What's up everyone? First and foremost, I want to
thank everyone in here for donating towards the the fires
in California for the Los Angeles Fire Department.
We we were able to raise a good amount of money.
So I'm super happy. And with that we were able to,
you know, help out whatever we can.
So whatever we can do here with the Hood Boy Family Foundation
and NCLEX High Yield, obviously her Boy Family Foundation is my
nonprofit with my family. So it is A51C3 nonprofit.
So you did donate directly. Everything, 100% of what you
donated does go directly to the LA Fire Department.
So be very happy that you contributed and you get to learn
at the same time. So with that said, we're going
to do Farm Power Hour typically, you know my teaching style.
Most of you know my teaching style where I break things down
on a level where you understand I'm not about memorization,
right? I always want you to understand
certain things. But today what we're going to do
is we're going to do this Farm Power Hour.
We're we're going to do a rapid review of drugs.
I'm going to try to get through as many drugs as I can where
where we're able to see what these drugs are labeled, what
they're used for, what their side effects are, maybe what the
contraindications are. We're going to literally power
through boom, boom, boom, boom, boom.
It's going to be a rapid fire type of a session, something
I've been done before, but I want to try it out because what
the consensus has been is farm is a tough subject for most
students. The first thing I'm going to
start off with before we even get into the drugs is the six
ways that the boards can ask farm questions.
There's only six ways. That's it.
So when people see farm questions or farm drugs, they
get intimidated by the idea of farm.
But there's only six ways I can ask you a question on farm.
On the boards, they're going to ask you to identify it.
So what is this drug? Do you know if it's a statin, if
it's a beta blocker, so on and so forth.
Do you know if it's an SSRI? Identified the drug point blank.
The second thing is its side effects.
So if I'm dealing with the statin rhabdomyolysis, OK, it's
a side effect, boom, that's it. Then we could talk about
contraindications. For instance, taking a beta
blocker with an asthmatic patient, not going to happen.
Then we're going to talk about dosages.
If the boards ask about dosages, not very high yield, but there
are drugs like atrophy and adenosine, things of that nature
where we do talk about dosages, education, the do's and don'ts.
For instance, eat consistent green leafy vegetables when
taking warfarin. Education, bleeding precautions,
education. And the last one, if there's an
antidote, know the antidote, IE heparin, portamine sulfate,
warfarin, vitamin K. So there's only six ways that
the boards can ask questions, identification, side effects,
contraindications, dosages, education and antidotes.
That's it. So now let's get into some
drugs. The first section of drugs we're
going to talk about is cardio medications, cardiac medication
overview. So many of these you're familiar
with, but I'm not going to skip any of these because they're
super high yield. Cardio being one of the biggest
subjects, the farm associated with it, of course, high yield.
So beta blockers. This one has a suffix.
Not all drugs will have a suffix, especially when you get
into mental health, but in cardio, we're fortunate to have
a suffix. So what do I mean the end
portion of the name of the drug? So beta blockers end in lol,
example, metoprolol, atenolol, propanolol.
So identifying the drug with that hint of lol, well that lets
you know what are some indications for beta blockers?
Well, we can use it for hypertension, angina, we can use
it for hyperthyroidism. We can use it just in general to
control the heart rate and blood pressure.
But if I'm going to control the heart rate and blood pressure,
what could be a side effect of it?
Well, low blood pressure and low heart rate, some other side
effects that we can deal with when we're dealing with beta
blockers as we're worried about Broncho constriction and
bronchospasm, which means that I have a clear contraindication.
If a patient is an asthmatic patient or COPD patient, we are
not to prescribe beta blockers, monitor their heart rate,
monitor their blood pressure, keeping it simple moving on ACE
inhibitors, ACE inhibitors and enpril.
So the most common one you'll see probably lisinopril,
nalapril, captopril and they're used in again, hypertension
predominantly. Are there other indications?
Yes, but the pneumonic is ACE I for the side effects and your
edema for the A cough for the CE is excess potassium and I is
instead use an ARB which ends in sartan.
Well angioedema cough, excess potassium.
So what am I going to monitor? Well, I'm going to monitor the
potassium levels. It is metabolized by the kidney,
so I'm worried about the renal function.
So excess potassium, I'm going to worry about their breathing
or swelling of the face, swelling of the lips, swelling
of the tongues, because that becomes ask Graf, it becomes a
prioritization question. The cough is a nagging cough, a
nighttime cough, a hacking cough.
It's not airway, it's just annoying.
So the I and ACE inhibitor is instead switch them to Arbs.
Arb's end in Sartan again use for hypertension predominantly,
but this drug and if you've ever seen me teach the renin
angiotensin aldosterone system, the RAAS, you'll understand why
potassium goes up. So if you want to review that,
review that. It's a great way to understand
why these drugs affect potassium.
So the side effect in this one is hyperkalemia.
So if I have an ACE inhibitor that causes excess potassium,
instead I'm going to use Sartan, but only if it's angioedema and
cough because both can cause excess potassium or
hyperkalemia. Both of these drugs, ACE
inhibitors and Arbs are contraindicated in pregnancy,
Contraindicated in pregnancy. The next set of drugs is one set
of calcium channel blockers and this one is the one that ends in
the pain, amlodipine, nifedipine, nicartopine.
Again, things like hypertension, coronary artery disease, angina,
but they are vasodilators. And if they're vasodilators,
hence why we use it in coronary artery disease or angina to get
that blood flow going, then it's not just going to work on the
coronary arteries, It's actually going to work systemically.
If it vasodilates systemically and they're on it for an
extended period of time, that blood when we vasodilate is
going to vasodilate in the periphery and well, gravity is
going to eventually work. So that blood is going to pool
because of gravity and that vasodilation.
We're going to see peripheral edema because it can decrease
blood pressure. We're worried about hypotension.
Any drug that's used for hypertension, we're always
worried about giving too much and the side effect being
hypotension. So if we're using it for
something and we use it too much, it can cause the opposite
effect. Calcium channel blockers are one
of those drugs that you avoid grapefruit products or
grapefruits in. I always tell my students make a
list of drugs where grapefruit effects the metabolization of
that drug because you have to educate.
Remember I said one of the six ways that you can ask a farm
question is in fact education. So you must educate them to
avoid grapefruit products. So make a list of the ones with
grapefruit being contraindicated with it.
Then the other one is make a list or if you have a quick tip
book, or if you know the quick tip on one of our social media
platforms, it is in fact Tarato Wah, tirado wah.
So the pneumonic tirado wah, you can look it up.
It is on pretty much every platform of ours.
And in our quick tip book, those are the ones that are
contraindicated in pregnancy. So Tridogen, tirado wah
antibiotics. So the first one is penicillins
and then cillin, amoxicillin, pipersillin, penicillin.
When do we typically use it? Well, it's a broad spectrum
antibiotic, so infection, gram positive, gram negative, strep,
respiratory infections, skin infections, we can use
penicillins, but the biggest thing that the boards are going
to test on when it comes to penicillins is allergic
reaction. And it's not just an allergic
reaction, it's in fact an anaphylactic reaction.
Why do we find out that we're allergic to penicillin?
When do we find out that we're allergic to penicillin?
And why does everyone find out at some point if there are or
are not allergic to penicillin? Well, as we're children, we're
prone to getting sick. Guess what?
The first line is our first line of antibiotic that we're going
to give a child. The first infection that they
get, we're going to give them a penicillin.
So those of you that remember when you were kids, it was that
pink little bubble gum tasting syrup.
That was your penicillin. That was your amoxicillin, to be
more specific. But that's our first line in a
first line drug. The first time we give it, are
they going to have an anaphylactic reaction?
No. The first time we give it to
them, they're going to develop hives, they're going to develop
itching of the throat, swelling of the throat, trouble
breathing. But it's not an anaphylactic
reaction. It's an allergic reaction
indicating to us that whoa, this person is allergic and is
anaphylactically allergic to penicillins.
So when you see the question on the boards, when you're going to
see it, it's the first dose. The first dose that you receive
is going to be indication that you're anaphylactically reactive
and it has to be hives, swelling or itching on the throat.
If I get a skin rash or I get a little diarrhea as a child, is
that going to indicate that they're anaphylactically
reactive? 2 penicillins, No.
So again, for the teaching, for the intervention, oh you know,
the first time I got it I got hives and I got, you know, itchy
throat. But I could probably take it
again and I'll be just fine. No, no, absolutely not for the
teaching, for the intervention. The next thing is GI upset.
I always say this, it's not 100% going to be true for every
single drug, But if you think about it, if you're taking
something orally for the first time or you're taking something
orally that's you're not used to, chances are if you have any
type of reaction, it could be GI discomfort, nausea, vomiting,
diarrhea, stomach pain. So typically with oral drugs, if
we see a reaction, don't be surprised that just select all
that apply. It could be nausea, vomiting,
diarrhea, stomach upset, stomach pain.
Because we're taking something orally and especially when it
takes a toll on us or we're taking it for the first time or
we're taking for extended period of time.
The next antibiotic is your cephalosporins.
With cephalosporins, again, we can use them for respiratory
infections, you can use them for strep, we can use them for a
bunch of different infections. But what we're concerned about,
what the boards are going to ask about is that cross reactivity
with penicillins, 10% of people with anaphylactic reaction of
penicillins, cephalosporins are going to react as well too.
So are we going to give a Cephalosporin to a person that's
anaphylactically reactive with penicillins?
Absolutely not. That's a further teaching,
further intervention. That's again education, one of
the six ways that the boards can ask the question.
The next one is macrolides. The most common one that we're
going to look at is azithromycin.
So what do we know that as of course, I don't want you to know
the brand names or what it's like, what the lay terms are,
what we call it AZ pack azithromycin.
And it's great for respiratory infections and we may need to
use it for STI's GI distress. Yeah, absolutely.
Of course it can cause GI upset, but the one that we're worried
about is QT prolongation. QT prolongation, If you watch my
EKG videos, the QT interval is what part of the heart it is in
fact the ventricle. Which means if I'm prolonging
it, prolonging it, prolonging it, can I throw it into a
dysrhythmia? Absolutely.
I can't. And if I'm prolonging the QT,
prolonging the QT, prolonging the QT, that dysrhythmia that
I'm concerned about ventricular fibrillation, ventricular
fibrillation. So of course if we feel any
dysrhythmias, we're going to monitor them on EKG.
And if there's any, any side effect with any drug, remember
what I always say, stop the offending agent, stop the
offending agent. The next one is our
tetracyclines. Most common one that we're going
to look at is doxycycline. So doxycycline, doxycycline,
monocycline are going to be the ones that you're going to see
very common in acne, very common in acne, but it's a
tetracycline. So what is the mnemonic?
What is a quick tip? SAT for a photo SAT for a photo
Sulfa drugs S amiodarone A tetracyclines T fluoroquinolones
F SAT for a photo. Photo meaning photosensitivity.
So if a patient is on a tetracycline, what are we
concerned about? Photosensitivity.
With photosensitivity, we must educate our patients again with
tetracyclines. One of the six ways I can ask a
question sat for a photo, educate them on photo
sensitivity. So things like long sleeves,
wearing a hat, sunscreen, avoiding the sun.
These things are education, education, education.
This is a tridogen. So are we going to take it in
pregnancy? No avoiding pregnancy.
Why is this a really good one? So let's think about this.
When we're talking about doxycycline, we're talking about
acne being an indication. We're talking about St. is being
an indication. What population does acne and
St. is indicate a sexually active, potentially sexually
active or a sexually active population which means in the
female population. And remember when I say if they
say urine pregnancy test, if they say when was your last
menstrual cycle, if they ask for HCG level, if they ask that
you're sexually active, why did they put that in the answer
choice? Well in this drug especially not
and obviously the other drugs where pregnancy is
contraindicated in this pregnant in this particular drug
tetracyclines you've got acne and STI.
So maybe teenage or above population with acne they could
be sexually active. STI's indicates that they're
sexually active. So in a female patient with
acne, female patient that is sexually active, we must ask and
we must educate to avoid in pregnancy.
Avoid in pregnancy and fluoroquinolones.
Fluoroquinolones. So what is our fluoroquinolones?
Ciprofloxacin, moxifloxacin, levofloxacin.
Where are these indicated respiratory infections?
UT is, is this first line for UTI?
No, it's not. Cipro is an excellent drug for
UTI, commonly used for UTI, but it's not first line.
So fluoroquinolones again with the pneumonic SAT for a photo.
So educate them on photosensitivity.
But a nasty side effect of extended uses of
fluoroquinolones is it can develop a tendon rupture.
What tendon are we scared about that takes a long time to
recover? Those of you that watch sports
will probably recognize this, or even if you don't watch sports
will know this. What is the one tendon that we
are scared about rupturing? Our Achilles tendon.
Our Achilles tendon? Yeah.
So with the Achilles tendon, if it ruptures, those of you that
have watched basketball, football, you're talking about
season ending injuries. So if that's for an athlete
who's probably in the best shape, imagine how far, how long
it's going to take for one of us to recover.
And with all drugs, with all drugs, if they cause GI upset,
nausea, vomiting, diarrhea, do you think it's common for the
patient to be like, oh, I'm going to go ahead and take some
bismuth salicylate or Pepto Bismol, or I'm going to take
some Tums, or I'm going to take some Rolaids, antacids.
We must educate these patients. Do not take antacids prior to
taking this medication. And if you did take an antacid,
how long am I waiting before I take my medication?
Two hours, Two hours? Imagine what the boards are
going to ask. Think about this.
Drugs commonly, I said, can cause GI distress.
Patients going to go into local pharmacy is going to look at GI
upset or GI distress drugs and acids.
Oh, it's going to help with my or not indigestion, but my
nausea, vomiting, diarrhea. And lo and behold, they decide
to take it and then they pop their medication with it.
Is that medication going to work?
Not to its fullest potential, not even close.
Does that mean things like proton pump inhibitors?
No, Proton pump inhibitors are different.
PPS are different. Our puzzles are different.
I'm talking about our antacids. Antacids, the ones that
instantly change the pH of our stomach, making it more basic,
more alkalotic, decreasing the acidity, changing the entire way
that we break down medication, that we break down medication.
Let's move on. All right.
So this is one that I typically don't cover as its own subject.
I cover this individually as we see drugs and this is high yield
antidotes and the common ones that the boards are going to
ask, the most common one that the boards are going to ask is
probably opioids. And we talked about this in
mental health because opioids are going to cause respiratory
depression, not only respiratory depression.
A lot of people are going to combine this drug with alcohol
or they're going to overdose on it because they take too much of
it. And or they're abusing not only
a prescribed version of it where they're taking too much, or
they're going to a street version like heroin and they're
taking too much overdosing. Why?
Opioids build tolerance, and as you get tolerance like this, you
need your fix even quicker and quicker and you need more and
more. And now you're taking such a
large amount that this drug that causes severe respiratory
depression can literally kill you.
So now what do they offer for free at pharmacies when you get
an opioid drug prescribed to you now?
Laxon naloxone, which is Narcan naloxone, so the big one for
opioids, naloxone antidote huge because we see so many people
passing away from opioid overdose, opioid overdose.
The next one is acetaminophen, well again acetaminophen brand
name Tylenol acetaminophen over the counter.
Well, what is our Max dose over a 24 hour period?
It is in fact 4G or 4000 milligrams, 4G or 4000
milligrams in a 24 hour period. Why is the antidote so important
for acetaminophen? Because it's over the counter.
Each pill typically, typically you can see is going to be 500
milligrams, 500 milligrams, and it tells you to take 2 pills at
a time, which means you're taking a gram.
How many times can you take that dose?
Well, a little Med math, you can take it four times in 24 hours,
which means you can take every six hours Max Max, not four to
six hours, probably 6 to 8 hours.
But the reason why we're concerned is that people that
are in pain, people that have fevers, people that have
suicidal ideation can overdose like this, especially in
suicidal ideation. If somebody has suicidal
ideation, they can go to the cabinet, take a handful of pills
at 500 milligrams. Let's do a little bit of math.
I'll slow down here real quick. We got 4000 milligrams and 24
hours that we can take before it becomes overdose.
If each pill is 5000 milligrams, 4000 / 500 is how many pills in
a 24 hour period? 8 pills, That's it.
If somebody takes a handful or two, do you think they've
exceeded 8 pills 100%? They have suicidal ideation, so
we must give them their antidote within 8 hours of their
overdose. And the antidote is in fact
acetylcysteine or N acetyl cysteine, acetylcysteine or N
acetylcysteine. The next one is benzodiazepines,
again another mental health drug, because we prescribe it
for anxiety. And the one thing that we've
learned is that the world is anxious.
The world is anxious, students are anxious.
People taking the Anclex are anxious.
Anxiety is all over, so benzodiazepines, obviously not
the first line anymore. What we try to do is what in
mental health always think about before we give a drug for
anxiety, what do we do first in mental health before we give a
drug? We always do cognitive
behavioral therapy, CBT. Then we move on to a newer drug
that's prescribed for anxiety, which is Buspirone.
Buspirone takes about two weeks to get active.
So educate your patient. Hey, it's not going to work
right away, so give it some time.
Another alternative is an SSRI. So we have alternatives before
we get to benzodiazepines, but benzodiazepines are fast acting
similar to opioid, similar to opioids, they cause respiratory
depression. Now the thing about benzos and
opioids is they both you can build tolerance to both of them,
which means that if I'm popping one pill, it'll work right away.
And I'm like, oh, I feel great. The next time it works, the next
time you get, you know, anxiety, you take, it's like it's not
working. Let me take another one real
quick, OK, It's working. And now we're talking about
people that abuse it. They may combine it with
opioids. They may combine it with
alcohol. Because when we take alcohol or
when we drink alcohol and we're removed from alcohol, anxiety
levels go up. So what did they do?
Papabenzo? Well, then they're going to
drink again. Then they pop a benzo and now
maybe they're combining the two. Respiratory depression, The
other thing that benzodiazepines are used for.
Think about lorazepam, Lorazepam, brand name, Ativan,
lorazepam. When we think lorazepam or
Ativan, again, Ativan is a brand name, but lorazepam, lorazepam,
what do we think about seizures? We use it for seizures.
If somebody's having seizures in the hospital, we are giving them
lorazepam. Give him 2 milligrams, 4
milligrams, give him lorazepam while they're seizing, which
means if this drug decreases seizures, if I take this drug
for a long time and I rapidly remove it, guess what's going to
happen? A seizure.
If it treats seizures and I take it away, the seizures come back.
So again, we must educate our patients not to abruptly stop,
but to taper off. But the antidote, the antidote
is flumazonil. Flumazonil, Another common
antidote is warfarin and vitamin K.
Warfarin and vitamin K, and the next one related to it is
heparin and protamine sulfate. So I always say when it comes to
the antidote of these two, if you know 1 drug by default, you
know the other. Make a column.
If you're taking notes right now, make a column.
Put heparin in one column, Put warfarin in one column.
Heparin. What do we call heparin for
short HAP? How many letters in HAP 3?
How many letters in PTT 3 HAP PTT antidote protamine sulfate
so HAP 3 letters PTT 3 letters protamine sulfate with AP so HAP
PTT protamine sulfate. You got the alliteration which
means by default I should know warfarin.
So if heparin is PTT, warfarin by default is what PTINR, if
hep, PTT, protamine sulfate is the antidote for heparin by
default. I should know warfarin as
vitamin K. Don't mix them up because I can
almost guarantee you somebody is going to see this, if not many
of you, if not, you've already seen it before.
Because they're super high yield drugs.
Super high yield drugs. So antidotes, endocrine
medications, endocrine medications, oral hypoglycemics,
oral hypoglycemics. The first one, the most high
yield 1 is going to be metformin.
Metformin because we can cause lactic acidosis.
But what about this drug do the boards love?
You are going to stop this drug before you get contrast die.
Stop this drug before your contrast die.
But for how? How long before the time frame?
Educate them. It's going to be, in fact, 48
hours. 48 hours? Well, if they're getting
contrast die, we hold it for 48 hours, we get their contrast die
when we get to conscious diet. What are we going to do?
Aggressively hydrate, aggressively hydrate and monitor
what BU and creatinine, their kidney function.
And then when can I start them back on their metformin?
48 hours after. So 48 before, 48, after, 48
before, 48 after, the next one is sulfonarrias and these can
cause hypoglycemia. This is where I say ask graft
glucose less than 70. A patient again takes too much
of it, glucose level, and they're going to say glucose
level below 70 or they're going to say a patient tried to do
what? Again, going back to mental
health, suicidal ideation, they took a handful of a sulfa on the
urea and now they're becoming severely hypoglycemic.
Ask Graf. It is one that we're freaking
out about. Obviously in this drug it says
sulfa. There's sulfa in the beginning
of it. So again, sat for a photo, SAT
for a photo. The next one is our thyroid
medications. Our thyroid medications.
So things like levothyroxine, propyl thio uracil or PTU with
levothyroxine, we are replacing our thyroid.
So what? What have we done?
Maybe we've done a thyroidectomy, maybe we've done
radioactive iodine, not the uptake, but radioactive iodine.
We try to burn it out and we're not making our T4 anymore, so we
give them levothyroxine. What are we going to educate
them on? Take it first thing in the
morning. Again, one of the ways that
we're going to ask this question, take it first thing in
the morning on an empty stomach and well, if I'm giving them
thyroid replacement, I'm going to monitor their TSHT 4 levels,
TSHT 4 levels. If you have a thyroidectomy or
if your thyroid is gone, it is a lifelong drug.
Now the thing about thyroid drugs is, is there like a
standard dose like, oh, here's X amount of micrograms, here you
go. It's not.
So you must educate your patient that we must monitor their blood
and depending on the endocrinologist, however, three
months, six months depending on how under control it is.
So again, how often you know, doctor Z, doctor Z, how often
are we supposed to monitor them? It becomes a depends question
because people react to different dosages, have
different maintenance and the endocrinologist will determine
how often to monitor that with propylthiol, uracil and
methymethoxyzol. Propylthioluracil, PTO or
methymethoxyzol. We are concerned about using
this for hyper thyroidism, hyperthyroidism, because we're
not going to go straight to doing radioactive iodine.
We're not going to go straight to a thyroidectomy or partial
thyroidectomy. We always go from least invasive
to most invasive or in this situation we do have two drugs
and we are concerned about pregnancy with both of these
drugs. So monitor their liver function
along with if they're pregnant, make sure you're using the right
one in the right trimester and talk about that more in detail
in our thyroid lecture. And the last one in endocrine is
steroids. So the big one is Prednisone,
Prednisone, corticosteroid. Where do we see cortisol levels?
What do we see as? Too much or lifelong Prednisone?
When do we use? Let's use an example of this.
How about chronic bronchitis, where a patient has chronic
inflammation of their bronchioles.
Their airway is chronically lifelong affected by
inflammation. I need something that's going to
decrease inflammation. So can I give a steroid?
Absolutely. I'm not going to be on it for
lifelong if it's a chronic situation and we can't get over
it. Yes, absolutely.
Or at least an extended period of time, which means that I'm
increasing cortisol levels. So remember that pneumonic, a
big fib, excess cortisol levels, endocrine lecture knowing the
adrenals, knowing cortisol. So the thing about Prednisone is
educate your patient on what are we going to abruptly stop this
medication? Absolutely not taper the dose,
taper the dose. So what you'll see is when
patients get prescribed Prednisone for short term for an
acute situation, it comes in a pack where it's like 654321.
They taper it for you because they don't trust you.
So they, they put it in a pack for you.
They're like, Nope, we don't trust you.
So take it this way, take it this way, take it this way.
So that way we know you're tapering it off.
And then again, monitor for a big fib in the short term, look
for hyperglycemia and infection. Remember it is going to decrease
our immune system. We are susceptible to infection,
which means what are the common ones that the boards like to
ask? Sore throat?
It's just a sore throat. No, no, no.
You're on Prednisone, you're on a steroid, then you've got a
UTI. Oh, that's just a UT.
I I get them all the time. Then you've got gastroenteritis,
You've got infection. No, no, that's not normal.
Not with you, not with the patient that's on a steroid, not
with the patient that's on a steroid because we are
susceptible to infection. So we are scared about ask graft
sepsis.