Hey. Welcome back to the real Life pharmacology podcast. I'm your host Pharmacist sarah Christians. Thank you so much for listening. We are continuing on today with the, top 200 drugs list. We're gonna look at, prednisone ez that fish oil, re and ph. So hopefully, those drugs will keep you interested. I got a lot to cover on fe and prednisone specifically. Lots of details there, things that could come up, on your board exams, and your pharmacology exams throughout college. So with that said, I wanna remind you, please support the sponsor med 1 1 dot com slash store all your purchases there on Amazon books, other study materials, review courses, all that goes to support this podcast, help keep it free and available for all the benefits from. So again, all your purchases there, med 01:01 dot com slash store. Go check it out, support the sponsor and support this podcast as well. Alright. So let's get into the drugs today. And we've got number 41. Let's start with prednisone. Brand name in this medication is delta zone, and this is a cor steroid. You're going to see it used a lot in practice. I've seen it used a lot in practice. And it's mostly used shorter term basis for inflammatory type conditions. Also maybe anal type conditions as well. So, for instance, gout, rheumatoid arthritis, flares of those disease states where you have a high degree of inflammation as well as pain that's associated with that inflammation. Those are definitely common uses of prednisone. Other conditions where we've got some inflammation involved potentially, asthma, Copd ex, dermatitis, skin reactions, those type of conditions as well. So, you lots and lots of utilization. For prednisone. You're gonna see... It used for lots of different, inflammatory. Disorders. That's just the tip of the iceberg and the common indications that I I see it used for on a somewhat regular basis. In addition, I did wanna mention, prednisone can be used for I suppression purposes. So an organ transplantation, things that nature. Yeah it can also be or shown to be somewhat helpful in, reducing nausea, that cor steroids in in general, have been shown to kinda help with nausea symptoms as well, and things like that. Alright. So let's discuss adverse effects a little bit. So first and foremost, I wanna talk a little bit about the kinda of short term immediate adverse effects you're gonna see good ones to educate the patient on, Gi upset, stomach issues, yeah, it can increase ulcer risk. It's admit... It's recommended to administer prednisone, with food and or milk, and that's gonna help potentially reduce the risk or the incidence of some of those Gi adverse effects. Other kind of acute short term adverse effects, they can tender to ramp people up a little bit so you can definitely have some insomnia, so we'd like, you know, if you've got a, let's say, 20 milligrams of prednisone for 5 days. We'd like to give that prednisone earlier in the day if possible. So sometimes, you know, patients come into the clinic. They get prescribed it at you know, 4 5PM, They get to the pharmacy, at 6 or 7, you know, depending upon what the situation is and how we wanna get that prednisone started. You may give it in that situation, but obviously, we definitely want to educate our patients like, this may, keep you up a little bit at night. So ideally, the earlier in the day that we can take it with food, is generally the the better. So also associated with that insomnia, some people will get a little bit more anxiety. So if you have a patient that's really prone to that, definitely something, to be aware of and and pay attention to. Couple, few disease states I wanted to mention to maybe be a little bit careful with at least a little extra monitoring or patient education. So first and foremost diabetes, prednisone, can increase blood sugar in all cor can, can increase blood sugar cause at hyper. And really throw patients out of whack. So patients taking insulin, for example, I've seen some issues with that. Where patients have adjusted. It's let's say they've got a, you know, 05:10 day course of prednisone. They've adjusted their insulin dose. Because they've seen their blood sugars go higher. And then when that prednisone stops, then their blood sugars go back down normal and they make it hypoglycemia. So educating patients maybe to monitor, those blood sugars a little bit more closely, you know, and if you've got some mild moderate spikes in blood sugar, You know, that's maybe not, you know, a huge deal, but just keep patients aware that have been you know, very well controlled. They may see those spikes in those big fluctuations. Heart failure is another 1 to pay attention to can increase risk for signs and symptoms of of heart failure in those type of patients, blood pressure as well. It can bump blood pressure up a little bit. So pay attention to that too. The long term adverse effects of Prednisone, more so if you're taking it on a chronic basis, which again why we try to limit the use if we can. So we can have, you know, that I suppression risk, the longer they're on it, to higher the dose, that can increase that risk for infection and things like that. Hvac suppression, I mean, that's really probably 1 of the biggest primary reasons why we try to limit its used to you know, 1 week or less than 2 weeks. And then osteoporosis as well is a common long term adverse effect if you've got patient who's taking it chronically. Alright. Next medication number 42 is ez. Brand name of this medication is Z. It is a cholesterol agent, it is primarily focused on reducing Ldl. Now mechanistic, how does it do that and inhibits gut absorption of cholesterol by impacting naming Ne pick, c 1 like 1. Transport, abbreviated NP1L1. So Ne pick is kind of the thing that I always remember associated with that. And and if you're taking exams or preparing for exams regarding hyper board Sam's, that's probably the the big thing to remember from a mechanism standpoint. If you're required to remember that. Where do we see this use so it lowers Ldl? Like I I mentioned, it's typically added on to stat therapy. But you may see it used as kind of an alternative if you've got a patient that's tried numerous statins and they can't tolerate them for whatever reason. You may see as that I've used as mono therapy. The probably the biggest downside compared to statins is it's just not as potent. You know, to is there, it's not not bad that way, but it's just not as near as potent at reducing Ldl and reducing cardiovascular risk compared to the proven efficacy and benefit that we have with statins. So just to give you an an idea here, it's in the neighborhood of, 15 to 20 percent reduction in Ldl. Maybe It can get slightly higher than that, but versus statins, you can get, you know, above 50 percent reduction. In Ldl with stat therapy. So yet just not quite as potent, generally well tolerated. So from an adverse effect, standpoint, I, you know, I don't typically worry a ton about side effects with this medication. You may see some some Gi adverse effects reported. I would say it's pretty low. And then, have seen, reports of neuropathy as well. That's probably more likely in patients who are taking stat therapy already. With 43, we're gonna stick on the cholesterol theme. So we've got fish oil type product. Lo being a brand name product there. So these are omega 3, poly fatty acids. Mechanism of action isn't totally well understood, but ultimately, helps, kind of blunt the liver the production of triglycerides and liver production of of triglyceride rich Ldl. V is is what I should say there. So ultimately, the use of this is patients with hyper, so elevated triglycerides. We're trying to reduce those. Now in most patients, we focus on Ldl first. But if you got somebody with substantially, high triglycerides and there at risk for pan, then we might focus on those triglycerides first, and potentially consider a medication, like fish oil. Adverse effect profile, usually Gi upsets probably the most most common there. Sometimes these pills can be larger. So from an inherent standpoint from an administration standpoint, that may be challenging for some patients. We can get some burp and fishy type taste depending upon the product as well a little bit there. There is a theoretical risk on platelet function, I don't worry about it to a tremendous extent, but it it is out there in the literature a little bit. So I guess it's something to consider if you've got a patient that's, you know, severely an anemic or they're reporting bruising and bleeding, it might be something to look at and consider. And reassess kind of that risk versus benefit. I did wanna differentiate Lo a little bit from vest Vas. So Vas is, again, kind of a similar type product, but it does have evidence in lowering As d risk compared to Lava, which does not have that demonstrated benefit, at least from the literature I've seen. So kinda 1 differentiating thing there with Lo compared to some of the other fish oil type products. Alright. Moving on, we've got to number 44. We've got re, brand name is Avi vista. This is a ser type agent, so the SER that stands for selective estrogen receptor modi. So essentially, what this does is it stimulates specific estrogen receptors in bone and, also can act as an estrogen antagonist as well. So we've certainly got an indication for osteoporosis, where again, estrogen, more estrogen you have, the better it is for bone health. This is why post men women with less estrogen tend to be at greater risk. For osteoporosis. But then it's, you know, selectivity in what it does with estrogen receptors. It can act as an antagonist at other sites and potentially be useful, in certain types of breast cancer as well. So kind of a dual indication with this, for osteoporosis re is not considered a first line agent. It's kinda more down along the lines if somebody can't tolerate. Let's say an oral bi pho, like le, for whatever reason, you don't, ro may come into play as a potential alternative there. And then, obviously, if you've got the 2 birds of 1 stone, you know, where... It's beneficial with for oncology purposes. And using it in breast cancer, we can have that beneficial effect of osteoporosis management there. So if we can do that, that's certainly a great thing. With that said, just kinda in the osteoporosis realm here, reason why it's not utilized first line osteoporosis. Is we've got a risk of adverse effects, but we've also got lower efficacy. Than some of the other agents like bi and d, for example. Those adverse effects, let's touch on that a little bit here. 1 of the biggest things that I look out for is, risk for clot, so, Dv and stroke, that risk can increase with the use of. So that's something to look out for if you've got patients you know, who are taking anti regulation and you see that they have that clock risk. You know, re probably isn't a great medication to utilize in that patient population if we can avoid it. So definitely pay attention to that. And then with some of the estrogen blocking activities, you know, it it kinda has again. It's kinda selective on which estrogen receptors it's hitting and which ones it's not, which ones it's, you know, agonizing and which ones it's ant agonizing. With that said, it has been reported that you'll see some hot flashes with re, so that can be challenging for some patients there as well. Alright. And we are moving on to the last chin, it is fe. Brand name this medication is D lantern. Alright. As far as mechanism of action, chin it is an anti seizure medication and it's thought to do this by the inhibition of voltage gated sodium channels. Mechanism isn't totally well understood, but that's the the proposed most commonly proposed mechanism with Fe. Alright. So utilizing it for seizures, what adverse effects are we going to encounter? So Gi adverse facts can happen, Cns changes, you know, confusion, s evasion, a taxi as a good 1 to remember. So kind of that difficulty walking or stumbling if you notice changes in a patient's gate that may indicate that they've got some signs and symptoms of toxicity. It can actually induce the metabolism of vitamin d. So it can lower vitamin d levels and cause some deficiency there. So supplementation may be needed there. There has been issues reported with liver function changes. It's on the rare side, but that definitely has has happened there. Drug interactions. I definitely want to mention this with Fed and there's lots of them. And there's is a big challenge with Fe. So, few examples of meds that can increase concentration or potentially have some additive adverse effects. Flu, am, alcohols, editing, and flu box. I, these are all likely to increase the risk of toxicity or symptoms of toxicity there. In clinical practice, D is or Is 1 of those that scares me a little bit. And so if we have a new medication that's starting and I see somebody on Fe. That definitely prompts me. That's a good time to take a peek at their medication list. Maybe run a drug interaction screen. And make sure nothing's gonna mess with that fe level because remember, Fe is a narrow therapeutic window drug. So that is a really, really important thing to remember. Basically, what that means is there's really a small... Drug concentration, a small window where that drug concentration can fall, that's therapeutic in preventing seizures but not toxic in causing adverse effects. So that is definitely a a challenge there for sure. So that usual fe level is in the 10 to 20 range. This can be a little bit misleading if patients have low albumin. So in those type of situations at free level is considered best. But you also wanna look back. You know, and see what patient's previous levels have been where that baseline is, and, you know, see if there's any any trends in, you know, escalation. And then, obviously, the associated clinical symptoms that that may appear as well. So fe is highly albumin bound So if that albumin falls over time, probably the most common situation is older patients with malnutrition, they may have good example of lower albumin levels. And if that's true, we're gonna have a higher free fraction of drug and increase the risk for toxicity even though, you know, the total blood levels may look normal. And so that's why we consider doing a free level in some situations there. Those toxicity signs and symptoms I kind of alluded to it already in the adverse effects, but you know, that I attacks you difficulty walking confusion, Gi side effects, slur speech, I didn't wanna mention 1 other 1 that I didn't mention in the adverse effects. Vertical nice tag. So this is the kinda unique moving of the eyes, kind of this shutter or, moving up and down of the, eyes. So that is something to pay attention to. It's not something I've seen in practice, and I think from the literature, it takes pretty high levels to get that adverse effect. But if you happen to see that, you definitely wanna go a look at that patient's medication list and see if they're on Ph because it's definitely 1 of the medications that could potentially cause that adverse effect. Alright. So that wraps up the next 5, the top 200 drugs. Be sure to go check out the free top 200 study guide at real life dot com. It's a free 31 page pdf where I lay lay out some of the most important things. 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