1 00:00:00,040 --> 00:00:03,920 What's up everyone? First and foremost, I want to 2 00:00:03,920 --> 00:00:10,280 thank everyone in here for donating towards the the fires 3 00:00:10,280 --> 00:00:12,960 in California for the Los Angeles Fire Department. 4 00:00:14,160 --> 00:00:16,800 We we were able to raise a good amount of money. 5 00:00:16,800 --> 00:00:21,880 So I'm super happy. And with that we were able to, 6 00:00:22,800 --> 00:00:24,280 you know, help out whatever we can. 7 00:00:24,280 --> 00:00:28,800 So whatever we can do here with the Hood Boy Family Foundation 8 00:00:29,160 --> 00:00:31,920 and NCLEX High Yield, obviously her Boy Family Foundation is my 9 00:00:31,920 --> 00:00:35,560 nonprofit with my family. So it is A51C3 nonprofit. 10 00:00:35,560 --> 00:00:38,280 So you did donate directly. Everything, 100% of what you 11 00:00:38,280 --> 00:00:42,520 donated does go directly to the LA Fire Department. 12 00:00:42,800 --> 00:00:47,000 So be very happy that you contributed and you get to learn 13 00:00:47,240 --> 00:00:53,680 at the same time. So with that said, we're going 14 00:00:53,680 --> 00:01:02,280 to do Farm Power Hour typically, you know my teaching style. 15 00:01:02,360 --> 00:01:06,720 Most of you know my teaching style where I break things down 16 00:01:07,360 --> 00:01:11,840 on a level where you understand I'm not about memorization, 17 00:01:11,920 --> 00:01:14,080 right? I always want you to understand 18 00:01:14,080 --> 00:01:18,760 certain things. But today what we're going to do 19 00:01:19,520 --> 00:01:22,240 is we're going to do this Farm Power Hour. 20 00:01:22,720 --> 00:01:26,040 We're we're going to do a rapid review of drugs. 21 00:01:26,040 --> 00:01:30,880 I'm going to try to get through as many drugs as I can where 22 00:01:31,520 --> 00:01:37,760 where we're able to see what these drugs are labeled, what 23 00:01:37,760 --> 00:01:40,880 they're used for, what their side effects are, maybe what the 24 00:01:40,880 --> 00:01:44,760 contraindications are. We're going to literally power 25 00:01:44,760 --> 00:01:46,480 through boom, boom, boom, boom, boom. 26 00:01:46,480 --> 00:01:49,760 It's going to be a rapid fire type of a session, something 27 00:01:49,760 --> 00:01:54,480 I've been done before, but I want to try it out because what 28 00:01:54,480 --> 00:01:59,880 the consensus has been is farm is a tough subject for most 29 00:01:59,880 --> 00:02:02,360 students. The first thing I'm going to 30 00:02:02,360 --> 00:02:07,800 start off with before we even get into the drugs is the six 31 00:02:07,920 --> 00:02:13,600 ways that the boards can ask farm questions. 32 00:02:13,600 --> 00:02:16,440 There's only six ways. That's it. 33 00:02:17,400 --> 00:02:23,200 So when people see farm questions or farm drugs, they 34 00:02:23,200 --> 00:02:25,480 get intimidated by the idea of farm. 35 00:02:25,480 --> 00:02:28,560 But there's only six ways I can ask you a question on farm. 36 00:02:29,600 --> 00:02:32,840 On the boards, they're going to ask you to identify it. 37 00:02:34,360 --> 00:02:38,560 So what is this drug? Do you know if it's a statin, if 38 00:02:38,560 --> 00:02:40,560 it's a beta blocker, so on and so forth. 39 00:02:41,200 --> 00:02:45,520 Do you know if it's an SSRI? Identified the drug point blank. 40 00:02:46,800 --> 00:02:49,360 The second thing is its side effects. 41 00:02:50,640 --> 00:02:54,960 So if I'm dealing with the statin rhabdomyolysis, OK, it's 42 00:02:54,960 --> 00:03:01,160 a side effect, boom, that's it. Then we could talk about 43 00:03:01,160 --> 00:03:05,720 contraindications. For instance, taking a beta 44 00:03:05,720 --> 00:03:09,800 blocker with an asthmatic patient, not going to happen. 45 00:03:11,520 --> 00:03:14,640 Then we're going to talk about dosages. 46 00:03:15,960 --> 00:03:21,640 If the boards ask about dosages, not very high yield, but there 47 00:03:21,640 --> 00:03:24,240 are drugs like atrophy and adenosine, things of that nature 48 00:03:24,400 --> 00:03:31,280 where we do talk about dosages, education, the do's and don'ts. 49 00:03:31,880 --> 00:03:37,240 For instance, eat consistent green leafy vegetables when 50 00:03:37,240 --> 00:03:41,200 taking warfarin. Education, bleeding precautions, 51 00:03:41,560 --> 00:03:45,200 education. And the last one, if there's an 52 00:03:45,200 --> 00:03:49,680 antidote, know the antidote, IE heparin, portamine sulfate, 53 00:03:49,680 --> 00:03:53,160 warfarin, vitamin K. So there's only six ways that 54 00:03:53,160 --> 00:03:56,200 the boards can ask questions, identification, side effects, 55 00:03:56,480 --> 00:04:01,840 contraindications, dosages, education and antidotes. 56 00:04:02,200 --> 00:04:08,720 That's it. So now let's get into some 57 00:04:08,720 --> 00:04:12,120 drugs. The first section of drugs we're 58 00:04:12,120 --> 00:04:15,440 going to talk about is cardio medications, cardiac medication 59 00:04:15,440 --> 00:04:19,160 overview. So many of these you're familiar 60 00:04:19,160 --> 00:04:22,040 with, but I'm not going to skip any of these because they're 61 00:04:22,040 --> 00:04:25,040 super high yield. Cardio being one of the biggest 62 00:04:25,040 --> 00:04:30,600 subjects, the farm associated with it, of course, high yield. 63 00:04:31,440 --> 00:04:35,680 So beta blockers. This one has a suffix. 64 00:04:36,800 --> 00:04:39,320 Not all drugs will have a suffix, especially when you get 65 00:04:39,320 --> 00:04:43,440 into mental health, but in cardio, we're fortunate to have 66 00:04:44,080 --> 00:04:46,000 a suffix. So what do I mean the end 67 00:04:46,000 --> 00:04:50,720 portion of the name of the drug? So beta blockers end in lol, 68 00:04:51,200 --> 00:04:55,200 example, metoprolol, atenolol, propanolol. 69 00:04:56,120 --> 00:05:03,120 So identifying the drug with that hint of lol, well that lets 70 00:05:03,120 --> 00:05:07,120 you know what are some indications for beta blockers? 71 00:05:07,120 --> 00:05:12,720 Well, we can use it for hypertension, angina, we can use 72 00:05:12,720 --> 00:05:17,360 it for hyperthyroidism. We can use it just in general to 73 00:05:17,360 --> 00:05:19,760 control the heart rate and blood pressure. 74 00:05:21,080 --> 00:05:23,800 But if I'm going to control the heart rate and blood pressure, 75 00:05:24,240 --> 00:05:26,680 what could be a side effect of it? 76 00:05:27,080 --> 00:05:34,680 Well, low blood pressure and low heart rate, some other side 77 00:05:34,680 --> 00:05:36,760 effects that we can deal with when we're dealing with beta 78 00:05:36,760 --> 00:05:40,560 blockers as we're worried about Broncho constriction and 79 00:05:40,560 --> 00:05:48,640 bronchospasm, which means that I have a clear contraindication. 80 00:05:50,160 --> 00:05:56,080 If a patient is an asthmatic patient or COPD patient, we are 81 00:05:56,080 --> 00:06:01,280 not to prescribe beta blockers, monitor their heart rate, 82 00:06:02,800 --> 00:06:09,280 monitor their blood pressure, keeping it simple moving on ACE 83 00:06:09,280 --> 00:06:13,600 inhibitors, ACE inhibitors and enpril. 84 00:06:16,200 --> 00:06:18,640 So the most common one you'll see probably lisinopril, 85 00:06:19,040 --> 00:06:24,880 nalapril, captopril and they're used in again, hypertension 86 00:06:24,880 --> 00:06:26,800 predominantly. Are there other indications? 87 00:06:26,800 --> 00:06:35,800 Yes, but the pneumonic is ACE I for the side effects and your 88 00:06:35,800 --> 00:06:47,760 edema for the A cough for the CE is excess potassium and I is 89 00:06:47,760 --> 00:06:52,360 instead use an ARB which ends in sartan. 90 00:06:54,200 --> 00:06:57,960 Well angioedema cough, excess potassium. 91 00:06:58,320 --> 00:07:00,520 So what am I going to monitor? Well, I'm going to monitor the 92 00:07:00,520 --> 00:07:05,560 potassium levels. It is metabolized by the kidney, 93 00:07:05,560 --> 00:07:07,080 so I'm worried about the renal function. 94 00:07:07,600 --> 00:07:12,120 So excess potassium, I'm going to worry about their breathing 95 00:07:12,440 --> 00:07:15,560 or swelling of the face, swelling of the lips, swelling 96 00:07:15,560 --> 00:07:21,600 of the tongues, because that becomes ask Graf, it becomes a 97 00:07:21,600 --> 00:07:26,560 prioritization question. The cough is a nagging cough, a 98 00:07:26,560 --> 00:07:28,560 nighttime cough, a hacking cough. 99 00:07:28,920 --> 00:07:31,480 It's not airway, it's just annoying. 100 00:07:31,720 --> 00:07:37,920 So the I and ACE inhibitor is instead switch them to Arbs. 101 00:07:39,120 --> 00:07:45,400 Arb's end in Sartan again use for hypertension predominantly, 102 00:07:46,360 --> 00:07:51,080 but this drug and if you've ever seen me teach the renin 103 00:07:51,080 --> 00:07:58,000 angiotensin aldosterone system, the RAAS, you'll understand why 104 00:07:58,000 --> 00:08:02,280 potassium goes up. So if you want to review that, 105 00:08:02,280 --> 00:08:05,320 review that. It's a great way to understand 106 00:08:05,960 --> 00:08:09,960 why these drugs affect potassium. 107 00:08:10,320 --> 00:08:13,040 So the side effect in this one is hyperkalemia. 108 00:08:13,320 --> 00:08:17,680 So if I have an ACE inhibitor that causes excess potassium, 109 00:08:18,320 --> 00:08:22,360 instead I'm going to use Sartan, but only if it's angioedema and 110 00:08:22,360 --> 00:08:25,400 cough because both can cause excess potassium or 111 00:08:25,400 --> 00:08:28,960 hyperkalemia. Both of these drugs, ACE 112 00:08:28,960 --> 00:08:33,600 inhibitors and Arbs are contraindicated in pregnancy, 113 00:08:34,600 --> 00:08:42,240 Contraindicated in pregnancy. The next set of drugs is one set 114 00:08:42,280 --> 00:08:47,120 of calcium channel blockers and this one is the one that ends in 115 00:08:47,480 --> 00:08:53,520 the pain, amlodipine, nifedipine, nicartopine. 116 00:08:55,080 --> 00:08:59,440 Again, things like hypertension, coronary artery disease, angina, 117 00:09:01,880 --> 00:09:08,560 but they are vasodilators. And if they're vasodilators, 118 00:09:08,560 --> 00:09:11,720 hence why we use it in coronary artery disease or angina to get 119 00:09:11,720 --> 00:09:16,000 that blood flow going, then it's not just going to work on the 120 00:09:16,000 --> 00:09:18,600 coronary arteries, It's actually going to work systemically. 121 00:09:20,520 --> 00:09:24,640 If it vasodilates systemically and they're on it for an 122 00:09:24,640 --> 00:09:30,240 extended period of time, that blood when we vasodilate is 123 00:09:30,240 --> 00:09:35,400 going to vasodilate in the periphery and well, gravity is 124 00:09:35,400 --> 00:09:39,000 going to eventually work. So that blood is going to pool 125 00:09:39,000 --> 00:09:41,520 because of gravity and that vasodilation. 126 00:09:41,880 --> 00:09:46,960 We're going to see peripheral edema because it can decrease 127 00:09:46,960 --> 00:09:49,560 blood pressure. We're worried about hypotension. 128 00:09:49,880 --> 00:09:56,000 Any drug that's used for hypertension, we're always 129 00:09:56,000 --> 00:09:58,840 worried about giving too much and the side effect being 130 00:09:59,240 --> 00:10:03,880 hypotension. So if we're using it for 131 00:10:03,880 --> 00:10:09,040 something and we use it too much, it can cause the opposite 132 00:10:09,040 --> 00:10:13,080 effect. Calcium channel blockers are one 133 00:10:13,080 --> 00:10:18,560 of those drugs that you avoid grapefruit products or 134 00:10:18,560 --> 00:10:26,000 grapefruits in. I always tell my students make a 135 00:10:26,000 --> 00:10:34,200 list of drugs where grapefruit effects the metabolization of 136 00:10:34,200 --> 00:10:37,720 that drug because you have to educate. 137 00:10:37,720 --> 00:10:41,120 Remember I said one of the six ways that you can ask a farm 138 00:10:41,120 --> 00:10:46,000 question is in fact education. So you must educate them to 139 00:10:46,000 --> 00:10:50,160 avoid grapefruit products. So make a list of the ones with 140 00:10:50,160 --> 00:10:52,640 grapefruit being contraindicated with it. 141 00:10:54,040 --> 00:10:59,360 Then the other one is make a list or if you have a quick tip 142 00:10:59,360 --> 00:11:02,240 book, or if you know the quick tip on one of our social media 143 00:11:02,240 --> 00:11:07,040 platforms, it is in fact Tarato Wah, tirado wah. 144 00:11:07,040 --> 00:11:09,920 So the pneumonic tirado wah, you can look it up. 145 00:11:09,920 --> 00:11:12,000 It is on pretty much every platform of ours. 146 00:11:12,000 --> 00:11:14,320 And in our quick tip book, those are the ones that are 147 00:11:14,400 --> 00:11:18,120 contraindicated in pregnancy. So Tridogen, tirado wah 148 00:11:18,800 --> 00:11:23,360 antibiotics. So the first one is penicillins 149 00:11:23,640 --> 00:11:29,800 and then cillin, amoxicillin, pipersillin, penicillin. 150 00:11:30,840 --> 00:11:34,120 When do we typically use it? Well, it's a broad spectrum 151 00:11:34,120 --> 00:11:38,880 antibiotic, so infection, gram positive, gram negative, strep, 152 00:11:38,880 --> 00:11:41,880 respiratory infections, skin infections, we can use 153 00:11:42,080 --> 00:11:47,400 penicillins, but the biggest thing that the boards are going 154 00:11:47,400 --> 00:11:53,760 to test on when it comes to penicillins is allergic 155 00:11:53,760 --> 00:11:55,800 reaction. And it's not just an allergic 156 00:11:55,800 --> 00:11:58,760 reaction, it's in fact an anaphylactic reaction. 157 00:11:59,240 --> 00:12:02,960 Why do we find out that we're allergic to penicillin? 158 00:12:03,200 --> 00:12:05,200 When do we find out that we're allergic to penicillin? 159 00:12:05,200 --> 00:12:09,280 And why does everyone find out at some point if there are or 160 00:12:09,280 --> 00:12:17,440 are not allergic to penicillin? Well, as we're children, we're 161 00:12:17,440 --> 00:12:20,320 prone to getting sick. Guess what? 162 00:12:20,320 --> 00:12:25,440 The first line is our first line of antibiotic that we're going 163 00:12:25,440 --> 00:12:28,480 to give a child. The first infection that they 164 00:12:28,480 --> 00:12:33,760 get, we're going to give them a penicillin. 165 00:12:35,480 --> 00:12:39,520 So those of you that remember when you were kids, it was that 166 00:12:39,520 --> 00:12:43,040 pink little bubble gum tasting syrup. 167 00:12:44,600 --> 00:12:48,520 That was your penicillin. That was your amoxicillin, to be 168 00:12:48,520 --> 00:12:52,760 more specific. But that's our first line in a 169 00:12:52,760 --> 00:12:58,480 first line drug. The first time we give it, are 170 00:12:58,480 --> 00:13:00,080 they going to have an anaphylactic reaction? 171 00:13:01,960 --> 00:13:05,760 No. The first time we give it to 172 00:13:05,760 --> 00:13:10,200 them, they're going to develop hives, they're going to develop 173 00:13:10,400 --> 00:13:14,240 itching of the throat, swelling of the throat, trouble 174 00:13:14,240 --> 00:13:16,840 breathing. But it's not an anaphylactic 175 00:13:16,840 --> 00:13:19,080 reaction. It's an allergic reaction 176 00:13:19,400 --> 00:13:24,040 indicating to us that whoa, this person is allergic and is 177 00:13:24,080 --> 00:13:27,000 anaphylactically allergic to penicillins. 178 00:13:29,080 --> 00:13:32,520 So when you see the question on the boards, when you're going to 179 00:13:32,520 --> 00:13:38,000 see it, it's the first dose. The first dose that you receive 180 00:13:39,520 --> 00:13:42,920 is going to be indication that you're anaphylactically reactive 181 00:13:43,120 --> 00:13:45,960 and it has to be hives, swelling or itching on the throat. 182 00:13:47,400 --> 00:13:53,840 If I get a skin rash or I get a little diarrhea as a child, is 183 00:13:53,840 --> 00:13:56,280 that going to indicate that they're anaphylactically 184 00:13:56,280 --> 00:13:59,960 reactive? 2 penicillins, No. 185 00:14:01,160 --> 00:14:08,320 So again, for the teaching, for the intervention, oh you know, 186 00:14:08,320 --> 00:14:12,680 the first time I got it I got hives and I got, you know, itchy 187 00:14:12,680 --> 00:14:15,800 throat. But I could probably take it 188 00:14:15,800 --> 00:14:19,800 again and I'll be just fine. No, no, absolutely not for the 189 00:14:19,800 --> 00:14:23,920 teaching, for the intervention. The next thing is GI upset. 190 00:14:25,280 --> 00:14:32,880 I always say this, it's not 100% going to be true for every 191 00:14:32,880 --> 00:14:36,480 single drug, But if you think about it, if you're taking 192 00:14:36,480 --> 00:14:39,240 something orally for the first time or you're taking something 193 00:14:39,240 --> 00:14:44,800 orally that's you're not used to, chances are if you have any 194 00:14:44,800 --> 00:14:50,640 type of reaction, it could be GI discomfort, nausea, vomiting, 195 00:14:50,640 --> 00:14:57,160 diarrhea, stomach pain. So typically with oral drugs, if 196 00:14:57,160 --> 00:15:00,960 we see a reaction, don't be surprised that just select all 197 00:15:00,960 --> 00:15:04,600 that apply. It could be nausea, vomiting, 198 00:15:04,600 --> 00:15:08,160 diarrhea, stomach upset, stomach pain. 199 00:15:08,960 --> 00:15:11,920 Because we're taking something orally and especially when it 200 00:15:11,920 --> 00:15:15,320 takes a toll on us or we're taking it for the first time or 201 00:15:15,320 --> 00:15:16,760 we're taking for extended period of time. 202 00:15:19,240 --> 00:15:23,920 The next antibiotic is your cephalosporins. 203 00:15:26,240 --> 00:15:30,960 With cephalosporins, again, we can use them for respiratory 204 00:15:30,960 --> 00:15:33,960 infections, you can use them for strep, we can use them for a 205 00:15:33,960 --> 00:15:39,000 bunch of different infections. But what we're concerned about, 206 00:15:39,000 --> 00:15:42,880 what the boards are going to ask about is that cross reactivity 207 00:15:43,280 --> 00:15:51,320 with penicillins, 10% of people with anaphylactic reaction of 208 00:15:51,760 --> 00:15:55,760 penicillins, cephalosporins are going to react as well too. 209 00:15:56,800 --> 00:16:00,120 So are we going to give a Cephalosporin to a person that's 210 00:16:00,120 --> 00:16:02,320 anaphylactically reactive with penicillins? 211 00:16:04,000 --> 00:16:06,880 Absolutely not. That's a further teaching, 212 00:16:06,880 --> 00:16:12,280 further intervention. That's again education, one of 213 00:16:12,280 --> 00:16:15,120 the six ways that the boards can ask the question. 214 00:16:16,960 --> 00:16:21,400 The next one is macrolides. The most common one that we're 215 00:16:21,400 --> 00:16:23,120 going to look at is azithromycin. 216 00:16:23,640 --> 00:16:26,880 So what do we know that as of course, I don't want you to know 217 00:16:26,880 --> 00:16:30,000 the brand names or what it's like, what the lay terms are, 218 00:16:30,240 --> 00:16:32,800 what we call it AZ pack azithromycin. 219 00:16:33,600 --> 00:16:36,800 And it's great for respiratory infections and we may need to 220 00:16:36,800 --> 00:16:43,000 use it for STI's GI distress. Yeah, absolutely. 221 00:16:43,000 --> 00:16:47,160 Of course it can cause GI upset, but the one that we're worried 222 00:16:47,160 --> 00:16:54,560 about is QT prolongation. QT prolongation, If you watch my 223 00:16:54,560 --> 00:17:02,080 EKG videos, the QT interval is what part of the heart it is in 224 00:17:02,080 --> 00:17:07,040 fact the ventricle. Which means if I'm prolonging 225 00:17:07,040 --> 00:17:10,119 it, prolonging it, prolonging it, can I throw it into a 226 00:17:10,119 --> 00:17:13,040 dysrhythmia? Absolutely. 227 00:17:13,040 --> 00:17:16,359 I can't. And if I'm prolonging the QT, 228 00:17:16,359 --> 00:17:20,359 prolonging the QT, prolonging the QT, that dysrhythmia that 229 00:17:20,359 --> 00:17:25,720 I'm concerned about ventricular fibrillation, ventricular 230 00:17:25,800 --> 00:17:28,440 fibrillation. So of course if we feel any 231 00:17:28,440 --> 00:17:31,920 dysrhythmias, we're going to monitor them on EKG. 232 00:17:32,280 --> 00:17:38,000 And if there's any, any side effect with any drug, remember 233 00:17:38,000 --> 00:17:44,800 what I always say, stop the offending agent, stop the 234 00:17:44,800 --> 00:17:48,200 offending agent. The next one is our 235 00:17:48,200 --> 00:17:50,840 tetracyclines. Most common one that we're going 236 00:17:50,840 --> 00:17:57,840 to look at is doxycycline. So doxycycline, doxycycline, 237 00:17:57,840 --> 00:18:00,280 monocycline are going to be the ones that you're going to see 238 00:18:00,960 --> 00:18:05,440 very common in acne, very common in acne, but it's a 239 00:18:05,440 --> 00:18:08,720 tetracycline. So what is the mnemonic? 240 00:18:09,440 --> 00:18:16,680 What is a quick tip? SAT for a photo SAT for a photo 241 00:18:17,760 --> 00:18:27,520 Sulfa drugs S amiodarone A tetracyclines T fluoroquinolones 242 00:18:27,600 --> 00:18:33,880 F SAT for a photo. Photo meaning photosensitivity. 243 00:18:35,080 --> 00:18:40,640 So if a patient is on a tetracycline, what are we 244 00:18:40,640 --> 00:18:42,600 concerned about? Photosensitivity. 245 00:18:44,600 --> 00:18:49,720 With photosensitivity, we must educate our patients again with 246 00:18:49,720 --> 00:18:52,080 tetracyclines. One of the six ways I can ask a 247 00:18:52,080 --> 00:18:56,040 question sat for a photo, educate them on photo 248 00:18:56,240 --> 00:19:00,080 sensitivity. So things like long sleeves, 249 00:19:00,240 --> 00:19:03,720 wearing a hat, sunscreen, avoiding the sun. 250 00:19:05,720 --> 00:19:09,320 These things are education, education, education. 251 00:19:10,840 --> 00:19:14,000 This is a tridogen. So are we going to take it in 252 00:19:14,000 --> 00:19:16,240 pregnancy? No avoiding pregnancy. 253 00:19:16,480 --> 00:19:21,360 Why is this a really good one? So let's think about this. 254 00:19:21,880 --> 00:19:27,080 When we're talking about doxycycline, we're talking about 255 00:19:27,120 --> 00:19:30,520 acne being an indication. We're talking about St. is being 256 00:19:30,520 --> 00:19:37,000 an indication. What population does acne and 257 00:19:37,000 --> 00:19:44,360 St. is indicate a sexually active, potentially sexually 258 00:19:44,360 --> 00:19:51,880 active or a sexually active population which means in the 259 00:19:51,880 --> 00:19:55,600 female population. And remember when I say if they 260 00:19:55,600 --> 00:19:59,840 say urine pregnancy test, if they say when was your last 261 00:19:59,840 --> 00:20:05,240 menstrual cycle, if they ask for HCG level, if they ask that 262 00:20:05,240 --> 00:20:09,120 you're sexually active, why did they put that in the answer 263 00:20:09,120 --> 00:20:14,440 choice? Well in this drug especially not 264 00:20:14,440 --> 00:20:18,160 and obviously the other drugs where pregnancy is 265 00:20:18,320 --> 00:20:23,200 contraindicated in this pregnant in this particular drug 266 00:20:23,280 --> 00:20:26,240 tetracyclines you've got acne and STI. 267 00:20:26,240 --> 00:20:30,880 So maybe teenage or above population with acne they could 268 00:20:30,880 --> 00:20:34,160 be sexually active. STI's indicates that they're 269 00:20:34,160 --> 00:20:37,640 sexually active. So in a female patient with 270 00:20:37,640 --> 00:20:43,120 acne, female patient that is sexually active, we must ask and 271 00:20:43,120 --> 00:20:46,120 we must educate to avoid in pregnancy. 272 00:20:47,280 --> 00:20:51,880 Avoid in pregnancy and fluoroquinolones. 273 00:20:52,480 --> 00:20:55,400 Fluoroquinolones. So what is our fluoroquinolones? 274 00:20:55,560 --> 00:21:00,920 Ciprofloxacin, moxifloxacin, levofloxacin. 275 00:21:02,920 --> 00:21:06,280 Where are these indicated respiratory infections? 276 00:21:07,040 --> 00:21:10,400 UT is, is this first line for UTI? 277 00:21:10,800 --> 00:21:14,240 No, it's not. Cipro is an excellent drug for 278 00:21:14,240 --> 00:21:16,920 UTI, commonly used for UTI, but it's not first line. 279 00:21:18,480 --> 00:21:21,880 So fluoroquinolones again with the pneumonic SAT for a photo. 280 00:21:21,880 --> 00:21:24,960 So educate them on photosensitivity. 281 00:21:26,960 --> 00:21:32,640 But a nasty side effect of extended uses of 282 00:21:32,640 --> 00:21:36,600 fluoroquinolones is it can develop a tendon rupture. 283 00:21:37,560 --> 00:21:42,680 What tendon are we scared about that takes a long time to 284 00:21:42,680 --> 00:21:44,320 recover? Those of you that watch sports 285 00:21:44,320 --> 00:21:47,680 will probably recognize this, or even if you don't watch sports 286 00:21:47,800 --> 00:21:50,760 will know this. What is the one tendon that we 287 00:21:50,760 --> 00:21:56,160 are scared about rupturing? Our Achilles tendon. 288 00:21:56,960 --> 00:21:58,800 Our Achilles tendon? Yeah. 289 00:22:00,120 --> 00:22:04,120 So with the Achilles tendon, if it ruptures, those of you that 290 00:22:04,120 --> 00:22:06,680 have watched basketball, football, you're talking about 291 00:22:06,680 --> 00:22:10,480 season ending injuries. So if that's for an athlete 292 00:22:10,480 --> 00:22:14,160 who's probably in the best shape, imagine how far, how long 293 00:22:14,160 --> 00:22:15,720 it's going to take for one of us to recover. 294 00:22:16,520 --> 00:22:26,440 And with all drugs, with all drugs, if they cause GI upset, 295 00:22:26,960 --> 00:22:30,760 nausea, vomiting, diarrhea, do you think it's common for the 296 00:22:30,760 --> 00:22:33,040 patient to be like, oh, I'm going to go ahead and take some 297 00:22:33,520 --> 00:22:36,960 bismuth salicylate or Pepto Bismol, or I'm going to take 298 00:22:36,960 --> 00:22:41,560 some Tums, or I'm going to take some Rolaids, antacids. 299 00:22:42,200 --> 00:22:51,040 We must educate these patients. Do not take antacids prior to 300 00:22:51,040 --> 00:22:55,720 taking this medication. And if you did take an antacid, 301 00:22:56,000 --> 00:22:59,720 how long am I waiting before I take my medication? 302 00:23:02,280 --> 00:23:08,560 Two hours, Two hours? Imagine what the boards are 303 00:23:08,560 --> 00:23:10,000 going to ask. Think about this. 304 00:23:11,640 --> 00:23:15,960 Drugs commonly, I said, can cause GI distress. 305 00:23:17,400 --> 00:23:22,760 Patients going to go into local pharmacy is going to look at GI 306 00:23:23,360 --> 00:23:26,440 upset or GI distress drugs and acids. 307 00:23:27,680 --> 00:23:31,400 Oh, it's going to help with my or not indigestion, but my 308 00:23:31,480 --> 00:23:37,480 nausea, vomiting, diarrhea. And lo and behold, they decide 309 00:23:37,480 --> 00:23:39,800 to take it and then they pop their medication with it. 310 00:23:40,040 --> 00:23:41,200 Is that medication going to work? 311 00:23:42,680 --> 00:23:45,640 Not to its fullest potential, not even close. 312 00:23:46,720 --> 00:23:49,760 Does that mean things like proton pump inhibitors? 313 00:23:52,200 --> 00:23:55,080 No, Proton pump inhibitors are different. 314 00:23:55,240 --> 00:23:57,320 PPS are different. Our puzzles are different. 315 00:23:57,960 --> 00:24:02,440 I'm talking about our antacids. Antacids, the ones that 316 00:24:02,440 --> 00:24:07,520 instantly change the pH of our stomach, making it more basic, 317 00:24:07,680 --> 00:24:12,800 more alkalotic, decreasing the acidity, changing the entire way 318 00:24:13,160 --> 00:24:18,360 that we break down medication, that we break down medication. 319 00:24:20,720 --> 00:24:22,920 Let's move on. All right. 320 00:24:23,200 --> 00:24:28,320 So this is one that I typically don't cover as its own subject. 321 00:24:28,440 --> 00:24:34,280 I cover this individually as we see drugs and this is high yield 322 00:24:34,400 --> 00:24:38,680 antidotes and the common ones that the boards are going to 323 00:24:38,680 --> 00:24:42,400 ask, the most common one that the boards are going to ask is 324 00:24:42,400 --> 00:24:45,520 probably opioids. And we talked about this in 325 00:24:45,520 --> 00:24:50,800 mental health because opioids are going to cause respiratory 326 00:24:50,800 --> 00:24:53,000 depression, not only respiratory depression. 327 00:24:53,400 --> 00:24:56,280 A lot of people are going to combine this drug with alcohol 328 00:24:56,280 --> 00:24:58,880 or they're going to overdose on it because they take too much of 329 00:24:58,880 --> 00:25:03,800 it. And or they're abusing not only 330 00:25:03,800 --> 00:25:06,080 a prescribed version of it where they're taking too much, or 331 00:25:06,080 --> 00:25:09,680 they're going to a street version like heroin and they're 332 00:25:10,880 --> 00:25:13,440 taking too much overdosing. Why? 333 00:25:13,680 --> 00:25:20,680 Opioids build tolerance, and as you get tolerance like this, you 334 00:25:20,680 --> 00:25:23,000 need your fix even quicker and quicker and you need more and 335 00:25:23,000 --> 00:25:27,360 more. And now you're taking such a 336 00:25:27,360 --> 00:25:30,840 large amount that this drug that causes severe respiratory 337 00:25:30,840 --> 00:25:35,760 depression can literally kill you. 338 00:25:37,200 --> 00:25:44,400 So now what do they offer for free at pharmacies when you get 339 00:25:44,400 --> 00:25:48,720 an opioid drug prescribed to you now? 340 00:25:48,720 --> 00:26:01,080 Laxon naloxone, which is Narcan naloxone, so the big one for 341 00:26:01,080 --> 00:26:07,200 opioids, naloxone antidote huge because we see so many people 342 00:26:07,480 --> 00:26:13,120 passing away from opioid overdose, opioid overdose. 343 00:26:15,720 --> 00:26:23,760 The next one is acetaminophen, well again acetaminophen brand 344 00:26:23,760 --> 00:26:27,120 name Tylenol acetaminophen over the counter. 345 00:26:27,440 --> 00:26:32,400 Well, what is our Max dose over a 24 hour period? 346 00:26:35,080 --> 00:26:41,520 It is in fact 4G or 4000 milligrams, 4G or 4000 347 00:26:41,520 --> 00:26:50,920 milligrams in a 24 hour period. Why is the antidote so important 348 00:26:51,240 --> 00:26:56,400 for acetaminophen? Because it's over the counter. 349 00:26:58,520 --> 00:27:03,320 Each pill typically, typically you can see is going to be 500 350 00:27:03,320 --> 00:27:12,400 milligrams, 500 milligrams, and it tells you to take 2 pills at 351 00:27:12,400 --> 00:27:15,440 a time, which means you're taking a gram. 352 00:27:16,760 --> 00:27:18,320 How many times can you take that dose? 353 00:27:19,400 --> 00:27:23,360 Well, a little Med math, you can take it four times in 24 hours, 354 00:27:25,440 --> 00:27:31,640 which means you can take every six hours Max Max, not four to 355 00:27:31,640 --> 00:27:33,880 six hours, probably 6 to 8 hours. 356 00:27:37,360 --> 00:27:40,520 But the reason why we're concerned is that people that 357 00:27:40,520 --> 00:27:46,200 are in pain, people that have fevers, people that have 358 00:27:46,560 --> 00:27:56,480 suicidal ideation can overdose like this, especially in 359 00:27:56,480 --> 00:28:00,760 suicidal ideation. If somebody has suicidal 360 00:28:00,760 --> 00:28:08,320 ideation, they can go to the cabinet, take a handful of pills 361 00:28:09,000 --> 00:28:12,960 at 500 milligrams. Let's do a little bit of math. 362 00:28:12,960 --> 00:28:18,800 I'll slow down here real quick. We got 4000 milligrams and 24 363 00:28:18,800 --> 00:28:24,040 hours that we can take before it becomes overdose. 364 00:28:25,120 --> 00:28:37,560 If each pill is 5000 milligrams, 4000 / 500 is how many pills in 365 00:28:37,800 --> 00:28:42,640 a 24 hour period? 8 pills, That's it. 366 00:28:44,240 --> 00:28:48,360 If somebody takes a handful or two, do you think they've 367 00:28:48,360 --> 00:28:57,720 exceeded 8 pills 100%? They have suicidal ideation, so 368 00:28:57,720 --> 00:29:02,120 we must give them their antidote within 8 hours of their 369 00:29:02,120 --> 00:29:04,720 overdose. And the antidote is in fact 370 00:29:05,040 --> 00:29:11,200 acetylcysteine or N acetyl cysteine, acetylcysteine or N 371 00:29:11,200 --> 00:29:19,080 acetylcysteine. The next one is benzodiazepines, 372 00:29:19,120 --> 00:29:22,600 again another mental health drug, because we prescribe it 373 00:29:22,600 --> 00:29:26,600 for anxiety. And the one thing that we've 374 00:29:26,600 --> 00:29:30,160 learned is that the world is anxious. 375 00:29:32,000 --> 00:29:35,920 The world is anxious, students are anxious. 376 00:29:38,640 --> 00:29:40,320 People taking the Anclex are anxious. 377 00:29:40,400 --> 00:29:45,680 Anxiety is all over, so benzodiazepines, obviously not 378 00:29:45,680 --> 00:29:49,880 the first line anymore. What we try to do is what in 379 00:29:49,880 --> 00:29:54,240 mental health always think about before we give a drug for 380 00:29:54,240 --> 00:29:57,320 anxiety, what do we do first in mental health before we give a 381 00:29:57,320 --> 00:29:59,400 drug? We always do cognitive 382 00:29:59,600 --> 00:30:08,040 behavioral therapy, CBT. Then we move on to a newer drug 383 00:30:08,040 --> 00:30:12,600 that's prescribed for anxiety, which is Buspirone. 384 00:30:14,520 --> 00:30:17,560 Buspirone takes about two weeks to get active. 385 00:30:18,520 --> 00:30:20,640 So educate your patient. Hey, it's not going to work 386 00:30:20,640 --> 00:30:22,360 right away, so give it some time. 387 00:30:24,280 --> 00:30:33,400 Another alternative is an SSRI. So we have alternatives before 388 00:30:33,400 --> 00:30:37,920 we get to benzodiazepines, but benzodiazepines are fast acting 389 00:30:39,240 --> 00:30:46,000 similar to opioid, similar to opioids, they cause respiratory 390 00:30:46,000 --> 00:30:51,960 depression. Now the thing about benzos and 391 00:30:51,960 --> 00:30:56,920 opioids is they both you can build tolerance to both of them, 392 00:30:59,600 --> 00:31:03,120 which means that if I'm popping one pill, it'll work right away. 393 00:31:03,120 --> 00:31:06,520 And I'm like, oh, I feel great. The next time it works, the next 394 00:31:06,520 --> 00:31:09,840 time you get, you know, anxiety, you take, it's like it's not 395 00:31:09,840 --> 00:31:11,040 working. Let me take another one real 396 00:31:11,040 --> 00:31:16,480 quick, OK, It's working. And now we're talking about 397 00:31:16,480 --> 00:31:19,920 people that abuse it. They may combine it with 398 00:31:19,920 --> 00:31:21,840 opioids. They may combine it with 399 00:31:21,880 --> 00:31:26,120 alcohol. Because when we take alcohol or 400 00:31:26,120 --> 00:31:31,360 when we drink alcohol and we're removed from alcohol, anxiety 401 00:31:31,360 --> 00:31:35,040 levels go up. So what did they do? 402 00:31:35,040 --> 00:31:36,680 Papabenzo? Well, then they're going to 403 00:31:36,680 --> 00:31:39,240 drink again. Then they pop a benzo and now 404 00:31:39,240 --> 00:31:45,840 maybe they're combining the two. Respiratory depression, The 405 00:31:45,840 --> 00:31:48,040 other thing that benzodiazepines are used for. 406 00:31:48,520 --> 00:31:52,840 Think about lorazepam, Lorazepam, brand name, Ativan, 407 00:31:53,160 --> 00:31:56,040 lorazepam. When we think lorazepam or 408 00:31:56,040 --> 00:31:59,840 Ativan, again, Ativan is a brand name, but lorazepam, lorazepam, 409 00:31:59,840 --> 00:32:03,720 what do we think about seizures? We use it for seizures. 410 00:32:03,720 --> 00:32:07,000 If somebody's having seizures in the hospital, we are giving them 411 00:32:07,360 --> 00:32:11,520 lorazepam. Give him 2 milligrams, 4 412 00:32:11,520 --> 00:32:17,880 milligrams, give him lorazepam while they're seizing, which 413 00:32:17,880 --> 00:32:26,120 means if this drug decreases seizures, if I take this drug 414 00:32:26,120 --> 00:32:29,360 for a long time and I rapidly remove it, guess what's going to 415 00:32:29,360 --> 00:32:32,000 happen? A seizure. 416 00:32:32,800 --> 00:32:37,760 If it treats seizures and I take it away, the seizures come back. 417 00:32:39,520 --> 00:32:43,240 So again, we must educate our patients not to abruptly stop, 418 00:32:43,240 --> 00:32:50,280 but to taper off. But the antidote, the antidote 419 00:32:50,280 --> 00:32:55,360 is flumazonil. Flumazonil, Another common 420 00:32:55,360 --> 00:33:02,400 antidote is warfarin and vitamin K. 421 00:33:03,680 --> 00:33:10,280 Warfarin and vitamin K, and the next one related to it is 422 00:33:10,280 --> 00:33:15,640 heparin and protamine sulfate. So I always say when it comes to 423 00:33:15,640 --> 00:33:21,520 the antidote of these two, if you know 1 drug by default, you 424 00:33:21,520 --> 00:33:23,240 know the other. Make a column. 425 00:33:24,320 --> 00:33:26,440 If you're taking notes right now, make a column. 426 00:33:26,680 --> 00:33:29,480 Put heparin in one column, Put warfarin in one column. 427 00:33:31,440 --> 00:33:33,840 Heparin. What do we call heparin for 428 00:33:33,840 --> 00:33:37,320 short HAP? How many letters in HAP 3? 429 00:33:38,680 --> 00:33:46,280 How many letters in PTT 3 HAP PTT antidote protamine sulfate 430 00:33:46,880 --> 00:33:53,760 so HAP 3 letters PTT 3 letters protamine sulfate with AP so HAP 431 00:33:54,000 --> 00:33:56,640 PTT protamine sulfate. You got the alliteration which 432 00:33:56,640 --> 00:33:59,520 means by default I should know warfarin. 433 00:34:00,080 --> 00:34:08,719 So if heparin is PTT, warfarin by default is what PTINR, if 434 00:34:08,920 --> 00:34:15,400 hep, PTT, protamine sulfate is the antidote for heparin by 435 00:34:15,400 --> 00:34:17,719 default. I should know warfarin as 436 00:34:17,719 --> 00:34:21,520 vitamin K. Don't mix them up because I can 437 00:34:21,600 --> 00:34:27,199 almost guarantee you somebody is going to see this, if not many 438 00:34:27,199 --> 00:34:29,920 of you, if not, you've already seen it before. 439 00:34:30,120 --> 00:34:31,639 Because they're super high yield drugs. 440 00:34:33,400 --> 00:34:36,679 Super high yield drugs. So antidotes, endocrine 441 00:34:36,800 --> 00:34:42,760 medications, endocrine medications, oral hypoglycemics, 442 00:34:42,880 --> 00:34:48,760 oral hypoglycemics. The first one, the most high 443 00:34:48,760 --> 00:34:51,840 yield 1 is going to be metformin. 444 00:34:52,960 --> 00:34:58,200 Metformin because we can cause lactic acidosis. 445 00:34:58,200 --> 00:35:02,560 But what about this drug do the boards love? 446 00:35:04,640 --> 00:35:11,080 You are going to stop this drug before you get contrast die. 447 00:35:11,720 --> 00:35:13,760 Stop this drug before your contrast die. 448 00:35:13,760 --> 00:35:18,720 But for how? How long before the time frame? 449 00:35:18,840 --> 00:35:24,120 Educate them. It's going to be, in fact, 48 450 00:35:24,240 --> 00:35:29,280 hours. 48 hours? Well, if they're getting 451 00:35:29,280 --> 00:35:34,080 contrast die, we hold it for 48 hours, we get their contrast die 452 00:35:34,680 --> 00:35:36,480 when we get to conscious diet. What are we going to do? 453 00:35:36,480 --> 00:35:41,160 Aggressively hydrate, aggressively hydrate and monitor 454 00:35:41,160 --> 00:35:45,600 what BU and creatinine, their kidney function. 455 00:35:47,240 --> 00:35:49,840 And then when can I start them back on their metformin? 456 00:35:50,720 --> 00:35:57,360 48 hours after. So 48 before, 48, after, 48 457 00:35:57,560 --> 00:36:09,040 before, 48 after, the next one is sulfonarrias and these can 458 00:36:09,040 --> 00:36:15,400 cause hypoglycemia. This is where I say ask graft 459 00:36:15,720 --> 00:36:21,400 glucose less than 70. A patient again takes too much 460 00:36:21,400 --> 00:36:24,600 of it, glucose level, and they're going to say glucose 461 00:36:24,600 --> 00:36:32,320 level below 70 or they're going to say a patient tried to do 462 00:36:32,320 --> 00:36:34,800 what? Again, going back to mental 463 00:36:34,800 --> 00:36:40,600 health, suicidal ideation, they took a handful of a sulfa on the 464 00:36:40,600 --> 00:36:46,480 urea and now they're becoming severely hypoglycemic. 465 00:36:46,480 --> 00:36:50,040 Ask Graf. It is one that we're freaking 466 00:36:50,120 --> 00:36:53,800 out about. Obviously in this drug it says 467 00:36:53,800 --> 00:36:56,440 sulfa. There's sulfa in the beginning 468 00:36:56,440 --> 00:37:00,040 of it. So again, sat for a photo, SAT 469 00:37:00,040 --> 00:37:05,400 for a photo. The next one is our thyroid 470 00:37:05,400 --> 00:37:09,200 medications. Our thyroid medications. 471 00:37:10,120 --> 00:37:20,640 So things like levothyroxine, propyl thio uracil or PTU with 472 00:37:20,640 --> 00:37:26,640 levothyroxine, we are replacing our thyroid. 473 00:37:26,640 --> 00:37:28,120 So what? What have we done? 474 00:37:28,120 --> 00:37:33,320 Maybe we've done a thyroidectomy, maybe we've done 475 00:37:33,480 --> 00:37:37,880 radioactive iodine, not the uptake, but radioactive iodine. 476 00:37:37,880 --> 00:37:43,680 We try to burn it out and we're not making our T4 anymore, so we 477 00:37:43,680 --> 00:37:47,720 give them levothyroxine. What are we going to educate 478 00:37:47,720 --> 00:37:50,080 them on? Take it first thing in the 479 00:37:50,080 --> 00:37:52,040 morning. Again, one of the ways that 480 00:37:52,040 --> 00:37:55,880 we're going to ask this question, take it first thing in 481 00:37:55,880 --> 00:38:01,640 the morning on an empty stomach and well, if I'm giving them 482 00:38:01,640 --> 00:38:10,240 thyroid replacement, I'm going to monitor their TSHT 4 levels, 483 00:38:11,080 --> 00:38:17,360 TSHT 4 levels. If you have a thyroidectomy or 484 00:38:17,360 --> 00:38:24,320 if your thyroid is gone, it is a lifelong drug. 485 00:38:25,480 --> 00:38:30,760 Now the thing about thyroid drugs is, is there like a 486 00:38:30,760 --> 00:38:36,120 standard dose like, oh, here's X amount of micrograms, here you 487 00:38:36,120 --> 00:38:38,760 go. It's not. 488 00:38:39,360 --> 00:38:44,800 So you must educate your patient that we must monitor their blood 489 00:38:45,200 --> 00:38:50,760 and depending on the endocrinologist, however, three 490 00:38:50,760 --> 00:38:54,600 months, six months depending on how under control it is. 491 00:38:55,400 --> 00:38:58,960 So again, how often you know, doctor Z, doctor Z, how often 492 00:38:58,960 --> 00:39:02,160 are we supposed to monitor them? It becomes a depends question 493 00:39:02,760 --> 00:39:05,520 because people react to different dosages, have 494 00:39:05,520 --> 00:39:08,600 different maintenance and the endocrinologist will determine 495 00:39:08,800 --> 00:39:15,200 how often to monitor that with propylthiol, uracil and 496 00:39:15,200 --> 00:39:19,120 methymethoxyzol. Propylthioluracil, PTO or 497 00:39:19,120 --> 00:39:22,840 methymethoxyzol. We are concerned about using 498 00:39:22,840 --> 00:39:28,760 this for hyper thyroidism, hyperthyroidism, because we're 499 00:39:28,760 --> 00:39:33,520 not going to go straight to doing radioactive iodine. 500 00:39:33,520 --> 00:39:35,840 We're not going to go straight to a thyroidectomy or partial 501 00:39:35,840 --> 00:39:38,520 thyroidectomy. We always go from least invasive 502 00:39:38,520 --> 00:39:42,120 to most invasive or in this situation we do have two drugs 503 00:39:43,240 --> 00:39:46,560 and we are concerned about pregnancy with both of these 504 00:39:46,560 --> 00:39:50,960 drugs. So monitor their liver function 505 00:39:50,960 --> 00:39:54,440 along with if they're pregnant, make sure you're using the right 506 00:39:54,440 --> 00:39:57,160 one in the right trimester and talk about that more in detail 507 00:39:57,160 --> 00:40:03,760 in our thyroid lecture. And the last one in endocrine is 508 00:40:03,800 --> 00:40:10,640 steroids. So the big one is Prednisone, 509 00:40:12,120 --> 00:40:19,080 Prednisone, corticosteroid. Where do we see cortisol levels? 510 00:40:20,280 --> 00:40:25,680 What do we see as? Too much or lifelong Prednisone? 511 00:40:26,200 --> 00:40:29,440 When do we use? Let's use an example of this. 512 00:40:29,920 --> 00:40:35,680 How about chronic bronchitis, where a patient has chronic 513 00:40:35,680 --> 00:40:38,600 inflammation of their bronchioles. 514 00:40:39,120 --> 00:40:43,600 Their airway is chronically lifelong affected by 515 00:40:43,600 --> 00:40:46,360 inflammation. I need something that's going to 516 00:40:46,720 --> 00:40:49,280 decrease inflammation. So can I give a steroid? 517 00:40:49,480 --> 00:40:51,840 Absolutely. I'm not going to be on it for 518 00:40:51,960 --> 00:40:55,480 lifelong if it's a chronic situation and we can't get over 519 00:40:55,480 --> 00:40:56,840 it. Yes, absolutely. 520 00:40:57,760 --> 00:41:01,920 Or at least an extended period of time, which means that I'm 521 00:41:02,000 --> 00:41:07,240 increasing cortisol levels. So remember that pneumonic, a 522 00:41:07,240 --> 00:41:16,480 big fib, excess cortisol levels, endocrine lecture knowing the 523 00:41:16,480 --> 00:41:21,960 adrenals, knowing cortisol. So the thing about Prednisone is 524 00:41:22,000 --> 00:41:25,360 educate your patient on what are we going to abruptly stop this 525 00:41:25,360 --> 00:41:30,040 medication? Absolutely not taper the dose, 526 00:41:30,640 --> 00:41:33,520 taper the dose. So what you'll see is when 527 00:41:33,520 --> 00:41:39,560 patients get prescribed Prednisone for short term for an 528 00:41:39,560 --> 00:41:44,720 acute situation, it comes in a pack where it's like 654321. 529 00:41:45,440 --> 00:41:48,720 They taper it for you because they don't trust you. 530 00:41:49,080 --> 00:41:51,160 So they, they put it in a pack for you. 531 00:41:51,160 --> 00:41:52,920 They're like, Nope, we don't trust you. 532 00:41:53,600 --> 00:41:56,000 So take it this way, take it this way, take it this way. 533 00:41:56,400 --> 00:41:58,240 So that way we know you're tapering it off. 534 00:41:59,080 --> 00:42:03,640 And then again, monitor for a big fib in the short term, look 535 00:42:03,640 --> 00:42:09,240 for hyperglycemia and infection. Remember it is going to decrease 536 00:42:09,240 --> 00:42:13,080 our immune system. We are susceptible to infection, 537 00:42:13,080 --> 00:42:17,360 which means what are the common ones that the boards like to 538 00:42:17,360 --> 00:42:19,080 ask? Sore throat? 539 00:42:20,000 --> 00:42:21,960 It's just a sore throat. No, no, no. 540 00:42:22,160 --> 00:42:27,360 You're on Prednisone, you're on a steroid, then you've got a 541 00:42:27,360 --> 00:42:30,760 UTI. Oh, that's just a UT. 542 00:42:30,760 --> 00:42:34,800 I I get them all the time. Then you've got gastroenteritis, 543 00:42:34,880 --> 00:42:39,120 You've got infection. No, no, that's not normal. 544 00:42:40,040 --> 00:42:44,360 Not with you, not with the patient that's on a steroid, not 545 00:42:44,360 --> 00:42:48,440 with the patient that's on a steroid because we are 546 00:42:48,440 --> 00:42:52,480 susceptible to infection. So we are scared about ask graft 547 00:42:53,120 --> 00:42:53,760 sepsis.