients treated with ¹³¹I develop metastatic nonthyroid cancers in response to the drug

d. Oral antithyroid drugs should be administered up to and including the day of ¹³¹I administration

e. There is a high incidence of delayed hypothyroidism after using ¹³¹I for eradication of a thyroid tumor, and so thyroid hormone supplements may be needed later on

378. A 20-year-old woman, otherwise healthy, presents with irregular and occasionally missed menstrual periods, oily facial skin and acne, and slight hirsutism. She was a competitive runner during high school and now is in training for a triathlon. She is not taking any medications other than an estrogen-progesterone oral contraceptive. A pelvic ultrasound evaluation reveals numerous immature ovarian follicles (generally but incorrectly referred to as cysts). The diagnosis is polycystic ovarian syndrome (PCOS). Which drug would be the most rational initial therapy to prescribe to help provide symptom relief without compromising the woman’s ability to conceive?

a. Estrogen (dose higher than in her oral contraceptive)

b. Ketoconazole

c. Metformin

d. Prednisone (or a similar oral glucocorticoid)

e. Testosterone

379. A 50-year-old woman with a high risk of breast cancer is started on tamoxifen for prophylaxis. What is the main mechanism of action of this drug?

a. Blocks estrogen receptors in breast tissue

b. Blocks estrogen receptors in the endometrium

c. Increases the risk of osteoporosis

d. Raises plasma LDL cholesterol and total cholesterol, lowers HDL

e. Reduces the risk of thromboembolic disorders

380. A 50-year-old woman is recently diagnosed with type 2 diabetes mellitus. Exercise and diet do not provide adequate glycemic control, so drug therapy needs to start. The physician contemplates prescribing metformin. Which statement about this drug is correct?

a. Beneficial and unwanted actions are unaffected by liver function status

b. Lactic acidosis occurs frequently, but it is seldom serious

c. Metformin-induced hypoglycemia seldom occurs

d. Useful for type 1 diabetes also

e. Weight gain is a common and unwanted side effect

381. Most therapeutic insulins nowadays are modifications of native human insulin, done by substituting some amino acids in the native protein using recombinant DNA technology. For all these genetically modified insulins, what is the one common result of such changes?

a. Changes the onsets, durations of action

b. Enables administration by either subcutaneous or intravenous routes

c. Prevents cellular K⁺ uptake as glucose enters cells

d. Reactivates endogenous (pancreatic) insulin synthesis

e. Selectively affects glucose metabolism, little/no effects on lipids

382. You have prescribed an oral agent to help control a patient’s blood glucose levels. He has type 2 diabetes. In explaining how the drug works, you describe it as a “starch blocker” that inhibits the intestinal uptake of complex carbohydrates in the diet. You advise also that flatus or some cramping or “grumbling sounds” in the belly may develop. Which drug fits this description?

a. Acarbose

b. Any thiazolidinedione (“glitazone”)

c. Glipizide

d. Metformin

e. Tolbutamide

383. A patient with type 1 diabetes is being treated with insulin glargine. What clinically important property sets this particular insulin apart, or otherwise differentiates it, from nearly all the other insulin formulations that might be used instead?

a. Blood levels, hypoglycemic effects, following insulin glargine injection are more accurately described as a plateau rather as a definite “spike” or peak

b. Disulfiram-like reactions (acetaldehyde accumulation from inhibited EtOH metabolism) more common, severe, with insulin glargine

c. Has an extremely fast onset, useful for immediate postprandial control of plasma glucose elevations

d. Poses little or no risk of hypoglycemia if the patient skips several meals in a row

e. Sensitizes parenchymal cells to insulin (eg, the administered insulin itself), not simply providing or replacing insulin, thereby enhancing glycemic control

384. A patient presents in the emergency department (ED) with a massive overdose of a drug. The most worrisome signs and symptoms include excessive cardiac stimulation (severe tachycardia, palpitations, angina, etc). The ED physician orders IV administration a β-adrenergic blocker, saying (correctly) it is the only drug likely to normalize cardiac function quickly and save the patient’s life. What was the most likely drug the patient overdosed on?

a. A second-generation sulfonylurea (eg, glipizide, glyburide)

b. Insulin

c. Levothyroxine

d. Prednisone (oral glucocorticoid)

e. Propylthiouracil

385. This week finds you accompanying an attending in her outpatient endocrinology clinic. One patient, a 56-year-old woman, is taking exena-tide, which is classified as an incretin mimetic. What phrase best describes exenatide’s actions or main clinical use?

a. Antagonizes testosterone effects, useful for treating hirsutism in men or women

b. Is a new adjunct to metformin and/or sulfonylurea therapy of hyperthyroidism

c. Often used as an add-on to a bisphosphonate for prophylaxis of postmeno-pausal osteoporosis

d. Preferred stimulant of cortisol production for treating Addison disease

e. Useful adjunct for some patients with poorly controlled type 2 diabetes mellitus

386. A patient with hypothyroidism following thyroidectomy will require lifelong hormone replacement therapy. What drug or formulation generally would be most suitable?

a. Levothyroxine (T₄)

b. Liothyronine

c. Liotrix

d. Protirelin

e. Thyroid, desiccated

387. A patient develops marked skeletal muscle tetany soon after a recent thyroidectomy. The attending confirms the diagnosis, in part, by lightly tapping the patient’s cheek in front of the ear. Stimulating the facial nerves in this manner leads to spasms of the local (oris) muscle (Chvostek sign). Which drug is most likely to be chosen to manage this adverse response to surgery?

a. Calcitonin

b. Calcium gluconate

c. Plicamycin (mithramycin)

d. PTH (parathyroid hormone)

e. Vitamin D

388. A 40-year-old man with a symmetrically enlarged thyroid gland associated with elevated levels of T₃ and T₄ is treated with propylthiouracil (PTU). Which phrase best summarizes the principal mechanism of action of PTU?

a. Blocks iodide transport into the thyroid

b. Increases hepatic metabolic inactivation of circulating T₄ and T₃

c. Inhibits proteolysis of thyroglobulin

d. Inhibits thyroidal peroxidase

e. Releases T₃ and T₄ into the blood

389. The attending in the endocrine/metabolic diseases clinic prescribes colesevelam as add-on therapy for a 58-year-old male with type 2 diabetes who is not getting adequate glycemic control (based on high levels of HbA_1c measured twice in the last 12 months) from his current medications: metformin and glyburide. The man has been a pack-a-day cigarette smoker for 40 years and says he “can’t seem to quit.” In addition to the diabetes and nicotine addiction he has several other comorbidities that are not optimally managed with his current medications for each, or recommended lifestyle modifications (he largely ignores them). The attending states that the cole-sevelam might just help one of those comorbidities in addition to possibly lowering HbA_1c levels after a few months on the drug. What is the “other condition” that is most likely to be favorably and rather directly influenced by the colesevelam?

a. Chronic bronchitis (or emphysema)

b. Hyperlipidemias

c. Hyperuricemia, gout

d. Nicotine addiction

e. Prostatism (ie, benign prostatic hypertrophy)

390. Your patient, who is taking an oral contraceptive, has heard about and asks about the risk of thromboembolism as a result of taking these drugs. To reduce the risk of this potentially severe adverse hematologic response, but still provide reasonably effective contraception, what would you prescribe?

a. A combination product with a higher estrogen dose

b. A combination product with a higher progestin dose

c. A combination product with a lower estrogen dose

d. A combination product with a lower progestin dose

e. A product that contains only estrogen

391. A 27-year-old woman is diagnosed with hypercortism. To determine whether cortisol production is independent of pituitary gland control, you decide to suppress ACTH production by giving a high-potency glucocorticoid. Which drug would be the best choice for this purpose?

a. Dexamethasone

b. Hydrocortisone

c. Methylprednisolone

d. Prednisone

e. Triamcinolone

392. A patient with Cushing syndrome is being treated by X-irradiation of the pituitary. It may take several months of this therapy for adequate symptomatic and metabolic improvement. Until that time, which drug would be administered to suppress glucocorticoid synthesis?

a. Cimetidine

b. Cortisol (massive doses)

c. Fludrocortisone

d. Ketoconazole

e. Spironolactone

393. A woman who has been taking an oral contraceptive (estrogen plus progestin) for several years is diagnosed with epilepsy and started on phenytoin. What is the most likely consequence of adding the phenytoin?

a. Agranulocytosis or aplastic anemia, requiring stopping both drugs immediately

b. Breakthrough seizures from increased phenytoin clearance

c. Phenytoin toxicity, significant and of fast onset

d. Profoundly increased risk of craniofacial abnormalities in the fetus

e. Reduced contraceptive efficacy

f. Thromboembolism from the estrogen component of the contraceptive

394. A woman wants a prescription for an oral contraceptive, and your choice is between an estrogen-progestin combination and a “minipill” (progestin only). Compared with a hormone combination product, what is the main difference that would occur when a progestin-only approach is used?

a. Better contraceptive efficacy

b. Direct spermicidal effects

c. Higher risk of thromboembolism

d. More menstrual irregularities (irregular cycle length, amenorrhea, spotting, etc)

e. Poorer compliance due to taking the drug on an irregular cycle, rather than daily

395. A woman is taking a combination estrogen-progestin combination oral contraceptive. She experiences a multitude of side effects. Which side effect is most likely due to what can be described as an “estrogen excess,” and not likely due to the progestin content of the medication?

a. Fatigue

b. Hypertension

c. Hypomenorrhea

d. Increased appetite

e. Weight gain

396. A comatose patient with an endocrine disorder undergoes a computed tomography (CT) diagnostic procedure that involves contrast media that has a tendency to induce lactic acidosis. He is also taking a drug that, in its own right, may cause lactic acidosis. Normally the drug would be stopped, at least temporarily, two days before the CT, but due to the patient’s acute and serious illness that could not be done. Lactic acidosis indeed develops and the patient nearly dies. Which drug was the most likely cause of this severe and potentially fatal metabolic derangement?

a. Insulin glargine, prescribed for type 1 diabetes mellitus

b. Levothyroxine, prescribed to maintain euthyroid status following thyroidectomy

c. Metformin, prescribed for type 2 diabetes mellitus

d. Propylthiouracil, prescribed for hyperthyroidism

e. Spironolactone, prescribed for an adrenal cortical tumor

397. A patient with type 2 diabetes mellitus begins gaining weight after several months of therapy with an oral antidiabetic agent. A complete work-up indicates edema and other signs and symptoms of heart failure. Which antidiabetic drug or group was the most likely cause?

a. Acarbose

b. Biguanides

c. Metformin

d. Pioglitazone

e. Sulfonylureas, both first- and second-generation agents (eg, tolbutamide, chlorpropamide, glyburide, glipizide)

398. A woman goes into premature labor early enough that there are great concerns about inadequate fetal lung development and the risk of fetal respiratory distress syndrome. Suitable uterine-relaxing drug therapy is started to slow labor, but parturition seems imminent. What other adjunct should be administered prepartum, specifically for the purpose of reducing the risks and complications of the newborn’s immature respiratory system development?

a. Albuterol (β₂ agonist)

b. Betamethasone

c. Ergonovine (or methylergonovine)

d. Indomethacin

e. Magnesium sulfate

399. We prescribe etidronate for a postmenopausal woman who is at great risk for developing for osteoporosis. Which side effect or adverse response to this drug is the patient most likely to experience?

a. Cholelithiasis

b. Esophagitis

c. Fluid/electrolyte loss from profuse diarrhea

d. Hepatic necrosis

e. Renal damage from calcium stone formation

f. Tetany

400. A 75-year-old man had surgery for prostate carcinoma, and local metastases were found intraoperatively. What is the most appropriate follow-up drug aimed at treating the metastases?

a. Aminoglutethimide

b. Fludrocortisone

c. Leuprolide

d. Mifepristone

e. Spironolactone

401. A 53-year-old woman with type 2 diabetes mellitus is started on glyburide. Diet, exercise, and usually effective doses of metformin have not provided adequate glycemic control based on periodic measurements of HbA_1c. What is the primary mechanism by which the glyburide is likely to provide better glycemic control?

a. Decrease insulin resistance by lowering body weight

b. Enhance renal excretion of glucose

c. Increase insulin synthesis

d. Promote glucose uptake by muscle, liver, and adipose tissue via an insulin-independent process

e. Release insulin from the pancreas

402. A 75-year-old woman with type 2 diabetes is taking an oral anti-diabetic drug. One day she goes without eating for 18 hours, but takes her drug nonetheless. She is transported to the emergency after passing out. Her plasma glucose concentration is 48 mg/dL (hypoglycemic) upon arrival at the ED, and she is in very serious condition. Which drug, that most likely aggravated this fasting hypoglycemia, did she take?

a. Acarbose

b. Colesevelam

c. Glyburide

d. Metformin

e. Pioglitazone

403. A man with type 2 diabetes is receiving a combination of oral drugs to maintain glycemic control. He becomes hypoglycemic one afternoon and ingests some orange juice and two chocolate bars—all containing abundant amounts of complex carbohydrates. Despite his ingestion of orange juice and several chocolate bars, his blood glucose levels remain low, his symptoms persist. Which antidiabetic that he was taking accounted for the failure of oral sugars to restore his plasma glucose?

a. Acarbose

b. Glyburide

c. Metformin

d. Repaglinide

e. Rosiglitazone

404. A 35-year-old woman has Graves disease, a small goiter, and symptoms that are deemed “mild-to-moderate.” Propylthiouracil is prescribed. What is the most serious adverse response to this drug, for which close monitoring is required?

a. Agranulocytosis

b. Cholestatic jaundice

c. Gout

d. Renal tubular necrosis

e. Rhabdomyolysis

f. Thyroid cancer

405. A 60-year-old man with type 2 diabetes mellitus is treated with pioglitazone (in addition to a proper diet and exercise). Which phrase summarizes best this drug’s main mechanism of action?

a. Blocks intestinal carbohydrate absorption

b. Causes glycosuria (increased renal glucose excretion)

c. Increases hepatic gluconeogenesis

d. Increases release of endogenous insulin

e. Increases target tissue sensitivity to insulin

406. A patient with a history of type 2 diabetes mellitus presents in the ED. His complaints include nonspecific gastrointestinal symptoms, including nausea and vomiting. He states he is bloated and has abdominal pain. His appetite has been suppressed for several days. He has malaise and difficulty breathing. His liver is enlarged and tender; liver function tests indicate hepatic damage. Plasma bicarbonate is low and lactate levels are high. Kidney function is falling rapidly.

The diagnosis is lactic acidosis, and the suspicion is that it was caused by an antidiabetic drug. Which of the following drugs is this patient most likely to be taking?

a. Acarbose

b. Glipizide

c. Glyburide

d. Metformin

e. Pioglitazone

407. A patient is transported to the ED shortly after taking a massive overdose of her levothyroxine in an apparent suicide attempt. Which of the following drugs should be administered for prompt control of the hormone-related effects that are most likely to lead to her death if not correctly managed?

a. Iodine/iodide

b. Liothyronine

c. Propranolol

d. Propylthiouracil

e. Radioiodine (¹³¹I)

408. There are two main formulations of oral contraceptives: those that are estrogen-progestin combinations, and those that contain only progestin (“minipill”). What is the main mechanism by which these drugs exert their desired contraceptive effects?

a. Acidify the cervical mucus, thereby making the mucus spermicidal

b. Displace/detach a fertilized egg from the endometrium

c. Inhibit nidation (implantation of a fertilized ovum)

d. Inhibit ovulation

e. Reduce uterine blood flow such that the fertilized ovum becomes hypoxic and dies

409. A 55-year-old postmenopausal woman develops weakness, polyuria, polydipsia, and significant increases of plasma creatinine concentration. A computed tomogram (CT scan) indicates nephrocalcinosis. A drug is considered to be the cause. Which drug was most likely responsible?

a. Estrogens

b. Etidronate

c. Glipizide

d. Prednisone

e. Vitamin D

410. A patient has severe Cushing disease. Surgery cannot be scheduled for several months, so the physician plans to treat the patient in the interim with a drug that she describes as a “potent inhibitor of corticosteroid synthesis.” Which drug best fits that description?

a. Dexamethasone

b. Hydrocortisone

c. Ketoconazole

d. Prednisone

e. Spironolactone

411. You prescribe bromocriptine for a woman with primary amenorrhea. Normal menstruation returns about a month after starting therapy. Which statement best describes the mechanism by which bromocriptine caused its desired effects?

a. Blocked estrogen receptors, enhanced gonadotropin release

b. Increased follicle-stimulating hormone (FSH) synthesis

c. Inhibited prolactin release

d. Stimulated ovarian estrogen and progestin synthesis

e. Stimulated gonadotropin-releasing hormone (GnRH) release

412. A patient has had his parathyroid glands excised during a total thyroidectomy. In addition to requiring supplemental thyroid hormone, interventions aimed at correcting hypoparathyroidism will be necessary. What is the main physiologic action or role of parathyroid hormone—one that necessitates suitable therapy?

a. Decreases active absorption of Ca from the small intestine

b. Decreases excretion of phosphate

c. Decreases renal tubular reabsorption of calcium

d. Decreases resorption of phosphate from bone

e. Increases mobilization of calcium from bone

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