MCQ Quiz: Personalized Medicine for Brain & Behavior Disorders

The era of “one-size-fits-all” pharmacotherapy is evolving, especially in the complex treatment of brain and behavior disorders. Personalized medicine, largely driven by the field of pharmacogenomics (PGx), allows clinicians to tailor drug selection and dosing based on an individual’s unique genetic makeup. This approach aims to maximize efficacy while minimizing the risk of adverse drug reactions, a crucial consideration for medications used in psychiatry and neurology. For PharmD students, understanding how to interpret and apply pharmacogenomic data is a key “transcending concept” integrated throughout the curriculum, from foundational courses like Principles of Drug Therapy Individualization to advanced Patient Care modules. This quiz will test your knowledge on the application of personalized medicine for conditions like depression, epilepsy, and ADHD.

1. Pharmacogenomics (PGx) is the study of how:

• a) Diet affects drug metabolism.
• b) Age affects drug response.
• c) Genes affect a person’s response to drugs.
• d) Lifestyle affects drug absorption. Answer: c) Genes affect a person’s response to drugs.

2. The Clinical Pharmacogenetics Implementation Consortium (CPIC) provides peer-reviewed, evidence-based guidelines for what purpose?

• a) To set the price of genetic tests.
• b) To help clinicians understand how to use genetic test results to optimize drug therapy.
• c) To mandate which genetic tests must be performed.
• d) To market new drugs to patients. Answer: b) To help clinicians understand how to use genetic test results to optimize drug therapy.

**3. A patient with a genotype of CYP2D6

4/4 would be classified with which phenotype?

• a) Ultrarapid Metabolizer (UM)
• b) Normal Metabolizer (NM)
• c) Intermediate Metabolizer (IM)
• d) Poor Metabolizer (PM) Answer: d) Poor Metabolizer (PM)

4. A patient who is a CYP2D6 Poor Metabolizer is prescribed paroxetine, an SSRI primarily metabolized by CYP2D6. Without a dose adjustment, this patient is at an increased risk for:

• a) Therapeutic failure due to rapid drug clearance.
• b) Increased side effects due to higher-than-expected drug concentrations.
• c) A severe drug-food interaction.
• d) No change in drug response compared to a Normal Metabolizer. Answer: b) Increased side effects due to higher-than-expected drug concentrations.

5. According to CPIC guidelines, a patient who is a CYP2C19 Ultrarapid Metabolizer is prescribed citalopram. What is the recommended therapeutic action?

• a) Use a standard starting dose of citalopram.
• b) Increase the starting dose of citalopram by 50%.
• c) Consider an alternative drug not primarily metabolized by CYP2C19.
• d) Avoid all SSRI medications. Answer: c) Consider an alternative drug not primarily metabolized by CYP2C19.

6. Before starting carbamazepine in a patient of Han Chinese descent, screening for which allele is recommended to prevent a potentially fatal skin reaction?

• a) HLA-B*57:01
• b) HLA-B*15:02
• c) CYP2C9*3
• d) DPYD2A **Answer: b) HLA-B15:02**

7. The presence of the HLA-B*15:02 allele is strongly associated with an increased risk of what adverse drug reaction when taking carbamazepine?

• a) Liver failure
• b) Agranulocytosis
• c) Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
• d) Myopathy Answer: c) Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

8. Phenytoin exhibits nonlinear pharmacokinetics and is metabolized by CYP2C9. A patient with a decreased-function CYP2C9 variant may require:

• a) A higher-than-normal dose of phenytoin.
• b) A lower starting dose of phenytoin to avoid toxicity.
• c) A switch to carbamazepine without genetic testing.
• d) Twice-daily dosing instead of once-daily dosing. Answer: b) A lower starting dose of phenytoin to avoid toxicity.

9. The non-stimulant medication atomoxetine, used for ADHD, is a substrate of which major polymorphic enzyme?

• a) CYP1A2
• b) CYP3A4
• c) CYP2D6
• d) CYP2C9 Answer: c) CYP2D6

10. Codeine provides analgesia primarily through its conversion to morphine. This conversion is catalyzed by:

• a) Aldehyde dehydrogenase
• b) UGT1A1
• c) CYP2D6
• d) CYP2C19 Answer: c) CYP2D6

11. A patient who is a CYP2D6 Ultrarapid Metabolizer takes a standard dose of codeine. What is the most likely outcome?

• a) Lack of pain relief due to insufficient conversion to morphine.
• b) Increased risk of morphine toxicity due to rapid and excessive conversion.
• c) The patient will experience a severe allergic reaction.
• d) There will be no difference in effect compared to a Normal Metabolizer. Answer: b) Increased risk of morphine toxicity due to rapid and excessive conversion.

12. Amitriptyline, a tricyclic antidepressant, is metabolized to its active metabolite nortriptyline by CYP2C19. A CYP2C19 Poor Metabolizer would be expected to have:

• a) Higher-than-expected nortriptyline levels.
• b) Lower-than-expected amitriptyline levels.
• c) Decreased conversion to nortriptyline, leading to higher amitriptyline levels.
• d) Increased conversion to nortriptyline. Answer: c) Decreased conversion to nortriptyline, leading to higher amitriptyline levels.

13. A “genotype” refers to the specific set of alleles a person carries for a particular gene, while a “phenotype” refers to the:

• a) Patient’s family history.
• b) Cost of the genetic test.
• c) Observable clinical trait, such as the rate of drug metabolism.
• d) Patient’s zip code. Answer: c) Observable clinical trait, such as the rate of drug metabolism.

14. What does the star (

) allele nomenclature (e.g., CYP2D61) represent in pharmacogenomics?

• a) A specific haplotype or variant of a gene.
• b) The predicted activity of the enzyme.
• c) The cost of the medication.
• d) The brand name of the genetic test. Answer: a) A specific haplotype or variant of a gene.

15. The primary goal of personalized medicine in treating brain and behavior disorders is to:

• a) Use the newest drug available for every patient.
• b) Optimize efficacy and minimize toxicity based on individual patient characteristics.
• c) Avoid all medications and use therapy only.
• d) Find a single drug that works for everyone. Answer: b) Optimize efficacy and minimize toxicity based on individual patient characteristics.

16. Which of the following is a key database for finding information on drug-gene interactions and pharmacogenomic guidelines?

• a) The FDA Orange Book
• b) The CDC Pink Book
• c) The Pharmacogenomics Knowledgebase (PharmGKB)
• d) The USP-NF Answer: c) The Pharmacogenomics Knowledgebase (PharmGKB)

17. A “drug-drug-gene interaction,” as discussed in the Principles of Drug Therapy Individualization course, occurs when:

• a) A patient takes two drugs that do not interact.
• b) A patient’s phenotype is predicted by their genotype alone.
• c) A patient’s genetic makeup alters their response to a drug-drug interaction.
• d) A patient has a gene that prevents all drug interactions. Answer: c) A patient’s genetic makeup alters their response to a drug-drug interaction.

18. A patient is a CYP2C19 Intermediate Metabolizer and is also taking omeprazole (a CYP2C19 inhibitor). When prescribed citalopram (a CYP2C19 substrate), the patient’s resulting phenotype would likely be similar to a:

• a) CYP2C19 Ultrarapid Metabolizer
• b) CYP2C19 Normal Metabolizer
• c) CYP2C19 Poor Metabolizer
• d) The omeprazole will have no effect. Answer: c) CYP2C19 Poor Metabolizer

19. A key limitation of current pharmacogenomic testing for antidepressants is that:

• a) It can predict with 100% certainty which drug will work best.
• b) The tests are only available for tricyclic antidepressants.
• c) Most tests only predict potential pharmacokinetic changes, not pharmacodynamic effects at the receptor.
• d) The results are never accurate. Answer: c) Most tests only predict potential pharmacokinetic changes, not pharmacodynamic effects at the receptor.

20. The role of the pharmacist in personalized medicine for brain and behavior disorders includes:

• a) Ordering and performing genetic tests without a physician’s order.
• b) Recommending and interpreting PGx tests and helping to apply guidelines to patient care.
• c) Ignoring genetic information as it is too complicated.
• d) Changing a patient’s diagnosis based on their genotype. Answer: b) Recommending and interpreting PGx tests and helping to apply guidelines to patient care.

21. Personalized medicine extends beyond genetics. Which of the following patient factors is also critical for personalizing treatment for brain and behavior disorders?

• a) Patient preferences and values
• b) Comorbid medical conditions
• c) Concurrent medications
• d) All of the above Answer: d) All of the above

22. Genetic variation in which drug transporter can affect statin-associated musculoskeletal symptoms?

• a) P-glycoprotein (ABCB1)
• b) OATP1B1 (encoded by SLCO1B1)
• c) BCRP (ABCG2)
• d) SERT (SLC6A4) Answer: b) OATP1B1 (encoded by SLCO1B1)

23. The “phenoconversion” concept refers to a situation where:

• a) A patient’s genotype changes over time.
• b) A genotypic Normal Metabolizer acts like a Poor Metabolizer due to an inhibiting drug.
• c) A genetic test result is converted into a lab value.
• d) A patient’s phenotype is used to predict their genotype. Answer: b) A genotypic Normal Metabolizer acts like a Poor Metabolizer due to an inhibiting drug.

24. The FDA label for which medication contains information regarding the HLA-B*15:02 allele and risk of SJS?

• a) Valproic acid
• b) Lamotrigine
• c) Carbamazepine
• d) Levetiracetam Answer: c) Carbamazepine

25. A patient who is a CYP2D6 Poor Metabolizer should be cautious when using which opioid for pain management due to lack of efficacy?

• a) Fentanyl
• b) Morphine
• c) Hydromorphone
• d) Codeine Answer: d) Codeine

26. A “diplotype” in a pharmacogenomic test result refers to:

• a) The patient’s predicted drug response.
• b) The pair of alleles for a specific gene (one inherited from each parent).
• c) The type of technology used for the test.
• d) The name of the testing laboratory. Answer: b) The pair of alleles for a specific gene (one inherited from each parent).

27. For which antidepressant class is pharmacogenomic testing of CYP2D6 and CYP2C19 most well-established?

• a) Monoamine oxidase inhibitors (MAOIs)
• b) Tricyclic antidepressants (TCAs) and Selective Serotonin Reuptake Inhibitors (SSRIs)
• c) Mirtazapine and bupropion
• d) Trazodone and nefazodone Answer: b) Tricyclic antidepressants (TCAs) and Selective Serotonin Reuptake Inhibitors (SSRIs)

28. An ethical consideration in pharmacogenomic testing is:

• a) The potential for genetic discrimination.
• b) Ensuring patient understanding and providing adequate counseling on the results.
• c) The privacy and security of the genetic data.
• d) All of the above. Answer: d) All of the above.

29. The term “normal metabolizer” is the same as:

• a) Extensive Metabolizer (EM)
• b) Poor Metabolizer (PM)
• c) Ultrarapid Metabolizer (UM)
• d) Intermediate Metabolizer (IM) Answer: a) Extensive Metabolizer (EM)

30. Which factor is NOT considered in the activity score used to assign a CYP2D6 metabolizer phenotype?

• a) The function of the first allele (*1)
• b) The function of the second allele (*2)
• c) The patient’s age
• d) Whether the gene has copy number variations (duplications) Answer: c) The patient’s age

31. The primary purpose of using pharmacogenomics in treating epilepsy is to:

• a) Select the most effective antiepileptic drug for every patient.
• b) Guarantee the patient will be seizure-free.
• c) Predict and avoid severe, life-threatening cutaneous adverse reactions.
• d) Increase the dose of all antiepileptic drugs. Answer: c) Predict and avoid severe, life-threatening cutaneous adverse reactions.

32. What is the pharmacist’s best action if a PGx test recommends a lower dose of a drug, but the prescriber is unfamiliar with the guideline?

• a) Change the dose without informing the prescriber.
• b) Dispense the original dose and say nothing.
• c) Contact the prescriber, provide the CPIC guideline or other evidence, and discuss a potential dose adjustment.
• d) Tell the patient the test results were wrong. Answer: c) Contact the prescriber, provide the CPIC guideline or other evidence, and discuss a potential dose adjustment.

33. The concept of using “OMICs” technologies in personalized medicine refers to analyzing:

• a) Only a patient’s genomics.
• b) A broad range of biological data, including genomics, proteomics, and metabolomics.
• c) Only the economic factors of treatment.
• d) Only the patient’s reported outcomes. Answer: b) A broad range of biological data, including genomics, proteomics, and metabolomics.

34. A patient’s insurance company refuses to pay for a PGx test. This represents what kind of barrier to personalized medicine?

• a) An educational barrier
• b) A logistical barrier
• c) A financial/reimbursement barrier
• d) A clinical utility barrier Answer: c) A financial/reimbursement barrier

35. A “preemptive” pharmacogenomic testing strategy involves:

• a) Testing a patient only after they have had an adverse drug reaction.
• b) Testing a panel of important PGx genes before a drug is needed, so the information is ready in the EHR.
• c) Testing only the patient’s family members.
• d) Testing only one gene at a time. Answer: b) Testing a panel of important PGx genes before a drug is needed, so the information is ready in the EHR.

36. Aripiprazole, an antipsychotic, is metabolized by CYP2D6 and CYP3A4. A patient who is a known CYP2D6 Poor Metabolizer would likely need:

• a) A higher dose of aripiprazole.
• b) A reduced dose of aripiprazole.
• c) No dose change, as CYP3A4 provides an alternative pathway.
• d) A switch to clozapine immediately. Answer: b) A reduced dose of aripiprazole.

37. The objective “Demonstrate how to use available pharmacogenomics databases” is a key learning objective from which foundational course?

• a) Sterile Compounding
• b) Principles of Law & Ethics
• c) Principles of Drug Therapy Individualization
• d) Population Health Answer: c) Principles of Drug Therapy Individualization

38. The goal of personalizing medicine for depression is to:

• a) Find a cure for depression in 24 hours.
• b) Reduce the trial-and-error process of finding an effective and well-tolerated antidepressant.
• c) Eliminate the need for psychotherapy.
• d) Ensure every patient receives the same SSRI. Answer: b) Reduce the trial-and-error process of finding an effective and well-tolerated antidepressant.

39. Genetic variation in the serotonin transporter gene (SLC6A4) has been studied for its effect on SSRI response. This is an example of pharmacogenomics affecting what process?

• a) Drug metabolism (pharmacokinetics)
• b) Drug action at its target (pharmacodynamics)
• c) Drug absorption
• d) Drug excretion Answer: b) Drug action at its target (pharmacodynamics)

40. Why is PGx testing for HLA-B*15:02 more critical in patients of Asian ancestry than in patients of European ancestry?

• a) The allele is much more common in Asian populations.
• b) The allele only causes SJS in Asian populations.
• c) Carbamazepine is not effective in European populations.
• d) The genetic test does not work in patients of European ancestry. Answer: a) The allele is much more common in Asian populations.

**41. A patient’s PGx test result is CYP2D6 1/1. This genotype indicates what predicted phenotype?

• a) Poor Metabolizer
• b) Intermediate Metabolizer
• c) Normal Metabolizer
• d) Ultrarapid Metabolizer Answer: c) Normal Metabolizer

42. Which drug class used for behavior disorders has the most robust, guideline-supported pharmacogenomic evidence for clinical use?

• a) Benzodiazepines
• b) Mood stabilizers like lithium
• c) Antidepressants
• d) Stimulants Answer: c) Antidepressants

43. The clinical utility of a pharmacogenomic test depends on:

• a) The cost of the test alone.
• b) Whether the test results will actually change clinical management and improve outcomes.
• c) How quickly the test results are returned.
• d) The brand name of the test. Answer: b) Whether the test results will actually change clinical management and improve outcomes.

44. A key educational point for a patient undergoing PGx testing is that:

• a) Their genetic information will change over their lifetime.
• b) The results may have implications for their family members.
• c) The test will tell them everything about their future health.
• d) The results are 100% predictive of drug response. Answer: b) The results may have implications for their family members.

45. Personalized medicine aims to stratify a patient population to:

• a) Identify which patients will benefit most from a therapy, and which are at highest risk of harm.
• b) Give every patient the same drug.
• c) Exclude certain populations from receiving any treatment.
• d) Increase the cost of healthcare for everyone. Answer: a) Identify which patients will benefit most from a therapy, and which are at highest risk of harm.

46. A “drug-gene pair” refers to:

• a) A specific drug and the specific gene known to influence its response.
• b) Any two drugs that interact.
• c) Any two genes that are located near each other.
• d) A patient and their pharmacist. Answer: a) A specific drug and the specific gene known to influence its response.

47. As part of a patient’s care plan, a pharmacist uses a CPIC guideline to recommend a dose change. This is an example of which Entrustable Professional Activity (EPA)?

• a) Fulfilling a medication order.
• b) Using evidence-based information to advance patient care.
• c) Identifying populations at risk.
• d) Performing administrative operations of a pharmacy. Answer: b) Using evidence-based information to advance patient care.

48. The future of personalized medicine for brain and behavior disorders will likely involve:

• a) Less reliance on genetics.
• b) Combining PGx data with other biomarkers, patient-reported outcomes, and clinical data.
• c) A return to a one-size-fits-all approach.
• d) Pharmacists having a smaller role in medication selection. Answer: b) Combining PGx data with other biomarkers, patient-reported outcomes, and clinical data.

49. For a patient who is a CYP2D6 Poor Metabolizer, which pain medication would be a better choice than codeine or tramadol?

• a) Hydrocodone
• b) Morphine or hydromorphone
• c) A higher dose of codeine
• d) A lower dose of tramadol Answer: b) Morphine or hydromorphone

50. The ultimate goal of teaching personalized medicine in the PharmD curriculum is to equip future pharmacists to:

• a) Sell more genetic tests.
• b) Make medicine more complicated and expensive.
• c) Move beyond a trial-and-error approach to drug therapy.
• d) Replace physicians in the diagnostic process. Answer: c) Move beyond a trial-and-error approach to drug therapy.