Diuretics, haematinics and drugs for blood formation

33 NEET-PG practice questions on Diuretics, haematinics and drugs for blood formation, part of Pharmacology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A man on maintenance haemodialysis receives epoetin alfa 4,000 units three times weekly, yet his haemoglobin has stayed at 8.4 g/dL for three months. Transferrin saturation is 13% and serum ferritin 90 ng/mL; CRP is normal and there is no bleeding. BP is 144/88 mmHg, and he takes his oral iron tablets irregularly. Which step is most appropriate?

   1. ATransfuse two units of blood
   2. BSwitch to darbepoetin
   3. CGive IV iron
   4. DDouble the epoetin dose

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   Answer: C · Give IV iron

   Iron deficiency is the commonest cause of a poor response to erythropoiesis-stimulating agents; in dialysis patients a TSAT under 20% and ferritin under 200 ng/mL indicate it, and IV iron is preferred because oral iron is poorly absorbed in CKD. Raising the ESA dose without iron is ineffective and increases the risk of hypertension and thrombosis.

   • A: Transfusion is not needed in stable anaemia and risks sensitisation before transplant.
   • B: Darbepoetin also fails without iron.
   • D: More epoetin will not work without iron and raises cardiovascular risk.

   Remember this

   Poor ESA response in CKD: first correct iron deficiency (TSAT under 20%) with IV iron.

2. Question 2 · Medium

   In the diabetes clinic, a man on metformin 2 g/day for nine years complains of burning feet and numbness in a stocking pattern. Haemoglobin 10.4 g/dL with MCV 106 fL; HbA1c 7.1%. Ankle jerks are absent and vibration sense is reduced; he eats fish and meat twice a week. Which deficiency should be checked first?

   1. AVitamin B12
   2. BIron
   3. CFolic acid
   4. DThiamine (vitamin B1)

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   Answer: A · Vitamin B12

   Long-term metformin reduces vitamin B12 absorption in the terminal ileum (a calcium-dependent uptake of the intrinsic factor complex), and deficiency can cause megaloblastic anaemia and a neuropathy easily mistaken for diabetic neuropathy. Periodic B12 measurement is advised in patients on long-term metformin, especially with neuropathy or anaemia.

   • B: Iron deficiency causes microcytic, not macrocytic, anaemia.
   • C: Folate deficiency causes macrocytosis but is not linked to metformin or neuropathy.
   • D: Thiamine deficiency causes neuropathy but not macrocytic anaemia.

   Remember this

   Long-term metformin causes vitamin B12 deficiency; check B12 in neuropathy or macrocytic anaemia.

3. Question 3 · Easy

   A trekking group from Kerala plans to fly to Leh (3,500 m) and climb higher over the next week. One member had headache, nausea and poor sleep on a previous trip at the same height. He is otherwise healthy and takes no regular medicines. Which drug, started a day before ascent, best prevents acute mountain sickness?

   1. ASpironolactone
   2. BHydrochlorothiazide
   3. CAcetazolamide
   4. DFurosemide

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   Answer: C · Acetazolamide

   Acetazolamide inhibits renal carbonic anhydrase, causing a bicarbonate diuresis and a mild metabolic acidosis that stimulates breathing and speeds acclimatisation to altitude. It is started a day before ascent; dexamethasone is an alternative, and descent is the definitive treatment for severe illness. Paraesthesia and an altered taste of carbonated drinks are common side effects.

   • A: Spironolactone has no role in altitude sickness.
   • B: Thiazides have no role in altitude sickness.
   • D: Furosemide does not aid acclimatisation and may cause dehydration.

   Remember this

   Acetazolamide prevents acute mountain sickness by causing a metabolic acidosis that drives ventilation.

4. Question 4 · Medium

   A 24-hour urine collection in a bus driver with his third calcium oxalate stone in two years shows calcium 380 mg/day (normal under 300), with normal serum calcium and PTH. He already drinks 3 litres of water daily and has cut his salt. Which drug best reduces further stones, and how?

   1. AFurosemide, by increasing urine volume
   2. BChlorthalidone, by increasing distal calcium reabsorption
   3. CAllopurinol, by lowering urinary calcium
   4. DAcetazolamide, by alkalinising the urine

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   Answer: B · Chlorthalidone, by increasing distal calcium reabsorption

   Idiopathic hypercalciuria is the commonest metabolic cause of calcium stones. Thiazide-type diuretics (chlorthalidone, indapamide, hydrochlorothiazide) increase calcium reabsorption in the distal tubule and, through mild volume contraction, in the proximal tubule, cutting urinary calcium and stone recurrence. Loop diuretics do the opposite and increase calcium excretion.

   • A: Loop diuretics increase urinary calcium and can promote stones.
   • C: Allopurinol helps hyperuricosuric calcium stones but does not lower urinary calcium.
   • D: Acetazolamide alkalinises urine and favours calcium phosphate stones.

   Remember this

   Thiazides lower urinary calcium and prevent recurrent calcium stones in idiopathic hypercalciuria.

5. Question 5 · Medium

   Adverse effects of epoetin therapy in chronic kidney disease include: 1. Rise in blood pressure 2. Pure red cell aplasia from anti-erythropoietin antibodies 3. Hypokalaemia 4. Thrombosis of the dialysis access. Which are correct?

   1. A1, 2 and 3
   2. B1, 2 and 4
   3. C2, 3 and 4
   4. D1 and 3

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   Answer: B · 1, 2 and 4

   Epoetin raises blood viscosity and peripheral resistance, so hypertension (sometimes with seizures) and thrombosis of fistulae and grafts are common; higher Hb targets also raise stroke risk. Rarely, neutralising anti-erythropoietin antibodies cause pure red cell aplasia with sudden severe anaemia and very low reticulocytes. Hypokalaemia is not a typical effect.

   • A: Hypokalaemia is not an epoetin effect, and access thrombosis is left out.
   • C: Hypokalaemia is wrong, and hypertension is left out.
   • D: Hypokalaemia is wrong, and aplasia and thrombosis are left out.

   Remember this

   Epoetin adverse effects: hypertension, access thrombosis, stroke at high Hb targets and rare antibody-mediated pure red cell aplasia.

6. Question 6 · Medium

   At 32 weeks, a second gravida at a CHC has haemoglobin 8.1 g/dL with microcytic indices. She stopped her oral iron tablets three weeks ago because of vomiting and constipation, and two changes of iron salt did not help. She has no heart failure or bleeding. Under Anaemia Mukt Bharat, what is the best treatment?

   1. APacked red cell transfusion
   2. BIM iron sorbitol injections
   3. CDouble the oral iron dose
   4. DIV ferric carboxymaltose

   Answer and explanation in LearnFree account

7. Question 7 · Hard

   Day 3 of admission for acute decompensated heart failure (EF 25%): a man still has gross oedema and basal crackles despite IV furosemide 80 mg twice daily, since raised to a continuous infusion of 20 mg/hour. Urine output is 900 mL/day, urine sodium 35 mmol/L, serum sodium 136 mmol/L, potassium 4.1 mmol/L and creatinine 1.4 mg/dL. His weight has fallen by only 0.5 kg in 48 hours. Salt and fluid intake are restricted and he takes no NSAID. BP is 118/76 mmHg. What is the best next step to achieve diuresis?

   1. ASwitch to oral torsemide at the same dose
   2. BAdd IV mannitol infusion
   3. CAdd spironolactone 25 mg for diuresis
   4. DAdd metolazone for sequential nephron blockade

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8. Question 8 · Hard

   For IV iron sucrose, the gynaecologist calculates the total iron deficit with the Ganzoni formula (weight in kg x [target Hb - actual Hb in g/dL] x 2.4 + iron stores). The patient weighs 60 kg, has haemoglobin 8 g/dL from menorrhagia and cannot tolerate oral iron; the target Hb is 13 g/dL and stores are taken as 500 mg. Her ferritin is 5 ng/mL and transferrin saturation 6%, she has no history of drug allergy or asthma, and her menorrhagia is now controlled with tranexamic acid. What total dose of elemental iron is needed?

   1. A1,720 mg
   2. B1,000 mg
   3. C720 mg
   4. D1,220 mg

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9. Question 9 · Medium

   A man on lithium for 10 years for bipolar disorder passes 5-6 litres of dilute urine a day. Serum sodium is 146 mmol/L, urine osmolality 160 mOsm/kg, and there is no rise in urine osmolality after desmopressin. His psychiatrist prefers to continue lithium, which has kept him well. Which drug is preferred to reduce the polyuria?

   1. AFurosemide
   2. BSpironolactone
   3. CDesmopressin
   4. DAmiloride

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10. Question 10 · Hard

    A woman on haemodialysis for diabetic kidney disease, with a past transient ischaemic attack, receives darbepoetin weekly. Her haemoglobin has risen from 9.6 to 12.8 g/dL over two months; iron stores are adequate and BP is 156/94 mmHg. Her daughter asks whether a normal Hb of 13-14 g/dL could be the goal. What is the best plan?

    1. ASwitch to epoetin to reach Hb 13 g/dL
    2. BStop the ESA permanently
    3. CContinue to aim for Hb 13-14 g/dL
    4. DReduce the dose; keep Hb no higher than 11.5 g/dL

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11. Question 11 · Medium

    A tribal youth from Wayanad with sickle cell anaemia (HbSS) has had four painful crises needing admission and one episode of acute chest syndrome in the past year. His Hb is 7.4 g/dL and HbF 6%, and he takes folic acid and penicillin regularly. Which drug reduces such events, and by what mechanism?

    1. AHydroxyurea, by raising fetal haemoglobin
    2. BFolic acid, by improving red cell survival
    3. CPenicillin V, by preventing pneumococcal infection
    4. DDeferasirox, by removing excess iron

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12. Question 12 · Medium

    By mistake, a woman with rheumatoid arthritis has taken methotrexate 15 mg daily instead of weekly for six days. She arrives with mouth ulcers, a total leucocyte count of 1,400/mm3 and platelets 40,000/mm3. Serum creatinine is 1.8 mg/dL, and she has also been taking ibuprofen for joint pain. Which drug should be given urgently, and why?

    1. AFilgrastim alone, as it restores neutrophils
    2. BVitamin B12, as it regenerates tetrahydrofolate
    3. CFolic acid, as it replaces depleted folate stores
    4. DFolinic acid, which bypasses the DHFR block

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13. Question 13 · Easy

    Serum iron is 650 µg/dL (normal 50-150) four hours after a preschool child ate about twenty of his pregnant aunt's red IFA tablets at home. He has bloody vomitus, diarrhoea and cool peripheries, is drowsy, and has a serum lactate of 5 mmol/L and bicarbonate of 14 mmol/L. Which chelating agent should be started?

    1. AIV desferrioxamine
    2. BOral deferasirox
    3. CIM dimercaprol (BAL)
    4. DOral penicillamine

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14. Question 14 · Easy

    Mannitol given to a patient with a head injury and raised intracranial pressure acts mainly by:

    1. AInhibiting NKCC2 in the loop of Henle
    2. BConstricting cerebral arterioles directly
    3. CBlocking carbonic anhydrase in the choroid plexus
    4. DDrawing water out of cells osmotically

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15. Question 15 · Medium

    Six weeks after two infusions of IV ferric carboxymaltose for iron deficiency from menorrhagia, a woman reports bone pain and severe tiredness, although her haemoglobin has risen to 12.2 g/dL. Serum phosphate is 1.2 mg/dL (normal 2.5-4.5) with raised urinary phosphate loss. Her serum calcium and PTH are normal and 25-hydroxyvitamin D is 28 ng/mL. What mechanism explains this?

    1. AFGF23 rise causing phosphate wasting
    2. BIron-induced parathyroid hormone excess
    3. CPhosphate binding by iron in the gut
    4. DVitamin D deficiency from iron overload

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16. Question 16 · Medium

    Serum sodium is 118 mmol/L (normal 135-145) and potassium 3.0 mmol/L in a frail widow from Kottayam brought by her son with two days of confusion and unsteady gait. Three weeks ago her doctor added a new tablet for hypertension; she drinks plenty of water. She is euvolaemic, and urine sodium is 52 mmol/L. Which drug is the most likely cause?

    1. AChlorthalidone
    2. BSpironolactone
    3. CAmlodipine
    4. DFurosemide

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17. Question 17 · Medium

    A woman with pernicious anaemia and haemoglobin 4.8 g/dL is started on IM hydroxocobalamin in the medical ward. Her reticulocyte count is 0.5% and she has mild jaundice from ineffective erythropoiesis. On the third day she becomes weak, and an ECG shows prominent U waves. Which change most likely explains this?

    1. AHyperkalaemia from haemolysis of megaloblasts
    2. BHypocalcaemia from rapid bone formation
    3. CHypokalaemia as new cells take up potassium
    4. DHypomagnesaemia from vitamin B12 injection

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18. Question 18 · Medium

    Haemoglobin is still 8.6 g/dL (from 8.8) after 8 weeks of ferrous sulphate in a young clerk who says she takes it daily without side effects. Serum ferritin is 6 ng/mL, she has no menorrhagia, stool occult blood is negative, and she has occasional bloating and loose stools. Which test should come next?

    1. AIgA anti-tissue transglutaminase
    2. BSerum vitamin B12 level
    3. CBone marrow aspiration
    4. DHaemoglobin electrophoresis

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19. Question 19 · Medium

    A patient with non-dialysis CKD stage 4 and anaemia (haemoglobin 9.0 g/dL, iron stores replete) is reluctant to take injections. The nephrologist offers an oral drug, roxadustat. How does it raise haemoglobin?

    1. ABlocks hepcidin with a monoclonal antibody
    2. BDirectly activates the erythropoietin receptor
    3. CInhibits HIF prolyl hydroxylase, raising EPO
    4. DStimulates thrombopoietin receptors on progenitors

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20. Question 20 · Medium

    Long-term hydrochlorothiazide therapy may cause: 1. Hyperuricaemia 2. Hypercalcaemia 3. Hyperkalaemia 4. Hyperglycaemia. Select the correct combination.

    1. A2 and 3
    2. B1, 3 and 4
    3. C1 and 4
    4. D1, 2 and 4

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21. Question 21 · Medium

    Small-cell lung cancer has caused SIADH in a smoker: serum sodium 124 mmol/L, serum osmolality 258 mOsm/kg, urine osmolality 520 mOsm/kg, euvolaemic and without symptoms. Fluid restriction to 800 mL/day for a week has not helped. What is the next drug option, started in hospital with close sodium checks?

    1. AFludrocortisone
    2. BTolvaptan
    3. CDesmopressin
    4. DHypertonic saline infusion

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22. Question 22 · Hard

    A man with heart failure on digoxin 0.25 mg daily has had his furosemide dose doubled for worsening oedema. Ten days later he has nausea, palpitations and blurred yellowish vision. ECG: frequent ventricular bigeminy; serum potassium 2.8 mmol/L, magnesium 1.3 mg/dL, creatinine 1.1 mg/dL, digoxin level 1.6 ng/mL. Pulse 88/min, BP 118/72 mmHg. He is alert and has no chest pain, and the ward has potassium chloride and magnesium sulphate ready for infusion; the house officer asks the cardiology registrar what to do first. What is the most appropriate first step?

    1. AGive IV calcium gluconate
    2. BSynchronised DC cardioversion
    3. CGive digoxin-specific Fab fragments
    4. DStop digoxin; give IV potassium and magnesium

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23. Question 23 · Medium

    A potassium of 6.3 mmol/L (normal 3.5-5.0) is reported for a man with HFrEF and diabetic kidney disease (eGFR 32) two weeks after spironolactone 25 mg was added to ramipril 10 mg and furosemide. ECG shows peaked T waves without QRS widening. After emergency treatment of the potassium, what change to his drugs is most appropriate?

    1. AContinue all drugs and add bicarbonate
    2. BChange spironolactone to eplerenone
    3. CStop furosemide and add amiloride
    4. DStop spironolactone and recheck potassium

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24. Question 24 · Easy

    A pregnant woman at 20 weeks is given ferrous sulphate tablets at her antenatal visit in a PHC. She asks how to take them. Which advice best increases the iron she absorbs?

    1. ATake it with tea after meals
    2. BTake it with an antacid tablet
    3. CTake it with a glass of lemon juice
    4. DTake it with milk at bedtime

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25. Question 25 · Medium

    Which loop diuretic can be used in a patient with a documented severe allergy to sulfonamide drugs?

    1. ATorsemide
    2. BEthacrynic acid
    3. CBumetanide
    4. DFurosemide

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