EXAMINATION PAPER: ACADEMIC SESSION 2021/2022

Campus Medway
Faculty Engineering and Science
Department Medway School of Pharmacy
Stage THREE
Exam Session May 2022
COURSE CODE PHAM1130
COURSE TITLE Integrated Therapeutics – Cancer, Infection,
Joints, Lungs and Skin
Examination Type Main Assessment
Duration of examination 3 hours

Instructions to Candidates
THE PAPER IS DIVIDED INTO THREE SECTIONS

SECTION A: This section is specifically designed to assess depth of knowledge

• Answer ONE out of TWO questions
• 23% weighting
• Allow 40 minutes to complete this section.

SECTION B: This section is specifically designed to assess depth of knowledge

• Answer TWO out of THREE questions
• 47% weighting
• Allow 1 hour 20 minutes to complete this section.

Additional Information
Calculators are allowed to be used during this exam.
The pass mark for this assessment is 50%.

Page 1 of 9
SECTION A - Answer ONE out of TWO questions

Question 1

a) A patient enters your pharmacy and tells you that they are travelling to Malawi
for a three-week holiday, which has a high risk of malaria. They want to know
how they can stop themselves from catching malaria when they are there and
also what else to look out for when travelling. You look up Malawi on the fit for
travel NHS website and find that it recommends the atovaquone/proguanil
combination of medication.

Explain the life cycle of malaria. What advice should you give this patient on
preventing malaria, including how to take the prophylactic medication
recommended by the NHS and what other public health interventions could you
suggest when travelling?

[50 marks]

Mosquito Bites

Parasites released Sporozoites

to invade RBCs Injected

Plasmodium
Taken up by the
develops into
Liver
Schizont in Liver

Question 1 Continued on the following page…

Page 2 of 9
Question 1 continued…

The same customer returns to your pharmacy a few months later and asks you for
some advice regarding treatment for her husband who has an upset stomach. On
questioning, you discover that her 35-year-old husband had gone to a BBQ the day
before, and whilst there, he had eaten some ‘dodgy looking pink chicken’. She
further explains, that within the past 2 hours her husband has complained of
abdominal cramps, feeling sick and had noticed some bloody diarrhoea.
Her husband has no allergies, takes no medicines and is normally fit and healthy.

b) Assuming the customer’s husband has a gastro-intestinal infection, discuss 4

main bacterial organisms that could be responsible for causing food poisoning in
the United Kingdom? Within your answer provide details of each bacterium such
as virulence factors, how they are spread, incubation period and symptoms. (DO
NOT INCLUDE CHOLERA)
[20 marks]

c) What are the 3 clinical manifestations of diarrhoea and why does the patient
have blood in his diarrhoea?

[15 marks]

d) How can the risk of food poisoning be minimised and what advice would you
give to the customer regarding how to treat her husband?
[15 marks]

Total 100 MARKS

Page 3 of 9
Question 2

a) Mrs Burns is a 45-year-old woman of South Asian descent. On investigation she

has a Qrisk2 of 16.6% for which atorvastatin 20mg once daily is recommended for
primary prevention of cardiovascular disease (CVD). Alongside this she is
borderline type 2 diabetic, is a moderate smoker (10-19 per day) and drinks
approximately 18 units of alcohol per week and her most recent BP measurement
was 132/83mmHg. Her BMI is calculated as 26kg/m2. She has a very busy
lifestyle being a mum of 3 children.

Would Mrs Burns benefit from pharmacy Public Health Services? What
interventions would you recommend and why?

Include in your answer

• An explanation of what is meant by the term Public Health
• How these recommendations would benefit wider Public Health
• Any targets which Mrs Burns should try to achieve
[60 marks]

b) As Mrs Burns has such a busy lifestyle, she often neglects her own health needs.
She was diagnosed with blepharitis a few months ago but doesn’t really
understand what it is.

Describe the causes, signs and symptoms, and treatment options for blepharitis.
[Total 40 marks]
[Total 100 marks]

END OF SECTION A

PROCEED TO SECTION B

Page 4 of 9
 SECTION B - Answer TWO out of THREE questions

Question 3

a) Mrs Smythe was recently diagnosed with cancer, and she started chemotherapy
(Sianycin) soon after the diagnosis. The adverse effects following her
chemotherapy, which included rapid hair loss and persistent vomiting led the
specialist to conclude the regimen was unsustainable and recommended a review.
The specialist replaced Sianycin with a newer drug in the form of the antibody-
Sianycin conjugate. Mrs Smythe responded very well to the new drug and is now
showing signs of considerable remission with reduced adverse effects.

Using a suitable diagram to illustrate a possible mode of drug action and

highlighting fundamental differences between the two drugs, explain why the new
drug is more therapeutically beneficial with reduced adverse effects.
[60 marks]

b) Mrs Smythe also suffers from mild depression. A newly approved molecule
MD2441 is considered safe and effective for patients on antibody-Sianycin
conjugates treatment as it is known to have no contraindications to this therapy and
shows very mild side effects. MD2441 is classed as a BCS class II molecule, and
the drug absorption is known to be dissolution rate limited.

Your team has been tasked with developing a solid formulation with a higher
dissolution rate of the drug. Discuss FOUR methods that could be used to achieve
this in detail. Your answer must include the associated principles and rationale
behind your choices.
[40 marks]
[Total 100 marks]

Page 5 of 9
 Question 4

a) Mr B is a 26-year-old office manager who has had asthma since he was a young
child. He has been brought to A&E by his sister who he has been visiting recently.
He is suffering from acute shortness of breath. His sister has a dog which she
knows he is allergic to, so she has been trying to keep it out of the same room as
him, sometimes unsuccessfully.

His normal medication is Relvar® Ellipta 92/22 (fluticasone furoate

92micrograms/dose + vilanterol 22 micrograms/dose) 1 dose each morning plus
Bricanyl® turbohaler (terbutaline) 500 micrograms/ dose 1 dose when required. Mr
B has used his terbutaline six times in the past two hours.

On examination, Mr B has an audible wheeze, is becoming distressed and is

unable to speak more than a couple of words before stopping. His respiratory rate
is 30 breaths per minute and his heart rate is 120 beats per minute. His oxygen
saturations are 93% on air. He has no fever or sounds of crackles on his chest. He
is unable to perform a peak flow due to his breathlessness, but his sister says his
reading was 350L/min this morning. He can’t remember his best reading, but he is
175cm tall and so his predicted would be around 610L/min. He weighs 90kg, has
never smoked and is not allergic to any medicines.

What are the signs and symptoms Mr B is showing which indicate a severe asthma
attack?

Explain the management of severe asthma and specifically how Mr B should be

treated. Include a plan for how this can be escalated if each step proves
unsuccessful in improving his symptoms.

After his recovery, what could be done to reduce his chance of a further severe
attack?
[50 marks]

Question 4 Continued on the following page…

Page 6 of 9
 Question 4 continued…

b) Mr B continues to deteriorate and the respiratory consultant requests that

theophylline is started and that he is transferred to the high dependency unit.

Recommend a loading dose of theophylline for this patient. State any assumptions
that you have made in determining the dose.

Describe how the dose should be administered. What monitoring would you
recommend?
[50 marks]
The following information may be required to answer this question:

Population Volume of distribution – 0.48 L/kg

Population Clearance (adult) – 0.04 L/h/kg

Clearance Factors
Chronic Obstructive Pulmonary Disease – 0.8
Hepatic Cirrhosis - 0.5
Mild congestive heart failure – 0.8
Chronic alcohol – 0.5
Smoking - 1.6
Ciprofloxacin -0.7
Erythromycin - 0.75
Tricyclic antidepressants – 1.2

Nuelin SA (sustained release theophylline) is available as 175 and 250 mg tablets.

It is given twice a day.

Theophylline is given by injection as aminophylline (25 mg/mL).

Page 7 of 9
Question 5

This integrative question is regarding the standards used in selecting anticancer

chemotherapy. The type of therapy used is often determined by the molecular
mechanisms or pathways which lead to malignant transformation. This knowledge
allows to us determine whether a combination of cytostatic medications should be
applied, or targeted therapy would be preferable. Therefore, in this question you are
expected to demonstrate knowledge of both pharmaceutical and biological aspects
of the subject.

You are the pharmacy lead in a multidisciplinary team running an adult

chemotherapy service that is commissioned by NHS England and the standards for
which are set by the Service Level Agreement for Cancer: Chemotherapy (Adult).
Your hospital is being investigated as it is not meeting the national NHS target, “All
patients should have their first definitive treatment from deciding with their clinician
on a treatment plan to actual commencement of treatment within 31 days.” The
standard is set at 96%.
The reason appears to be due to medication issues (stemming from the pharmacy
production of medications) and not surgery or radiotherapy. On further investigation
you discover the following:

• Medication is not received on time at the clinic.

• Pre-chemotherapy analysis of blood tests arrive late, and so individual patient
chemotherapy medication plans are made at the last minute and are assembled
at short notice resulting in unrealistic deadlines to make the preparations.
• Doctors signing off the blood tests and making/prescribing the chemotherapy
prescription don’t prioritise this work.
• Pharmacy staff vacancy and sickness rates have increased due to work
pressures.
• Core medication is not available at the right time to make the chemotherapy
medications, leading to severe delays in producing the individual patient
chemotherapy medications.
• Lack of sufficient accredited pharmacy technicians to make the chemotherapy.
• A large increase in overtime outside of core hours of the pharmacy staff resulting
in overspends, following the late delivery of core medication and specified
prescriptions for making the chemotherapy products.

Question 5 continues on next page…

Page 8 of 9
 Question 5 continued…

You audit the pharmacy service to explore what is happening.

Topic: Exploring the delays in pharmacy production of individual
patient medication

Criteria Standard
All blood tests to be completed one day before 75%
chemotherapy products are made
All medication for the chemotherapy to be 80%
received one day before chemotherapy
products are made
Percentage of accredited pharmacy technicians 100%
working in the unit

a) Explain the benefits of clinical audit and critically review whether the criteria and
standards are appropriate to ensure delivery of the medication on time at the
clinic.
[30 marks]

b) How would you ensure the success of your audit?

[10 marks]

c) Write two new standards for a clinical audit of patients receiving care at this
chemotherapy service
[20 marks]

d) Explain the terms “oncogene” and “proto-oncogene”. Describe three strategies of

oncogene activation. Give an example of how crucial growth factor can become
highly oncogenic.
[50 marks]

END OF SECTION B

END OF EXAMINATION

Page 9 of 9