1. Mrs Lee is a 47-year-old married clerk. There was a reduction of manpower in her department in the company 3 months ago and she felt increasingly stressed at work. Her concentration has gotten worse and she found it more difficult to get things done. Her mood is low almost every day and has been tearful for no reason. She becomes tired easily and her sleeping pattern is altered (insomnia). She also loses her appetite and has lost 5 kilograms in the recent two months. 

(a) What type of disorder does Mrs Lee likely have? Explain your answer. Name TWO addition symptoms of this disorder. (2+2 marks) 

(b) Describe "monoamine hypothesis". Explain whether this hypothesis is perfect or not. (4 marks) 

(c) What is the drug class and mode of action of Fluoxetine? (2 marks) 

(d) Explain the mode of action of serotonin antagonist-reuptake inhibitor Trazodone in treating depression and name TWO side effects. (4+2 marks) 

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

2. Mr Lee, a 68-year-old taxi driver, had chronic obstructive pulmonary disease ("COPD”) with a chronic cough producing thick sputum, breathlessness and exercise limitation. The cough and sputum production have not changed recently. He stopped smoking for 3 months previously because of his dyspnea. Prior to his smoking cessation, he has been smoking 20 cigarettes a day for 50 years. He had no other significant medical illnesses. His forced expiratory volume in one second ("FEV1") was 1.34 L (about 45% of predicted). He was given the combination of ipratropium and salbutamol via a pressurized metered dose inhaler ("pMDI") for symptomatic relief. A trial of inhaled budesonide given 3 months previously provided no benefit and it has been stopped now. 

(a) Which classes of drugs do ipratropium and salbutamol belong to? (2 marks) 

(b) Describe the mechanisms of action for ipratropium and salbutamol. (6 marks) 

(c) Which class of drugs does budesonide belong to? State how this class of drugs works. (4 marks) 

(d) What will be the most appropriate combination inhaler with an example to replace the current medication for symptomatic relief? What is the rationale? (4 marks) 

(e) List ONE class of therapeutic drug with an example that can be used for add-on treatment to break down his thick sputum. State the mechanism of action for such a drug. (4 marks) 

3. You are a hospital pharmacist who provides antiepileptic drug services to the Neurology clinic. Jessie, a 24-year-old lady who has just been married, is contemplating pregnancy in the future. She has a known medical history of generalized tonic clonic epilepsy since the age of 14. The frequency of convulsions is about once a month. Her current medication includes sodium valproate 400 mg twice daily. 

(a) She would like to seek your advice on the use of oral contraceptive pills ("OCP"). Please advise and explain if OCP is a safe contraceptive method for her. (2 marks) 

(b) Name TWO fetal risks of sodium valproate exposure in utero in a lady considering future pregnancy. (2 marks) 

(c) Discuss the BENEFITS and RISKS of the following THREE approaches on epilepsy management during pregnancy. (6 marks) 

(i) Withdraw of valproate 

(ii) Switch from valproate to an alternative treatment 

(iii) Unchanged treatment with valproate 

(d) If Jessie chooses to continue sodium valproate treatment during pregnancy, what would be the ideal maximal dosage? (1 mark) 

(e) If Jessie decides to change to other alternative antiepileptic drugs before conceiving, suggest TWO alternative drugs which have lower risk of teratogenicity and are effective in controlling generalized seizures, but do not interfere the function of OCP. (2 marks) 

(f) What supplement and dosage of the supplement should Jessie take before and during pregnancy in order to prevent fetal malformation? (1 mark) 

(g) What are the pregnancy-associated physiological changes on antiseizures drug metabolism? Do you advise therapeutic drug monitoring for the antiseizure drugs listed in question (e)? (3 marks) 

(h) After delivery of the baby, Jessie keeps taking the same dose of the antiseizure drug because she is worried of sleep deprivation and seizure recurrence. Is she at risk of antiseizure drug overdose and why? (2 marks) 

(i) Jessie is concerned about antiseizure drug exposure to her newborn baby if she breastfeeds him. What is your advice? (1 mark) 

4. A 50-year-old lady was admitted with heart failure. Her echocardiogram showed reduced ejection fraction of 35%. She was given intravenous furosemide and improved. On discharge, she was started on guideline- directed medical therapy for heart failure. She was started on empagliflozin, lisinopril and spironolactone. 

(a) Name the FOUR classes of drugs that are used as part of guideline- directed medical therapy of heart failure. (4 marks) 

(b) What is the mechanism of action of lisinopril? How is it helpful in the treatment of heart failure? (3 marks) 

(c) Name TWO side effects of spironolactone. (2 marks) 

(d) What is the mechanism of action of empagliflozin? What are the potential adverse effects of empagliflozin? What precautions should be taken during acute illness? (5 marks) 

(e) Name THREE beta blockers with long term benefits in heart failure. (3 marks) 

(f) Despite optimal treatment, the patient was readmitted with acute heart failure three months later. Her physician considers starting her on an angiotensin receptor-neprilysin inhibitor ("ARNi"). What are the adverse effects of ARNI? Which of her current medications needs to be discontinued? (3 marks) 

5. Autism Spectrum Disorder ("ASD") is a neurodevelopmental disorder. Although there is currently no pharmacological treatment available to cure ASD, pharmacological treatments are frequently used to control the symptoms of ASD. 

(a) Briefly describe the common core symptoms of ASD. (6 marks) 

Stephen Wang is 15 years old and was diagnosed with ASD when he was 3 years old. You have just received a prescription from Stephen's psychiatrist: risperidone 500 mcg once every day for 7 days. His mother tells you that the risperidone helps to calm him down. 

(b) What are the common short-term adverse effects of the medication and what are the rare but serious side effects? (4 marks) 

Stephen's behaviour improved significantly and he remains on risperidone 500 mcg once every day over the next few months. His mother noticed that he has put on a lot of weight. She reads that risperidone can cause weight gain in the patient information leaflet. 

(c) What is the pharmacological action of risperidone and mechanism for causing weight gain? (3 marks) 

(d) What non-pharmacological and pharmacological options are available to manage Stephen's weight gain? (4 marks) 

(e) Stephen's mother also mentions his sleeping problem, what advice would you give? (3 marks)