Okay, I'm here with my APPE student and we're going to go over
GI pharmacology working on a new book got inspired to do some things that are more visual
You know that I'm all about the suffixes and prefixes so we'll include those but I want to go through quickly what it is that
We're trying to do and try to make more of a visual more kinesthetic way of approaching pharmacology
so I'll show you what I have on the board
and what we're going to do is we're going to go through the classes antacids, H2 blockers,
PPIs, gastric protective, motility agents, a little bit about H Pylori which goes with the PPIs here
and then
We paired a couple of different
pathophysiologic classes, diarrhea, constipation, nausea with vomiting, irritable bowel syndrome, and irritable bowel disease and
Normally on a YouTube video you have somebody who's a really good artist, and they're drawing
what is amazing and it helps you remember it. Our goal is to not
Draw it necessarily for you
But to help you draw it for yourself because they show that if you teach someone else it's about 90% retention
So the idea is if you can replicate this then you can learn this probably in the best way possible
And so we'll start with the antacids. I just alphabetize them because
There's no real relationship that's necessarily too big between them. Aluminum
hydroxide, calcium carbonate,
both of them have to do, you can both get constipation from both of them you can both get
deal with
phosphate binding as well so hyperphosphatemia, but that is just as a coincidence that those two are together
And then you put the brand name. Now I know on the NCLEX for the nurses
you only [have] the generic name, but a lot of people remember things brand name first and then the generic
So and then patients use brand names so I always recommend still trying to learn the brand names
so aluminum hydroxide is Amphojel
Calcium carbonate this is Tums and also the active ingredient in Children's Pepto so again
Pepto-bismol for adults is that liquid and the Children's Pepto is a tablet. That's a little bit counterintuitive
Usually the children's is the liquid
Magnesium Hydroxide this is Milk of Magnesia and
This unlike these two which cause constipation
This one has a laxative effect and is often used as a laxative and then sodium bicarbonate is so old I
couldn't even find a brand name for it, but there's some issues with alkalosis and things like that
So we start with the antacids and we put them on the top of what I call this fish bowl
and the fish bowl is meant to show you how these relate and
Antacids you use after you have a meal so think of this rise in
I guess you would call it liquid or acid as something that happens after you eat so antacids use one to three hours after a meal
H2 blockers and PPIs are actually meant to suppress acid
So I put them above the acid and the H2 blockers again
We remember that those end in -tidine and we think of maybe a
dining room table, and that people are going to dine because after you've dined
then it's when the acid problems come the reflux and so forth I
Put these in alphabetical order as well
And the nice thing is that the oldest ends up first, cimetidine, and this is the one that has those
P450 interactions, we don't really see it too much in clinical practice anymore, but cimetidine, famotidine
nizatidine, ranitidine
Tagamet, Pepcid, Axid, and Zantac
And I'm not going to go over the mnemonics right now for the words you can find those in other videos I've made
But the goal is to see everything visually and together so most of the time somebody would try an antacid first
Then they would go to an H2 blocker
And then they would go to a PPI, so now we have a proton pump inhibitor again
We have our -prazole ending be careful again with this. It's not -azole, -azole is a the type of organic chemistry
compound because there's fluconazole, which is a
an antifungal. There's aripiprazole which is for certain schizophrenia, things like that
So what we want is to make sure we have the right ending so -prazole
And then we have six of these and I just put them alphabetically dexlansoprazole, esomeprazole
omeprazole
lansoprazole, pantoprazole, rabeprazole they say how do you remember all of that well lansoprazole and
dexlansoprazole are related. esomeprazole and omeprazole
are related and then pantoprazole and rabeprazole are just two that we add on there so again look to the other
videos for the
for the mnemonics for these brand names
Goodnight Pharm, Memorizing Pharmacology, but what we're trying to do is say, okay
Well let's in relation to the antacids and H2 blockers where do the PPIs come in and these take a bit longer to work
But we're looking at a proton pump
We're stopping those protons those hydrogen ions from getting into the stomach and causing that additional acidity, okay
So then we're going to kind of pan over a little bit, so this H. Pylori is
Helicopter-like shaped bacteria, and I put a helicopter in there and what I did was I said, okay
We'll just think of what my kids would do my kids are six years old
And they would throw a helicopter into a fish bowl not blink and so we're going to say well
what do we need to do to get rid of this helicopter and
There's right now triple therapy, quadruple therapy, there are many different combinations
But I thought it was important with the new book that I'm writing to start
With the old book I didn't want to mix drug classes
So if it was GI, I kept it in GI
but this is really getting into immune and if you're studying for
The licensing board the NCLEX NAPLEX or USMLE Step-1 you want to start using these
antibiotics, so amoxicillin
Again the -cillin stem is a penicillin antibiotic clarithromycin this -thro- is sort of a sub stem
-mycin tells you it's from the Streptomyces class, but
Again, we've got two different drugs. So we're trying to prevent resistance and
We're trying to lower dosages of each drug individually and then we could have used any of the PPIs
I just put esomeprazole because amoxicillin, clarithromycin, esomprazole spells ACE, so I thought just triple ACE
That's one way of attacking H. Pylori, but in the Midwest I'm in Iowa. We have a lot of trouble with clarithromycin
resistance so because of this clarithromycin resistance
We think, okay
well maybe we'll need to use the quad which is to use four different drugs
and I thought well when you get to bed after a
meal
then that acidity starts to come up, especially if it's duodenal ulcer and
so I put BEDM as a way to remember all of the drugs so bismuth subsalicylate
from the Pepto-bismol, esomeprazole which is Nexium, doxycycline a
tetracycline antibiotic which is brand Vibramycin, and metronidazole, which is brand Flagyl and so again
we have an acid, something to reduce the acid, and three to attack as antibiotics and
Again, what we're doing
Now is we're including other drug classes to make sure that we have an understanding of mechanisms
How we treat and so we're kind of going a little bit from pharmacology to pharmacology and therapeutics
And so now we come back over here
And so we've looked at the H. Pylori if that helicopter is missing okay
And we still have an ulcer. It's probably an NSAID induced ulcer okay, so the ibuprofen, the
Naproxens, the Meloxicams
and what we're going to use in that case is probably a gastric protected of one kind or another and
So I put them down here. We have sucralfate
which is Carafate and this is a pink liquid that really coats the stomach to protect against ulceration
but the one drug that's only approved for these NSAID induced ulcers is this misoprostil which is Cytotec
and this is Pregnancy Category X
It's very dangerous to the fetus. We don't want to use it in that way
But again what we're doing is we're saying okay. We're at the bottom of the fish bowl
So we're thinking spatially we're going to have something that protects the bottom of the fish bowl against this ulceration
And sucralfate and misoprostol really that's where they work
the last one we think about is the motility agent and maybe you want to put some kind of
opening or leak to the fish bowl where metoclopramide is
actually a motility agent that speeds the acid and gets it out of there faster, so rather than suppress the amount of acid
We're trying to get it out of there, there are some issues with metoclopramide
which is brand Reglan that it in some cases has interactions with other drugs
But what we're trying to do with the fish bowl would say okay, how do we spatially remember all of these drug classes?
So then we are thinking okay the fish bowl is kind of a stomach, now
we're going down to the intestines with these other three pairs of drugs.
So we'll start with diarrhea constipation and the way that we go from one drug to the next is
severity so the first thing you might do is just pull a bottle of pepto off the shelf bismuth subsalicylate and
say, okay well if that helps great the diarrhea went away is just some upset stomach
Maybe it's a little bit worse then you would use loperamide which is brand Imodium
and you would take maybe a couple tablets the way that it works is that you take two tablets the first time usually
and then one tablet after each bowel movement to a certain maximum
but let's say it still hasn't gone away, and we don't have any kind of a
bacterial diarrhea rather it's still you know we're still kind of idiopathic
we're not sure what it is. Then the physician or prescriber might give you diphenoxylate with atropine
Which low creates low motility or slows the bowel as well
but this is by prescription and it also has a DEA drug class
so the atropine is there is so that someone doesn't crush it and inject it and
Abuse it so again these three drugs for diarrhea, bismuth, loperamide, diphenoxalate or all in an order that says okay?
well, it's getting worse getting worse. This is our therapeutic steps.
With constipation we did the exact same thing,
So just as where we went from bismuth to the opioid that's over-the-counter and when I say opioid
It's not addicting it just has some kind of an opioid agonist effect
And then a little bit more with the prescription version, so we again kind of going up the ladder
We're going to start with something that's bulk forming, it's psyllium. It's really just fiber
So what we're doing is we're just adding that fiber that's completely absent in the American diet
Then if that doesn't work, then maybe we use a stool softener, and if that doesn't work, maybe we use a stimulant
We can combine these two
To have the stool softener and stimulant, and then maybe an osmotic and these are completely different
But let me go through the four in order
so the psyllium is Metamucil and
it comes in a very large
kind of a circular tube thing and the way that I think of these is I think it is large tube first then the
docusate bottle then the Senna box and then the cap of the MiraLax, so it goes down
physically in my mind when I'm thinking about it, and so this is bulk forming, and it's just trying to
Make you really more regular by giving you something that's missing from your diet this docusate sodium
or Colace is going to pull water into the bowel
So you do want to take it with water not because you want the pill to go down easier
But because you're going to be pulling water
and you want to make sure that the patient isn't dehydrated
this you usually see with something like an opioid like a
Percocet or something like that
Because those are very constipating Senna is something that gets things moving quite a bit
It's called a stimulant and so we can either use this alone or add them together
To get more of a stimulant effect, and then polyethylene glycol has two extremes you have MiraLax
Which is this very gentle cap full of
Medicine that you can get over-the-counter
and then you've got GoLytely and there is nothing lytley about this. It's a gallon jug and
it's meant for bowel prep, so
Polyethylene glycol depending how you use it is one of these osmotics that either
Has a very gentle way of doing things or a very severe way of doing things so again. We're thinking
Therapeutically what's the next thing? What's the next thing? What's the next thing?
With nausea and vomiting what we have is we're going to have another kind of therapeutic
Triad here
We're going to start with these 5HT3s so -setron again is the stem for ondansetron, palonosetron
[brand] Zofran this one is PO
[brand] Aloxi this is IV
These 5HT3s are meant to prevent especially
Chemotherapy induced nausea and vomiting it's used for other things, but
The idea was that if we can stop the brain from
Wanting to vomit then we can help these patients that are on chemotherapy
Who are already weak to begin with if this doesn't work by itself a lot of times we add dexamethasone
which is a corticosteroid
In the book this is in the respiratory section. So again what we're doing is we're kind of going in this advanced
version to other chapters that we already know because for someone that's studying for the boards
They'll have know what dexamethasone is and while -sone isn't a stem, it's something that you'll see in a lot of the steroids and
Then if we have something like delayed
Emesis where it just happens a bit later. We might use aprepitant or fosaprepitant
With -prepitant stem and these are NK1s. I'm not sure how they both have the same brand name
I've never seen that but that's what I see
and because I'm community pharmacy, I don't really see these two drugs in my personal practice
so for nausea and
Preventing nausea we can start here with the 5HT3 then we can add a corticosteroid
And then the NK1 and this is all trying to prevent something from happening
If someone is actively vomiting and you can see where the arrow goes because unfortunately that's where these drugs are going to end up
Both Compazine and Phenergan have suppository forms and these are both
phenothiazines
And because they have suppository forms
It allows us to help someone who's actively vomiting who wouldn't be able to take a pill or something like that
IBS and IBD, this usually ends up at the end of most chapters or most at the end of
sections because when we start thinking about the board exams you want to think 'high yield' and
we'll definitely be using high yield when we are thinking about proton pump inhibitors and
Gastroesophageal reflux disease and things like
you know peptic ulcer disease, but IBS and IBD well ideas is prevalent and that happens a lot
We don't necessarily see that as much on the board exams, but something like lubiprostone
Or Amitiza, this is a C-II chloride channel activator
I don't know what you'll have to know that depending on your exam, but the idea is that
We're going to be dealing with a condition that is
an irregularity, sometimes you have diarrhea sometimes you have constipation. We're trying to
regulate that
With infliximab we have irritable bowel disease which is an autoimmune condition
And so we want to do just like we contrasted diarrhea and constipation
as opposites, nausea and vomiting is happening at
The treatments are happening at opposite parts of the body the syndrome versus the disease
This is much much more severe and because we have an autoimmune disease
We're going to use something like a biologic like infliximab so again these endings
This is a sub stem. This is a sub stem and this says it's a monoclonal antibody and
what you have to know these about sub-stems depends on your board exam, but
Knowing them allows you to know
Well was it humanized? Was it chimeric?
Was it human? and all these things that kind of give you some extra details
But this is a remission aid
Where the brand-name Remicade comes from
And the idea with irritable bowel disease is that if the body is attacking itself
Then we want to shut down the immune system a little bit so that we prevent it from hurting itself
So again, this is a
Summary of GI kind of the direction I'm going with a new book trying to get you a lot more
to see things visually
The analogy that I want to use is while you might not know exactly where the states are in the country in
the United States, and you might not know
the exact shapes of them if you put Florida down here with an orange and you put California over here
With maybe like Hollywood or something like that in New York over here with statue of Liberty
You know a lot about those places, or you start gathering memories from those places
So the idea is that on a board exam
where you can't go back you have to know the answer right there because you're forced to go to the next question,
You need to use visuals to get that answer right away and to get it correctly right away. I hope this helped