All of the following statements related to the ClinCalc DrugStats database are correct EXCEPT which one?
A. ClinCalc DrugStats provides prescription drug utilization data estimates based on the annual Medical Expenditure Panel Survey.
B. The list of the Top Prescription Drugs of 2017 reflects data collected in 2017.
C. The Top 200 Prescription Drugs of 2017 represent 40% of the available 500 active ingredients and comprise 90% of all prescription drugs.
D. The Top 300 Prescription Drugs of 2017 represent 60% of the available 500 active ingredients and comprise 97% of all prescription drugs.
Which of the following statement related to the DailyMed website is correct?
A. DailyMed, a useful online resource, is the official repository for FDA-approved package inserts, i.e., for individual drug-related, clinically relevant data.
B. The information on DailyMed is the most recent submitted to the FDA by pharmaceutical companies and includes warnings undergoing FDA review.
C. The information is accurate; when possible it is based on human experience; and does not contain promotional or misleading information (e.g., implied claims).
D. All of the above.
Which of the following statement related to the Top 300 Drugs of 2017 is correct?
A. The majority of epinephrine formulations were prescribed for “self-administration” by patients (or caretakers) in ambulatory settings.
B. Epinephrine in auto-injectors are indicated for intramuscular (IM) administration in the emergency treatment of Type I allergic reactions, i.e., anaphylaxis.
C. Epinephrine formulations in MDIs that were available in 2014 are no longer available commercially in the United States.
D. All of the above.
All of the following statements related to the peripheral nervous system (PNS) are correct EXCEPT which one?
A. The PNS is divided into sensory and motor divisions.
B. The sensory (afferent) and motor (efferent) neurons, conduct signals from peripheral tissues to the CNS and from the CNS to peripheral tissues, respectively.
C. The somatic nervous system, a component of the motor division of the PNS regulates involuntary skeletal muscle responses.
D. The sympathetic branch of the ANS mobilizes body systems to provide energy for “fight or flight” responses.
All of the following statements related the sympathetic branch of the ANS are correct EXCEPT which one?
A. Activation of the sympathetic branch and subsequent release of catecholamine is initiated by signals originating in the PNS.
B. Norepinephrine is synthesized primarily at sympathetic nerve endings and is released at synapses on specific target organs.
C. Epinephrine is synthesized by neuroendocrine (chromaffin) cells of the adrenal medulla and it is released into the bloodstream to be transported to target organs.
D. To produce an effect, both norepinephrine and epinephrine must interact with adrenergic receptors (adrenoceptors), which have an organ-specific distribution.
All of the following statements related to adrenoceptors are correct EXCEPT which one?
A. Epinephrine interacts with adrenoceptors which are divided into three classes; α1 (α1A , α1B , and α1D ), α2 (α2A , α2B , and α2C ), and β (β1 , β2 , and β3 ).
B. Each of the adrenoceptor subtype is a member of the G protein-coupled receptor family (i.e., transmembrane receptors coupled to intracellular G proteins).
C. The binding of epinephrine to a G protein-coupled adrenoceptor invariably increases, i.e., stimulates the target organ.
D. G proteins are composed of α- and βγ-subunits, the binding of an agonist to a G protein-coupled adrenoceptor causes the exchange of GTP for GDP on the α-subunit, the α-GTP subunit dissociates from the βγ-subunit and interacts with effector proteins.
All of the following statements related to signaling mechanisms of adrenoceptors are correct EXCEPT which one?
A. Prototypical signaling mechanism of α1 -adrenoceptors primarily involves Gαq , resulting in increased sympathetic activity.
B. Prototypical signaling mechanism of α2 -adrenoreceptors primarily involves Gαi , resulting in increased cAMP, which activates protein kinases affecting a variety of intracellular proteins, including ion channels.
C. Alpha2 -adrenoceptors are expressed primarily in pancreatic β-cells, platelets, vascular smooth muscles, and at various sites in the CNS.
D. Prototypical signaling mechanism of β-adrenoceptors primarily involves Gαs , resulting in increased sympathetic activity.
All of the following statements related to the pharmacokinetics of epinephrine are correct EXCEPT which one?
A. Epinephrine is well absorbed and has rapid onset of action following parenteral administration, e.g., in combination with LAs or when administered IM.
B. Epinephrine in LAs reaches peak plasma concentrations in 5-10 minutes; following IM injection it reaches peak plasma concentrations in 8±2 min.
C. Epinephrine is distributed to most tissues: it crosses the placenta, it is secreted into milk, and it crosses the blood-brain barrier.
D. Epinephrine is inactivated primarily by catechol-O-methyltransferase and monoamine oxidase and excreted in the urine (elimination half-life: ≈2 minutes).
All of the following statements related to the use of epinephrine in the treatment of anaphylaxis are correct EXCEPT which one?
A. Epinephrine is the drug of choice for the emergency treatment of severe Type 1 allergic reactions, i.e. anaphylaxis.
B. No absolute contraindications exist to the use of epinephrine in the emergency treatment of acute anaphylactic reactions.
C. Because of serious medication errors with epinephrine, dosage strengths on single-entity preparations must be expressed as ratios (e.g., 1:1000, 1:2000, etc.).
D. Pre-filled, single-use, auto-injectors are available in convenient dosage strengths such as 0.1 mg/0.1 mL, 0.15 mg/0.15 mL, 0.15 mg/0.3 mL, and 0.3 mg/0.3 mL.
Which of the following statement related to anaphylaxis is correct?
A. An anaphylactic reaction may occur within minutes after reexposure (previous sensitization is a prerequisite) to a specific allergen.
B. Anaphylaxis consists of urticaria, pruritus, angioedema (e.g., swelling of the lips, eyelids, and tongue), wheezing, dyspnea, and hypotension.
C. Epinephrine auto-injectors should always be available in various fixed-dose formulations in every office emergency kit.
D. All of the above.
All of the following statements related to the treatment of anaphylaxis in oral healthcare setting are correct EXCEPT which one?
A. When treating anaphylaxis, select an auto-injector with the appropriate dosage strength predicated on the patient’s body weight.
B. Immediately following the administration of epinephrine, the patient must be referred for additional medical care - Call 911.
C. With severe persistent anaphylaxis a repeat injection of epinephrine, with an additional auto-injector, may be necessary in 15-20 minutes.
D. More than two sequential doses of epinephrine should only be administered under direct medical supervision of the patient by the dentist.
All of the following statements related to the consequences of treating anaphylaxis are correct EXCEPT which one?
A. ADRs are not likely to occur with the administration of therapeutic doses of epinephrine.
B. ADRs usually subside rapidly with rest and recumbency.
C. Signs and symptoms of ADRs include restlessness, tremor, palpitations, tachycardia, sweating, nausea and vomiting, pallor, headache, dizziness, feelings of panic or anxiety, and respiratory difficulties.
D. Overdosage (and even therapeutic doses in some patients) of epinephrine may precipitate angina pectoris and/or produce ventricular arrhythmias.
All of the following statements related to the rationale for including a vasoconstrictor in LA formulations are correct EXCEPT which one?
A. Decrease the rate of LAs’ systemic absorption.
B. Prolong LAs’ duration of action.
C. With block anesthesia, reduce bleeding in the operative field.
D. Reduce the risk of LAs’ systemic toxicity.
All of the following statements related levonordefrin are correct EXCEPT which one?
A. 2% mepivacaine is available w/levonordefrin 1:20,000 (i.e., 0.05 mg/mL) which is bioequivalent to epinephrine 1:100,000 (i.e., 0.01 mg/mL).
B. Levonordefrin is a derivative of norepinephrine and activates peripheral α2 -adrenoceptors in vascular smooth muscles and produces vasoconstriction.
C. Levonordefrin is more likely than epinephrine to cause cardiac arrhythmias.
D. Levonordefrin activates α2 -adrenoceptors in the cardiovascular control center of the CNS, suppresses sympathetic output from the brain and lowers BP.
All of the following statements related to the available 2% lidocaine formulations w/epinephrine are correct EXCEPT which one?
A. In general, the maximum recommended dose (MRD) of epinephrine in LA formulations for healthy adults is 0.2 mg per visit.
B. The maximum safe dose of 2% lidocaine w/epinephrine 1:100,000 (0.01 mg/mL) is 20 mL.
C. The maximum safe dose of 2% lidocaine w/epinephrine 1:50,000 (0.02 mg/mL) is 10 mL.
D. The MRD of 2% lidocaine is reached before the MRD of epinephrine 1:100,000 (0.01 mg/mL) or epinephrine 1:50,000 (0.02 mg/mL).
All of the following statements related to mepivacaine 2% w/levonordefrin 1:20,000 (0.05 mg/mL) are correct EXCEPT which one?
A. Levonordefrin, 0.05 mg, is bioequivalent to epinephrine, 0.05 mg.
B. The MRD of levonordefrin is 1 mg.
C. The maximum safe dose of 2% mepivacaine w/levonordefrin 1:20,000 (0.05 mg/mL) is 20 mL.
D. With 2% mepivacaine formulation, the MRD of levonordefrin (1 mg) and the MRD of mepivacaine (400 mg) are both reached with 20mL of LA.
All of the following statements related to various available LA formulations are correct EXCEPT which one?
A. Based on the MRD of prilocaine (600 mg), the MRD of epinephrine 1:200,000 in prilocaine is reached after the MRD of 4% prilocaine.
B. Based on the MRD of articaine (500 mg), the MRD of epinephrine 1:100,000 in articaine is reached before the MDR of 4% articaine.
C. Based on the MRD of articaine (500 mg), the MRD of epinephrine 1:200,000 in articaine is reached after the MDR of 4% articaine.
D. Based on the MRD of bupivacaine (90 mg), the MDR of epinephrine 1:200,000 in bupivacaine is reached after the MDR of 0.5% bupivacaine.
All of the following statements related to epinephrine are correct EXCEPT which one?
A. Epinephrine has a relatively narrow therapeutic window.
B. Since epinephrine crosses the blood-brain barrier, epinephrine-associated ADRs are the result of CNS effects.
C. Common adverse effects may occur even with the administration of recommended therapeutic doses and include restlessness, agitation, anxiety, tremulousness, headache, dizziness, pallor, palpitation, and tachycardia.
D. In patients with Parkinson’s disease epinephrine may increase tremor and rigidity.
Particularly vulnerable populations to the effects of therapeutic doses of epinephrine include all of the following EXCEPT which one?
A. Patients with uncontrolled hypothyroidism.
B. The young and the old.
C. Those with high BP and severe cardiovascular diseases (i.e., unstable angina pectoris, recent myocardial infarction (MI), decompensated heart failure.
D. Patients with severe valvular disease, supraventricular arrhythmias with uncontrolled ventricular rate, and symptomatic ventricular arrhythmias).
Epinephrine should be _______________.
A. used with caution in patients on other sympathomimetic agents and in patients on nonselective β-adrenoceptor antagonists
B. avoided in patients on cocaine
C. used with caution in patients with supraphysiological thyroid levels (i.e., excess thyroid medication or hyperthyroidism)
D. All of the above.
All of the following statements related to epinephrine dosing in high-risk populations are correct EXCEPT which one?
A. In high-risk populations, the therapeutic benefits of epinephrine must outweigh possible risks and a lower maximum dose of 0.02 to 0.05 mg is recommended.
B. Since the main physiologic stimulus to epinephrine secretion is exercise, to establish the safe dose of epinephrine determine the patient’s functional capacity.
C. Functional capacity is expressed in metabolic equivalents (METs) and reflects a person’s functional reserve to meet physiological demand for oxygen.
D. Work at 1 MET requires a capacity to deliver 7 mL of O2 /kg/min.
All of the statements related to the relationship between cardiac risk, metabolic equivalents, plasma epinephrine levels, and stress testing are correct EXCEPT which one?
A. A functional capacity of <2 METs is indicative of increased perioperative and long-term cardiac risk.
B. Clues indicative of increased cardiac risk include the physical findings of tremor, anxiety, cyanosis, pallor, diaphoresis, dyspnea, tightness and/or pain in the chest with minimal activity, and peripheral edema.
C. The hemodynamic effects of infiltration anesthesia with 0.045 mg of epinephrine, was reported to be less than those produced by stress testing at 4 METs.
D. From a mean resting (supine) metabolic state, 0.045 mg of epinephrine produces about a 4-fold transient increase in mean plasma epinephrine concentration.
All of the following statements related to transient increases in mean plasma epinephrine levels are correct EXCEPT which one?
A. Significant transient elevation in mean plasma epinephrine levels was reported w/ nerve block anesthesia with 1.8 mL of 2% lidocaine without epinephrine.
B. Transient ≈3.5-fold elevation of mean plasma epinephrine level was reported w/ nerve block anesthesia with 1.8 mL of 2% lidocaine w/0.018 mg of epinephrine.
C. Transient ≈3.5-fold elevation of mean plasma epinephrine level was reported w/ restorative procedures under 1.8 mL of 2% lidocaine w/0.018 mg of epinephrine.
D. Transient ≈5-fold elevation of mean plasma epinephrine level was reported w/ third molar extractions under 5.4 mL of 2% lidocaine w/ 0.054 mg of epinephrine.
All of the statements related to transient elevation of mean plasma epinephrine levels are correct except which one? Mean resting (supine) values rise from mean resting (supine) values nearly _______________.
A. 2-fold during quite standing.
B. 3-fold during cigarette smoking.
C. 7-fold in response to an increment in plasma glucose levels from 60 to 95 mg/mL.
D. 2 to 13-fold during mild to heavy exercise.
All of the statements related to threshold epinephrine values for hemodynamic and metabolic effects are correct EXCEPT which one?
A. Threshold epinephrine values for hemodynamic and metabolic effects begin at or are slightly above normal values (range: (<10 to 70 pg/mL).
B. Plasma epinephrine threshold for increments in HR is 50-100 pg/mL, i.e., chronotropic effects occur at only 2 to 3-fold basal levels.
C. Plasma epinephrine threshold for increments in systolic BP is 75-125 pg/mL and for decrements in diastolic BP it is 150-200 pg/mL.
D. Plasma epinephrine threshold for increments in diastolic BP is 150-200 pg/mL.
All of the statements related to rises in mean plasma epinephrine values from a baseline of 24 pg/mL to peak plasma concentration of 1,020 pg/mL are correct EXCEPT which one?
A. Baseline HR rises by nearly 30 bpm.
B. Baseline systolic BP rises by slightly more than 20 mm Hg.
C. Baseline diastolic BP rises by about 20 mm Hg.
D. Transient mean plasma epinephrine concentration of 1,024 pg/mL would require ≈0.17 to 0.21 mg of epinephrine (MRD in healthy adults: 0.2 mg).
All of the statements related to the clearance of epinephrine are correct EXCEPT which one?
A. In general, ADRs with therapeutic doses of epinephrine subside rapidly with rest and recumbency.
B. Epinephrine has a half-life of about 2 hours; but it accelerates its own metabolic clearance through α-adrenergic mechanisms.
C. Mean plasma metabolic clearance rate of epinephrine in young men at steady-state plasma concentrations between 24-74 pg/mL is 52±4 mL/kg/min.
D. Mean plasma metabolic clearance rate of epinephrine in young men at steady-state plasma concentrations between 90-1020 pg/mL is 89±6 mL/kg/min.
Rarely, overdosage with epinephrine in oral healthcare settings may result from _______________.
A. intravascular injection and/or the administration of supratherapeutic doses, especially to high-risk patients
B. concomitant therapy with other drugs, which may potentiate adverse sympathetic effects
C. additivity of epinephrine administered with the LA and endogenous epinephrine released in response to surgical stress
D. All of the above.
The magnitude of surgical (procedure-related) stress depends on _______________.
A. the extent of tissue trauma and duration of the procedure
B. volume of blood loss, fluid shifts in the body
C. changes in core body temperature
D. All of the above.
All of the statements related to epinephrine-induced cardiac risk are correct EXCEPT which one?
A. Cardiac risk is defined as myocardial infarction or cardiac death within 30 days of a non-cardiac procedure.
B. Dental procedures under local anesthesia are low cardiac-risk procedures, i.e., cardiac-risk is negligible unless strong patient-specific risk factors are present.
C. The minimum lethal dose of epinephrine, based on data for subcutaneous injection, is estimated to be 0.4 mg.
D. Autopsy findings in patients who died of epinephrine overdosage include evidence of circulatory collapse and congestion of most organs with blood.
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