1.

You are a hospital pharmacist who provides antibiotics services. A 72-year- old man has just been diagnosed with pulmonary tuberculosis infection. He has a known medical history of chronic obstructive airway disease, diabetes mellitus, and atrial fibrillation. His body weight is 60 kg. He has moderately impaired renal function (creatinine clearance 40 mL/min). His current medication includes salbutamol 2 puffs 4 times daily, Trelegy Ellipta (fluticasone 100 mcg, umeclidinium 62.5 mcg, vilanterol 25 mcg) 1 puff daily, glimepiride 2 mg daily, metformin 500 mg twice daily, metoprolol 25 mg twice daily, and dabigatran 110 mg twice daily. 

(a) What are the initial recommended conventional anti-tuberculosis drugs in a THRICE-WEEKLY REGIME (dosage and duration) for the patient? (3 marks) 

(b) In patients with moderate to severe renal impairment, list THREE anti- tuberculosis drug options and their dosage adjustments, or which drug should be avoided. (3 marks) 

(c) Discuss the advantages of a thrice-weekly regime over a daily regime for tuberculosis treatment. (2 marks) 

(d) In light of the patient's medications, suggest ONE potential significant drug-drug interaction with anti-tuberculosis drugs. Explain the mechanism of the drug-drug interaction. Suggest TWO alternative medications to use in order to avoid this drug interaction and discuss the PROS and CONS of these two options. (6 marks) 

(e) Three weeks after the commencement of anti-tuberculosis drugs, the patient develops hepatitis with ALT levels up to 400 U/L (Reference interval ALT < 55 U/L). What patient characteristics are associated with the increased risk of hepatotoxicity in general? What is your advice on the anti-tuberculosis treatment in the context of suspected drug-induced hepatitis? (6 marks) 

2.

Ann Lee, aged 38, has moderate persistent asthma and uses a combination of two drugs in a single inhaler as daily maintenance and reliever therapy to reduce exacerbation frequency. Unfortunately, she experienced waking with asthma symptoms three to four times a week and had increased asthma symptoms during her daily walk to work and workouts about three months ago. Upon her visit to your respiratory speciality clinic, she completed a 5-day course of oral prednisone from her family doctor a month ago without significant improvement in her asthma symptoms. Therefore, you offer her to get a subcutaneous injection of benralizumab as add-on therapy because she has a high number of blood eosinophils. 

(a) What are the TWO classes of drugs with given drug names in the inhaler? (3 marks) 

(b) State the mechanism of action for each class of drugs. What is the rationale for such a combination of two drugs? (7 marks) 

(c) What is prednisone? Why does the family doctor decide to give her oral prednisone? (2 marks) 

(d) State the THREE major side (adverse) effects of the two classes of drugs. (3 marks) 

(e) Which class of drug does benralizumab belong to? State its mechanism of action and TWO major side effects. (5 marks) 

3.

MY is a 60-year-old housewife. Her husband was diagnosed with brain cancer six months ago, and MY is the only caregiver. She recently showed symptoms including fatigue, difficulty in coping with daily life and having low mood every day. She also lost her appetite and 7 kg in the past three months. 

(a) What type of disorder is MY likely to have? Explain your answer. (2 marks) 

(b) What is the neurotrophic hypothesis? (4 marks) 

(c) What is the first-line drug for MY's disorder? Describe the mode of action of this drug. (3 marks) 

(d) What is the mode of action of a-adrenoceptor antagonist ("NASA")? Name TWO side effects. (5 marks) 

(e) Explain why monoamine oxidase inhibitor ("MAOI") should not be taken together with banana or cheese. (4 marks) 

(f) In addition to medication, provide TWO non-pharmacological treatments to MY for the management of her disorder. (2 marks) 

4.

(a) A female patient initially presented with amenorrhea-galactorrhea syndrome because of a brain tumor that secreted an excessive amount of hormone. What is this hormone, and how does it cause amenorrhea and galactorrhea? (4 marks) 

(b) Identify ONE drug that can reduce this hormone and explain its pharmacological action. (2 marks) 

(c) After three years of therapy with no significant tumor shrinkage, she developed Cushing's syndrome. Name ONE drug that can be used to treat Cushing's syndrome and explain how it works. (3 marks) 

(d) This patient was diagnosed with metastatic bladder cancer when she was old. Her cancer was treated with a combination therapy that included methotrexate, vinblastine, doxorubicin, and cisplatin. Explain the mechanisms by which they can kill cancer cells and list any side effects. (8 marks) 

(e) Durvalumab, a monoclonal antibody, was recently approved to treat bladder cancer. What is its mechanism of action? (3 marks) 

5. Mrs S is a 65-year-old lady who presents with new-onset atrial fibrillation. She has a history of hypertension and hyperlipidemia. She does not have a history of stroke or major bleeding. She was started on diltiazem for heart rate control. Following a discussion of the risks and benefits, she agrees to commence anticoagulation for the prevention of stroke. 

(a) What is the mechanism of action of warfarin? (2 marks) 

(b) Name THREE important drug-drug interactions that will reduce the international normalised ratio ("INR") in patients treated with warfarin. (3 marks) 

(c) Name FOUR direct oral anticoagulants ("DOACS") that can reduce the risk of thromboembolism from atrial fibrillation. (2 marks) 

(d) Describe the mechanisms of action, similarities and differences in the pharmacokinetics of these DOACs. (6 marks) 

(e) The patient has a planned elective colonoscopy with polypectomy. She has normal creatinine clearance. When should her DOAC be discontinued? (3 marks) 

(f) What management options for DOAC-related major life-threatening bleeding events are there? (4 marks)