Nitrates. Let's talk pharmacology.
Nitrates are a super, super high yield drug because they save
lives. But before we get into nitrates,
I want to give a shout out to Sangas.
Romeo Johnson, one of the best vocal coaches, hooked me up with
some clothing. A little bit of personalization
right there with Doctor Z right there.
So sing his clothing. Romeo Johnson little background
on who he is. Romeo Johnson is the best vocal
coach in the world. He was Michael Jackson's vocal
coach, Janet Jackson's vocal coach, lead backup singer for
both of them, Beyoncé's vocal coach, Trey Songz, Usher, you
name somebody, he's worked with them.
So shout out to Romeo Johnson and sing his clothing for
hooking me up always with the flyest gear.
So thank you so much again Romeo Johnson for that.
Now let's get into nitrates. So there are two types of
nitrates. There's short acting and there's
long acting. So short acting nitrates, we're
going to be dealing with them sublingually or with sprays.
But for the sake of the boards, let's focus on sublingual
because that's the one the boards are going to test on.
You're going to put it under the tongue and you're going to allow
it to dissolve. It's fast acting, whereas long
acting is going to be an oral tablet.
You're going to take it with water and takes a little bit
longer, 30 to 60 minutes for it to work, whereas sublingual
nitrates are going to work within 5 minutes.
So with the long acting ones, we're not going to chew them,
we're not going to crush them. So educate your patients on that
with sublingual we and with long acting oral or PO, we're going
to worry about side effects. So things that you would expect,
things like headache, flushing, these are expected.
So if you feel light headed or dizzy, lay down orthostatic
hypotension. So avoid changing positions
suddenly. Gradually move from laying down
to sitting up to standing up. So that way you don't lose that
cerebral profusion because if you do, you'll have a syncopal
episode. You fall down and hit your head
and now you're dead. Nausea and vomiting, diarrhea.
I always tell people in pharmacology that if you see a
medication, you're taking it for the first time and or you're
looking at a side effect, always look for GI distress because
it's more common than not with introducing a new drug into your
system that you develop some sort of GI distress, especially
when it's an oral drug. So look out for that.
Nausea, vomiting, diarrhea. So we're going to educate them
again on positional changes. We want to educate them on
contraindications. These are potent systemic
vasodilators. So what drug are we concerned
about? We're concerned about our
erectile dysfunction drugs are AFIL drugs, Afil, so tadalafil,
verdanafil, sildanafil, our Viagra, Cialis, Levitra.
So we want to make sure that we educate them because a great
question on the boards is going to be a further teaching,
further intervention. So this is exactly how I would
ask it. So you should write this
question down. 68 year old male patient was recently prescribed
nitrates for angina, sublingual nitrates for angina or PO
nitrates for angina. And which of the following
statements by this patient needs for the teaching, for the
education, for the understanding, for the
clarification. I'm really excited to get away
for the weekend with my partner. I've got this magic little blue
pill or sildenafil Viagra and I can't wait to use it.
And you're going to be like, wait, no, no, no, no.
That needs for the teaching for the intervention because you
cannot take an erectile dysfunction drug, which is a a
vasodilator as well too with a potent systemic vasodilator
because we're going to cause contraindication, we're going to
cause side effects of really bad orthostatic hypotension or
hypotension in general. So again, for the teaching for
the intervention, a great board question.
The way that we take sublingual nitrates, we must educate our
patient on. So we're going to take one pill
sublingually upon chest pain every 5 minutes for three doses.
If that chest pain does not resolve in that first dose, in
that first 5 minutes, you are automatically calling 911.
If it doesn't resolve in three doses, clearly it didn't work.
The first dose, you're calling 911, but you're continuously
taking it because you want to buy yourself time while that
ambulance is coming. So you're taking that up to
three doses. The pills come in a little dark
container, a little dark bottle in order to avoid sunlight.
So we're putting in a little tinted bottle and it's only good
for six months. So we want to keep it in a cool,
dry place. We want to keep it in the
bottle. So again, another further
teaching for their intervention type of a question because
they're education questions, right?
So how about I'm going to be going on a long drive.
I'll put a couple of them in a Ziploc, throw my glove
compartment just in case. No, you're going to keep them in
their bottle. You're going to keep them in a
cool, dry place and you're not going to take them out of the
bottle and put them in a Ziploc and throw them in a glove
compartment. Heat and sunlight are going to
decrease the potency of something that's supposed to
save your life. So very important to do that.
You can actually take nitrates prophylactically.
So if you do have angina, stable angina, because remember, stable
angina is upon exertion. So let's just say, you know,
you're going to do something stressful, exercise, maybe
you're going to do something that's going to trigger that
angina, be in cold temperatures, eat a large meal, exertion,
right? Stable angina.
You can actually take it prophylactically 5 minutes
before whatever you do. So that way you do get that
oxygen going to that portion of the heart because the last thing
we want to do is decrease that portion of the heart because
you'll get that chest pain, chest pain, chest pain, which is
in fact angina. And because it's upon exertion,
it is actually stable angina. With the oral or long acting.
There's another way that we can actually give the long acting 1
is we can give them a patch. So with the patch, it's
typically 12 to 14 hours for one patch.
Use one patch at a time, never multiple patches.
If it falls off or it loosens, you replace it, but you have to
account for the time that you wore it.
So for instance, let's just say this patch is good for 12 hours.
A little mad math here. So the patch is good for 12
hours, but it fell off after three hours.
I'm going to replace that patch, but how long am I going to put
the next patch on for? I'm going to put the next patch
on for 9 hours, for 9 hours. So again, totalling 12 hours. 3
hours that was already on. It fell off 12 -. 3 hours that I
already had it on equals 9 hours for the next patch.
We want to put it on a clean, dry place, but what we'll talk
about is just patch education in general.
So not just nitrate patches, but patch education in general for
the boards. Never cut a patch.
Never wear more than one patch. You want it on a clean, dry
site. Typically you want to put on a
hairless area, but you're never going to shave that area.
You never want to create micro cuts because now it's not going
transdermally, it's going right into the bloodstream.
So don't shave that area. You don't want an infected, wet
or scarred area because that's not typical skin.
So again, the patches are made to go through your skin that's
intact. That's intact when you're
discarding it, you fold the patch, wear gloves and rotate
sites. But with Nitro patches, you're
going to give yourself a break. You take a break from nitrates
for a little bit as prescribed by your HCP.
So again, there's something that's going to be there, but we
take nitrate breaks so we don't develop tolerance to it and that
we're not continuously using that nitrate.
So again, give yourself that break from nitrates education,
education, education. As far as lifestyle
modifications with the nitrates, of course, we're dealing with
angina. So teach your patient about
needs nutrition, exercise, ETOH, alcohol, avoid, don't smoke and
sleep. So eliminate those risk factors
that are actually going to make this engine worse and hopefully
we can try to get this patient off of it without getting them
into a stent, which is what we're going to have to do
eventually if that atherosclerotic plaque
continues. So we're going to monitor them.
We're going to look for side effects, we're going to educate
them. So very simple when it comes to
a long acting versus short acting, we're long acting, we're
talking PO or patches, short acting, we're talking about
sublingual or sprays. Again, for the boards, we like
sublingual. Look at the side effects.
Again, that headache, flushing, orthocytic hypertension, nausea,
vomiting, diarrhea, look for those, educate them on the
contraindications, which is again, those erectile
dysfunction drugs that end in AFIL, teach them about storage
and handling. So make sure that they're
keeping it in a cool dry place in that bottle.
And again, how we dose it out when we're taking it, when we
get that chest pain, when we get that stable angina, when we get
that, those signs and symptoms starting to approach, take it
sublingually and remember, if it doesn't resolve in that first 5
minutes, call 911, continue those doses for three more doses
as we wait for that prophylactically, we can take it
when we're going to do something that might trigger that angina.
And then again, patch education as I've talked about South super
high yield topic with nitrates and with pharmacology here.
So again, great, great, great matrix grid style questions on
education with nitrates, whether it be long acting or short
acting, you can do that. You can basically do the select
all that apply right there or select all that apply question
for the teaching for the interventions as I've taught
you. So again, nitrates, super, super
high yield.