1 00:00:00,560 --> 00:00:03,040 Nitrates. Let's talk pharmacology. 2 00:00:04,240 --> 00:00:08,480 Nitrates are a super, super high yield drug because they save 3 00:00:08,480 --> 00:00:11,200 lives. But before we get into nitrates, 4 00:00:11,240 --> 00:00:12,600 I want to give a shout out to Sangas. 5 00:00:12,880 --> 00:00:16,680 Romeo Johnson, one of the best vocal coaches, hooked me up with 6 00:00:16,680 --> 00:00:19,600 some clothing. A little bit of personalization 7 00:00:19,600 --> 00:00:20,720 right there with Doctor Z right there. 8 00:00:21,160 --> 00:00:24,080 So sing his clothing. Romeo Johnson little background 9 00:00:24,080 --> 00:00:26,320 on who he is. Romeo Johnson is the best vocal 10 00:00:26,320 --> 00:00:29,280 coach in the world. He was Michael Jackson's vocal 11 00:00:29,280 --> 00:00:32,119 coach, Janet Jackson's vocal coach, lead backup singer for 12 00:00:32,119 --> 00:00:37,480 both of them, Beyoncé's vocal coach, Trey Songz, Usher, you 13 00:00:37,480 --> 00:00:39,120 name somebody, he's worked with them. 14 00:00:39,240 --> 00:00:43,480 So shout out to Romeo Johnson and sing his clothing for 15 00:00:43,480 --> 00:00:46,160 hooking me up always with the flyest gear. 16 00:00:46,160 --> 00:00:48,800 So thank you so much again Romeo Johnson for that. 17 00:00:48,880 --> 00:00:52,480 Now let's get into nitrates. So there are two types of 18 00:00:52,480 --> 00:00:55,360 nitrates. There's short acting and there's 19 00:00:55,360 --> 00:01:00,120 long acting. So short acting nitrates, we're 20 00:01:00,120 --> 00:01:03,240 going to be dealing with them sublingually or with sprays. 21 00:01:03,240 --> 00:01:06,680 But for the sake of the boards, let's focus on sublingual 22 00:01:06,680 --> 00:01:08,160 because that's the one the boards are going to test on. 23 00:01:08,960 --> 00:01:11,160 You're going to put it under the tongue and you're going to allow 24 00:01:11,160 --> 00:01:16,520 it to dissolve. It's fast acting, whereas long 25 00:01:16,520 --> 00:01:19,680 acting is going to be an oral tablet. 26 00:01:20,040 --> 00:01:22,440 You're going to take it with water and takes a little bit 27 00:01:22,440 --> 00:01:25,720 longer, 30 to 60 minutes for it to work, whereas sublingual 28 00:01:25,720 --> 00:01:27,360 nitrates are going to work within 5 minutes. 29 00:01:28,320 --> 00:01:32,680 So with the long acting ones, we're not going to chew them, 30 00:01:32,680 --> 00:01:35,400 we're not going to crush them. So educate your patients on that 31 00:01:35,800 --> 00:01:44,200 with sublingual we and with long acting oral or PO, we're going 32 00:01:44,200 --> 00:01:48,760 to worry about side effects. So things that you would expect, 33 00:01:49,120 --> 00:01:53,520 things like headache, flushing, these are expected. 34 00:01:53,520 --> 00:01:57,200 So if you feel light headed or dizzy, lay down orthostatic 35 00:01:57,480 --> 00:02:00,080 hypotension. So avoid changing positions 36 00:02:00,320 --> 00:02:02,960 suddenly. Gradually move from laying down 37 00:02:03,160 --> 00:02:07,240 to sitting up to standing up. So that way you don't lose that 38 00:02:07,240 --> 00:02:11,760 cerebral profusion because if you do, you'll have a syncopal 39 00:02:11,760 --> 00:02:13,120 episode. You fall down and hit your head 40 00:02:13,120 --> 00:02:17,440 and now you're dead. Nausea and vomiting, diarrhea. 41 00:02:18,360 --> 00:02:22,440 I always tell people in pharmacology that if you see a 42 00:02:22,440 --> 00:02:24,480 medication, you're taking it for the first time and or you're 43 00:02:24,480 --> 00:02:28,440 looking at a side effect, always look for GI distress because 44 00:02:28,560 --> 00:02:31,560 it's more common than not with introducing a new drug into your 45 00:02:31,560 --> 00:02:34,680 system that you develop some sort of GI distress, especially 46 00:02:34,680 --> 00:02:37,160 when it's an oral drug. So look out for that. 47 00:02:37,160 --> 00:02:42,360 Nausea, vomiting, diarrhea. So we're going to educate them 48 00:02:42,360 --> 00:02:46,320 again on positional changes. We want to educate them on 49 00:02:46,320 --> 00:02:48,920 contraindications. These are potent systemic 50 00:02:49,200 --> 00:02:53,400 vasodilators. So what drug are we concerned 51 00:02:53,400 --> 00:02:54,560 about? We're concerned about our 52 00:02:54,560 --> 00:03:00,320 erectile dysfunction drugs are AFIL drugs, Afil, so tadalafil, 53 00:03:00,440 --> 00:03:05,080 verdanafil, sildanafil, our Viagra, Cialis, Levitra. 54 00:03:06,680 --> 00:03:10,920 So we want to make sure that we educate them because a great 55 00:03:10,920 --> 00:03:13,920 question on the boards is going to be a further teaching, 56 00:03:13,920 --> 00:03:16,800 further intervention. So this is exactly how I would 57 00:03:16,800 --> 00:03:17,800 ask it. So you should write this 58 00:03:17,800 --> 00:03:26,880 question down. 68 year old male patient was recently prescribed 59 00:03:27,440 --> 00:03:34,080 nitrates for angina, sublingual nitrates for angina or PO 60 00:03:34,080 --> 00:03:38,640 nitrates for angina. And which of the following 61 00:03:38,640 --> 00:03:41,520 statements by this patient needs for the teaching, for the 62 00:03:41,680 --> 00:03:43,040 education, for the understanding, for the 63 00:03:43,040 --> 00:03:48,680 clarification. I'm really excited to get away 64 00:03:48,840 --> 00:03:51,840 for the weekend with my partner. I've got this magic little blue 65 00:03:51,840 --> 00:03:56,280 pill or sildenafil Viagra and I can't wait to use it. 66 00:03:56,280 --> 00:03:58,120 And you're going to be like, wait, no, no, no, no. 67 00:03:58,120 --> 00:04:00,960 That needs for the teaching for the intervention because you 68 00:04:00,960 --> 00:04:04,600 cannot take an erectile dysfunction drug, which is a a 69 00:04:04,720 --> 00:04:08,160 vasodilator as well too with a potent systemic vasodilator 70 00:04:08,160 --> 00:04:10,960 because we're going to cause contraindication, we're going to 71 00:04:10,960 --> 00:04:14,640 cause side effects of really bad orthostatic hypotension or 72 00:04:14,640 --> 00:04:17,600 hypotension in general. So again, for the teaching for 73 00:04:17,600 --> 00:04:19,839 the intervention, a great board question. 74 00:04:20,760 --> 00:04:25,280 The way that we take sublingual nitrates, we must educate our 75 00:04:25,280 --> 00:04:30,320 patient on. So we're going to take one pill 76 00:04:30,440 --> 00:04:35,640 sublingually upon chest pain every 5 minutes for three doses. 77 00:04:36,840 --> 00:04:39,600 If that chest pain does not resolve in that first dose, in 78 00:04:39,600 --> 00:04:42,680 that first 5 minutes, you are automatically calling 911. 79 00:04:43,080 --> 00:04:46,240 If it doesn't resolve in three doses, clearly it didn't work. 80 00:04:46,240 --> 00:04:48,320 The first dose, you're calling 911, but you're continuously 81 00:04:48,320 --> 00:04:51,280 taking it because you want to buy yourself time while that 82 00:04:51,280 --> 00:04:53,720 ambulance is coming. So you're taking that up to 83 00:04:53,720 --> 00:04:57,520 three doses. The pills come in a little dark 84 00:04:57,960 --> 00:05:02,400 container, a little dark bottle in order to avoid sunlight. 85 00:05:02,480 --> 00:05:05,640 So we're putting in a little tinted bottle and it's only good 86 00:05:05,640 --> 00:05:08,480 for six months. So we want to keep it in a cool, 87 00:05:08,480 --> 00:05:10,040 dry place. We want to keep it in the 88 00:05:10,040 --> 00:05:12,080 bottle. So again, another further 89 00:05:12,080 --> 00:05:14,640 teaching for their intervention type of a question because 90 00:05:14,640 --> 00:05:16,200 they're education questions, right? 91 00:05:16,720 --> 00:05:22,480 So how about I'm going to be going on a long drive. 92 00:05:22,480 --> 00:05:24,160 I'll put a couple of them in a Ziploc, throw my glove 93 00:05:24,160 --> 00:05:27,200 compartment just in case. No, you're going to keep them in 94 00:05:27,200 --> 00:05:28,280 their bottle. You're going to keep them in a 95 00:05:28,280 --> 00:05:30,640 cool, dry place and you're not going to take them out of the 96 00:05:30,640 --> 00:05:32,280 bottle and put them in a Ziploc and throw them in a glove 97 00:05:32,280 --> 00:05:34,760 compartment. Heat and sunlight are going to 98 00:05:34,760 --> 00:05:37,040 decrease the potency of something that's supposed to 99 00:05:37,040 --> 00:05:39,520 save your life. So very important to do that. 100 00:05:40,800 --> 00:05:43,760 You can actually take nitrates prophylactically. 101 00:05:44,640 --> 00:05:48,640 So if you do have angina, stable angina, because remember, stable 102 00:05:48,640 --> 00:05:51,400 angina is upon exertion. So let's just say, you know, 103 00:05:51,400 --> 00:05:54,240 you're going to do something stressful, exercise, maybe 104 00:05:54,240 --> 00:05:55,840 you're going to do something that's going to trigger that 105 00:05:55,840 --> 00:06:00,480 angina, be in cold temperatures, eat a large meal, exertion, 106 00:06:00,480 --> 00:06:01,600 right? Stable angina. 107 00:06:02,080 --> 00:06:04,600 You can actually take it prophylactically 5 minutes 108 00:06:04,600 --> 00:06:07,440 before whatever you do. So that way you do get that 109 00:06:07,440 --> 00:06:10,840 oxygen going to that portion of the heart because the last thing 110 00:06:10,840 --> 00:06:12,840 we want to do is decrease that portion of the heart because 111 00:06:12,840 --> 00:06:15,280 you'll get that chest pain, chest pain, chest pain, which is 112 00:06:15,440 --> 00:06:18,760 in fact angina. And because it's upon exertion, 113 00:06:19,160 --> 00:06:26,680 it is actually stable angina. With the oral or long acting. 114 00:06:27,640 --> 00:06:30,200 There's another way that we can actually give the long acting 1 115 00:06:30,920 --> 00:06:38,600 is we can give them a patch. So with the patch, it's 116 00:06:38,600 --> 00:06:41,240 typically 12 to 14 hours for one patch. 117 00:06:41,520 --> 00:06:44,440 Use one patch at a time, never multiple patches. 118 00:06:44,960 --> 00:06:49,280 If it falls off or it loosens, you replace it, but you have to 119 00:06:49,280 --> 00:06:51,200 account for the time that you wore it. 120 00:06:51,200 --> 00:06:55,160 So for instance, let's just say this patch is good for 12 hours. 121 00:06:55,440 --> 00:06:58,800 A little mad math here. So the patch is good for 12 122 00:06:58,800 --> 00:07:02,240 hours, but it fell off after three hours. 123 00:07:02,880 --> 00:07:06,080 I'm going to replace that patch, but how long am I going to put 124 00:07:06,080 --> 00:07:09,680 the next patch on for? I'm going to put the next patch 125 00:07:09,680 --> 00:07:17,200 on for 9 hours, for 9 hours. So again, totalling 12 hours. 3 126 00:07:17,200 --> 00:07:22,840 hours that was already on. It fell off 12 -. 3 hours that I 127 00:07:22,840 --> 00:07:25,720 already had it on equals 9 hours for the next patch. 128 00:07:25,720 --> 00:07:31,080 We want to put it on a clean, dry place, but what we'll talk 129 00:07:31,080 --> 00:07:33,000 about is just patch education in general. 130 00:07:33,280 --> 00:07:38,240 So not just nitrate patches, but patch education in general for 131 00:07:38,240 --> 00:07:40,200 the boards. Never cut a patch. 132 00:07:41,080 --> 00:07:44,720 Never wear more than one patch. You want it on a clean, dry 133 00:07:44,720 --> 00:07:47,080 site. Typically you want to put on a 134 00:07:47,080 --> 00:07:50,160 hairless area, but you're never going to shave that area. 135 00:07:50,400 --> 00:07:52,880 You never want to create micro cuts because now it's not going 136 00:07:52,880 --> 00:07:55,600 transdermally, it's going right into the bloodstream. 137 00:07:56,560 --> 00:08:00,040 So don't shave that area. You don't want an infected, wet 138 00:08:00,040 --> 00:08:03,800 or scarred area because that's not typical skin. 139 00:08:04,320 --> 00:08:07,720 So again, the patches are made to go through your skin that's 140 00:08:07,720 --> 00:08:10,760 intact. That's intact when you're 141 00:08:10,760 --> 00:08:13,600 discarding it, you fold the patch, wear gloves and rotate 142 00:08:13,600 --> 00:08:16,680 sites. But with Nitro patches, you're 143 00:08:16,680 --> 00:08:19,880 going to give yourself a break. You take a break from nitrates 144 00:08:19,880 --> 00:08:22,640 for a little bit as prescribed by your HCP. 145 00:08:22,640 --> 00:08:24,720 So again, there's something that's going to be there, but we 146 00:08:24,720 --> 00:08:29,160 take nitrate breaks so we don't develop tolerance to it and that 147 00:08:29,160 --> 00:08:31,520 we're not continuously using that nitrate. 148 00:08:31,520 --> 00:08:34,640 So again, give yourself that break from nitrates education, 149 00:08:34,640 --> 00:08:39,400 education, education. As far as lifestyle 150 00:08:39,400 --> 00:08:42,799 modifications with the nitrates, of course, we're dealing with 151 00:08:42,799 --> 00:08:45,320 angina. So teach your patient about 152 00:08:45,320 --> 00:08:52,520 needs nutrition, exercise, ETOH, alcohol, avoid, don't smoke and 153 00:08:52,520 --> 00:08:54,520 sleep. So eliminate those risk factors 154 00:08:54,520 --> 00:08:57,920 that are actually going to make this engine worse and hopefully 155 00:08:58,160 --> 00:09:01,480 we can try to get this patient off of it without getting them 156 00:09:01,480 --> 00:09:03,720 into a stent, which is what we're going to have to do 157 00:09:03,720 --> 00:09:06,040 eventually if that atherosclerotic plaque 158 00:09:06,280 --> 00:09:10,720 continues. So we're going to monitor them. 159 00:09:11,280 --> 00:09:13,360 We're going to look for side effects, we're going to educate 160 00:09:13,360 --> 00:09:15,840 them. So very simple when it comes to 161 00:09:15,840 --> 00:09:18,640 a long acting versus short acting, we're long acting, we're 162 00:09:18,640 --> 00:09:22,840 talking PO or patches, short acting, we're talking about 163 00:09:22,840 --> 00:09:25,600 sublingual or sprays. Again, for the boards, we like 164 00:09:25,600 --> 00:09:27,680 sublingual. Look at the side effects. 165 00:09:27,680 --> 00:09:30,480 Again, that headache, flushing, orthocytic hypertension, nausea, 166 00:09:30,480 --> 00:09:33,280 vomiting, diarrhea, look for those, educate them on the 167 00:09:33,280 --> 00:09:35,600 contraindications, which is again, those erectile 168 00:09:35,600 --> 00:09:40,520 dysfunction drugs that end in AFIL, teach them about storage 169 00:09:40,920 --> 00:09:42,480 and handling. So make sure that they're 170 00:09:42,480 --> 00:09:44,760 keeping it in a cool dry place in that bottle. 171 00:09:44,920 --> 00:09:47,760 And again, how we dose it out when we're taking it, when we 172 00:09:47,760 --> 00:09:50,600 get that chest pain, when we get that stable angina, when we get 173 00:09:50,600 --> 00:09:54,480 that, those signs and symptoms starting to approach, take it 174 00:09:54,480 --> 00:09:56,720 sublingually and remember, if it doesn't resolve in that first 5 175 00:09:56,720 --> 00:09:59,880 minutes, call 911, continue those doses for three more doses 176 00:10:00,520 --> 00:10:02,840 as we wait for that prophylactically, we can take it 177 00:10:03,320 --> 00:10:05,680 when we're going to do something that might trigger that angina. 178 00:10:06,120 --> 00:10:10,800 And then again, patch education as I've talked about South super 179 00:10:10,800 --> 00:10:16,240 high yield topic with nitrates and with pharmacology here. 180 00:10:16,520 --> 00:10:21,720 So again, great, great, great matrix grid style questions on 181 00:10:21,720 --> 00:10:24,720 education with nitrates, whether it be long acting or short 182 00:10:24,720 --> 00:10:27,280 acting, you can do that. You can basically do the select 183 00:10:27,280 --> 00:10:29,400 all that apply right there or select all that apply question 184 00:10:29,600 --> 00:10:31,320 for the teaching for the interventions as I've taught 185 00:10:31,320 --> 00:10:34,080 you. So again, nitrates, super, super 186 00:10:34,080 --> 00:10:34,560 high yield.