A 34-year-old woman with extensive plaque psoriasis has been on oral cyclosporine for 4 months. Her skin has cleared, but she now has overgrown gums, increased facial hair and BP 150/96 mmHg, and her serum creatinine has risen by 30% from baseline. How does this drug control her psoriasis?

It inhibits calcineurin and cuts IL-2 transcription

It inhibits IMP dehydrogenase in lymphocytes

It inhibits mTOR and blocks the response to IL-2

It inhibits dihydrofolate reductase in keratinocytes

A 50-year-old man with squamous cell carcinoma of the larynx is to receive weekly cisplatin with radiotherapy. Which measure does most to reduce the dose-limiting toxicity of this drug?

Vigorous IV normal saline hydration

Allopurinol started a day before

Leucovorin given 24 hours after each dose

Chemotherapy, targeted therapy and immunosuppressants

18 NEET-PG practice questions on Chemotherapy, targeted therapy and immunosuppressants, part of Pharmacology. The first 18 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
A 32-year-old woman with lupus nephritis is receiving monthly IV cyclophosphamide pulses. During the second pulse she passes blood-stained urine with frequency and suprapubic pain; urine culture is sterile. Which agent given with each pulse helps prevent this complication?
1. AAmifostine
2. BDexrazoxane
3. CMesna
4. DLeucovorin
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Answer: C · Mesna
Cyclophosphamide and ifosfamide release acrolein, which is excreted in urine and damages the bladder mucosa, causing haemorrhagic cystitis. Mesna is a thiol compound that is concentrated in urine and binds acrolein there, without reducing the drug's systemic effect. Generous hydration and frequent voiding also protect the bladder. Long-term cyclophosphamide raises the risk of bladder cancer, so haematuria later should still be investigated.
- A: Amifostine is used against cisplatin nephrotoxicity and radiation xerostomia.
- B: Dexrazoxane protects the heart against anthracyclines.
- D: Leucovorin rescues normal cells from methotrexate, not from acrolein.
Question 2 · Medium
A 34-year-old woman with extensive plaque psoriasis has been on oral cyclosporine for 4 months. Her skin has cleared, but she now has overgrown gums, increased facial hair and BP 150/96 mmHg, and her serum creatinine has risen by 30% from baseline. How does this drug control her psoriasis?
1. AIt inhibits IMP dehydrogenase in lymphocytes
2. BIt inhibits mTOR and blocks the response to IL-2
3. CIt inhibits dihydrofolate reductase in keratinocytes
4. DIt inhibits calcineurin and cuts IL-2 transcription
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Answer: D · It inhibits calcineurin and cuts IL-2 transcription
Cyclosporine binds cyclophilin, and the complex inhibits calcineurin, the phosphatase that activates the transcription factor NFAT in T cells. Activated T cells therefore fail to transcribe IL-2 and other cytokines, which damps the T-cell-driven inflammation of psoriasis. Its adverse effects are nephrotoxicity, hypertension, gum hyperplasia, hirsutism, tremor and hyperkalaemia, so BP and creatinine are monitored and a sustained rise in creatinine calls for a lower dose or stopping. Tacrolimus works the same way through FKBP-12 but causes more diabetes and neurotoxicity and less gum and hair growth.
- A: IMP dehydrogenase inhibition is the action of mycophenolate.
- B: mTOR inhibition is the action of sirolimus and everolimus.
- C: Dihydrofolate reductase inhibition is the action of methotrexate.
Question 3 · Medium
A 45-year-old woman with node-positive breast cancer is to receive a doxorubicin-containing regimen. Before she signs the consent form, the oncology resident explains four points about the risk to her heart: 1. The risk of cardiomyopathy rises with the cumulative dose. 2. Dexrazoxane can reduce the risk. 3. The damage is usually reversible once the drug is stopped. 4. Left ventricular ejection fraction is measured before treatment starts. Which statements are correct?
1. A1 and 3 only
2. B1, 2 and 4 only
3. C1 and 2 only
4. D1, 2 and 3 only
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Answer: B · 1, 2 and 4 only
Statements 1, 2 and 4 are correct. Anthracyclines damage cardiac myocytes through iron-dependent free radicals and inhibition of topoisomerase II beta, and the risk of cardiomyopathy climbs steeply with the cumulative dose, so a lifetime limit is kept. Dexrazoxane, an iron chelator, reduces this injury, and a baseline echocardiogram (or MUGA scan) is done and repeated during treatment. Statement 3 is false: anthracycline damage involves myocyte loss and is largely permanent, unlike trastuzumab cardiotoxicity, which is usually reversible.
- A: Includes reversibility and leaves out dexrazoxane and baseline LVEF.
- C: Leaves out baseline LVEF measurement, which is standard before treatment.
- D: Includes reversibility, which describes trastuzumab, and leaves out baseline LVEF.
Question 4 · Easy
A 50-year-old man with squamous cell carcinoma of the larynx is to receive weekly cisplatin with radiotherapy. Which measure does most to reduce the dose-limiting toxicity of this drug?
1. AAllopurinol started a day before
2. BLeucovorin given 24 hours after each dose
3. CMesna given with each dose
4. DVigorous IV normal saline hydration
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Answer: D · Vigorous IV normal saline hydration
The dose-limiting toxicity of cisplatin is damage to the proximal tubules, which can cause a rising creatinine and wasting of magnesium and potassium. Hydration with normal saline before and after each dose maintains urine flow, and the high chloride also keeps cisplatin in a less reactive form in the tubules. Other toxicities are severe vomiting, ototoxicity and peripheral neuropathy, so audiometry and electrolytes, including magnesium, are checked during treatment. Other nephrotoxic drugs such as aminoglycosides are avoided at the same time.
- A: Allopurinol prevents urate nephropathy in tumour lysis, not cisplatin tubular injury.
- B: Leucovorin is the rescue agent for methotrexate.
- C: Mesna protects the bladder from cyclophosphamide and ifosfamide metabolites.
Question 5 · Easy
A 5-year-old boy with B-cell acute lymphoblastic leukaemia is in induction chemotherapy at a regional cancer centre. After the third weekly dose of one drug he has constipation, jaw pain and absent ankle jerks, while his neutrophil count is well preserved. Which drug is responsible?
1. AVincristine
2. BMethotrexate
3. CDaunorubicin
4. DL-asparaginase
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Answer: A · Vincristine
Vincristine binds tubulin and stops microtubule assembly, arresting cells in metaphase; the same action on axonal transport in nerves causes its dose-limiting toxicity, a peripheral and autonomic neuropathy (areflexia, paraesthesia, jaw pain, constipation and even paralytic ileus). Unlike most cytotoxics it largely spares the marrow. Vincristine must never be given intrathecally, because that is almost always fatal; it is dispensed in a minibag clearly labelled for IV use only.
- B: Methotrexate mainly causes mucositis and marrow suppression, not areflexia.
- C: Daunorubicin causes marrow suppression and cumulative cardiotoxicity.
- D: Asparaginase causes hypersensitivity, pancreatitis and thrombosis, not neuropathy.
Question 6 · Hard
A 14-year-old boy with osteosarcoma of the distal femur is admitted for high-dose methotrexate at a regional cancer centre. The resident prepares notes for the nurses: 1. Leucovorin rescue works because it bypasses the blocked dihydrofolate reductase step. 2. Keeping urine pH at 7 or above reduces precipitation of methotrexate in the tubules. 3. Glucarpidase can be used if delayed clearance leads to renal failure with toxic levels. 4. Omeprazole and NSAIDs given alongside speed methotrexate excretion. Which statements are correct?
1. A1 and 2 only
2. B1, 2 and 3 only
3. C1, 2 and 4 only
4. D1 and 3 only
Answer and explanation in LearnFree account
Question 7 · Medium
A 55-year-old man is receiving IV irinotecan for metastatic colorectal cancer. Within an hour of the infusion he develops abdominal cramps, watery diarrhoea, sweating, salivation and watering of the eyes. What is the best immediate treatment?
1. ASubcutaneous atropine
2. BHigh-dose oral loperamide
3. CIntravenous ondansetron
4. DOctreotide infusion
Answer and explanation in LearnFree account
Question 8 · Medium
A 55-year-old man from Nagpur has a 9 cm gastric mass with liver metastases. Biopsy shows a spindle cell tumour strongly positive for CD117 (KIT) and DOG1, consistent with a gastrointestinal stromal tumour. Which drug is the first-line treatment?
1. AImatinib
2. BTrastuzumab
3. CErlotinib
4. DBevacizumab
Answer and explanation in LearnFree account
Question 9 · Medium
A 15-year-old boy with T-cell acute lymphoblastic leukaemia is in the second week of induction with prednisolone, vincristine, daunorubicin, intrathecal methotrexate and pegylated asparaginase. He develops severe epigastric pain radiating to the back with vomiting; serum lipase is eight times the upper limit and triglycerides are raised. Which drug is the most likely cause?
1. ADaunorubicin
2. BVincristine
3. CAsparaginase
4. DMethotrexate
Answer and explanation in LearnFree account
Question 10 · Medium
A 40-year-old man had a renal transplant 2 years ago and is stable on tacrolimus, mycophenolate mofetil and prednisolone. A general practitioner prescribed clarithromycin for a chest infection. A week later he has a fine hand tremor, serum creatinine has risen from 1.1 to 1.9 mg/dL and potassium is 5.9 mmol/L. What is the most likely explanation?
1. AInterstitial nephritis caused by clarithromycin
2. BMycophenolate build-up from poor renal clearance
3. CRejection from induced tacrolimus metabolism
4. DTacrolimus toxicity from CYP3A4 inhibition
Answer and explanation in LearnFree account
Question 11 · Medium
A 48-year-old schoolteacher from Kolkata who has never smoked has metastatic adenocarcinoma of the lung with two small brain metastases. Molecular testing shows an EGFR exon 19 deletion; ALK and ROS1 rearrangements are absent. Which is the preferred first-line treatment?
1. ACrizotinib
2. BPembrolizumab alone
3. CImatinib
4. DOsimertinib
Answer and explanation in LearnFree account
Question 12 · Medium
A 62-year-old man with metastatic colon cancer is on FOLFOX plus bevacizumab. Over two months his BP rises to 168/100 mmHg and his urine shows 3+ protein. He is now brought to casualty with sudden severe abdominal pain, and an erect chest X-ray shows free gas under the diaphragm. How does the targeted drug cause these effects?
1. AIt inhibits topoisomerase I in the gut mucosa
2. BIt blocks HER2 signalling in smooth muscle
3. CIt blocks EGFR on intestinal epithelial cells
4. DIt neutralises VEGF-A needed by endothelium
Answer and explanation in LearnFree account
Question 13 · Easy
A 24-year-old man is on BEP chemotherapy for a non-seminomatous testicular germ cell tumour. After his third cycle he has a dry cough and breathlessness on exertion, fine bibasal crackles and a fall in diffusing capacity (DLCO). The drug most likely responsible is:
1. ACisplatin
2. BEtoposide
3. CIfosfamide
4. DBleomycin
Answer and explanation in LearnFree account
Question 14 · Hard
A 63-year-old man with metastatic melanoma has received four cycles of nivolumab plus ipilimumab. He now passes 8 more watery stools a day than his usual, with cramping abdominal pain and some blood. Stool culture and C. difficile toxin are negative, and CT shows diffuse thickening of the colonic wall. What is the most appropriate management?
1. AStart IV metronidazole and oral vancomycin
2. BHold immunotherapy and give IV methylprednisolone
3. CContinue immunotherapy and give loperamide
4. DContinue immunotherapy and give infliximab
Answer and explanation in LearnFree account
Question 15 · Medium
A 6-year-old girl with acute lymphoblastic leukaemia in the maintenance phase takes daily oral 6-mercaptopurine and weekly methotrexate. Within three weeks at standard doses she develops profound pancytopenia; her liver tests are normal and she takes no other drugs. Which test would best explain her sensitivity and guide the dose?
1. ATPMT and NUDT15 genotyping
2. BDPYD genotyping
3. CUGT1A1*28 genotyping
4. DHLA-B*58:01 typing
Answer and explanation in LearnFree account
Question 16 · Hard
A 27-year-old woman received a living-donor kidney from her mother 3 years ago and has stable graft function on tacrolimus, mycophenolate mofetil and prednisolone. She and her husband want a child and ask whether her medicines are safe. What change should be made before she tries to conceive?
1. ATaper and stop the prednisolone
2. BReplace tacrolimus with sirolimus
3. CReplace mycophenolate with azathioprine
4. DStop all three drugs during pregnancy
Answer and explanation in LearnFree account
Question 17 · Hard
A 24-year-old man with relapsed B-cell acute lymphoblastic leukaemia receives CD19-directed CAR-T cells at a tertiary centre in Mumbai. On day 3 he has fever of 40.1°C, BP 84/50 mmHg that rises to 104/66 mmHg after 1 litre of IV fluid, and SpO2 90% needing 4 L/min of oxygen by nasal prongs. He is fully alert with normal handwriting and no focal signs. Ferritin and CRP are very high; blood cultures are sent and broad-spectrum antibiotics are started. What is the most appropriate specific treatment?
1. AIntravenous rituximab
2. BIntravenous immunoglobulin
3. CGranulocyte colony-stimulating factor
4. DIntravenous tocilizumab
Answer and explanation in LearnFree account
Question 18 · Medium
A 64-year-old retired bank clerk with multiple myeloma (serum M-protein 4.2 g/dL, lytic skull lesions, creatinine 1.6 mg/dL) is started on bortezomib, lenalidomide and dexamethasone, with acyclovir and aspirin as prophylaxis. Why are myeloma cells especially sensitive to bortezomib?
1. AThey rely on topoisomerase II to repair DNA
2. BThey depend on proteasomes to clear misfolded immunoglobulin
3. CThey carry CD20, to which the drug binds
4. DThey need BCR::ABL1 kinase signalling to grow
Answer and explanation in LearnFree account

Chemotherapy, targeted therapy and immunosuppressants

A 32-year-old woman with lupus nephritis is receiving monthly IV cyclophosphamide pulses. During the second pulse she passes blood-stained urine with frequency and suprapubic pain; urine culture is sterile. Which agent given with each pulse helps prevent this complication?

A 34-year-old woman with extensive plaque psoriasis has been on oral cyclosporine for 4 months. Her skin has cleared, but she now has overgrown gums, increased facial hair and BP 150/96 mmHg, and her serum creatinine has risen by 30% from baseline. How does this drug control her psoriasis?

A 50-year-old man with squamous cell carcinoma of the larynx is to receive weekly cisplatin with radiotherapy. Which measure does most to reduce the dose-limiting toxicity of this drug?

A 5-year-old boy with B-cell acute lymphoblastic leukaemia is in induction chemotherapy at a regional cancer centre. After the third weekly dose of one drug he has constipation, jaw pain and absent ankle jerks, while his neutrophil count is well preserved. Which drug is responsible?

A 55-year-old man is receiving IV irinotecan for metastatic colorectal cancer. Within an hour of the infusion he develops abdominal cramps, watery diarrhoea, sweating, salivation and watering of the eyes. What is the best immediate treatment?

A 55-year-old man from Nagpur has a 9 cm gastric mass with liver metastases. Biopsy shows a spindle cell tumour strongly positive for CD117 (KIT) and DOG1, consistent with a gastrointestinal stromal tumour. Which drug is the first-line treatment?

A 48-year-old schoolteacher from Kolkata who has never smoked has metastatic adenocarcinoma of the lung with two small brain metastases. Molecular testing shows an EGFR exon 19 deletion; ALK and ROS1 rearrangements are absent. Which is the preferred first-line treatment?

A 24-year-old man is on BEP chemotherapy for a non-seminomatous testicular germ cell tumour. After his third cycle he has a dry cough and breathlessness on exertion, fine bibasal crackles and a fall in diffusing capacity (DLCO). The drug most likely responsible is:

A 27-year-old woman received a living-donor kidney from her mother 3 years ago and has stable graft function on tacrolimus, mycophenolate mofetil and prednisolone. She and her husband want a child and ask whether her medicines are safe. What change should be made before she tries to conceive?

A 64-year-old retired bank clerk with multiple myeloma (serum M-protein 4.2 g/dL, lytic skull lesions, creatinine 1.6 mg/dL) is started on bortezomib, lenalidomide and dexamethasone, with acyclovir and aspirin as prophylaxis. Why are myeloma cells especially sensitive to bortezomib?