On this episode of the Real Life Pharmacology podcast, I take a dive into the most common mechanisms of drug interactions. Below I list some of the common drug interactions seen in practice and how they work! Opposing Effects Many drugs will work on various receptors throughout the body. To use as an educational point, there is no better example to point to than the beta receptor. Beta-blockers are frequently used in clinical practice for their ability to lower blood pressure and slow the heart rate. Both of these beneficial actions are primarily achieved by blocking the effects of beta-1 receptors. Some beta-blockers have action on alternative beta receptors. Propranolol is one such beta-blocker that is classified as a non-selective beta-blockers. This means that in addition to the positive effects on beta-1 receptors, it can also have blocking effects on beta-2 receptors. The blockade of the beta-2 receptor by propranolol can also be life-changing. It can directly oppose beta-2 agonists like albuterol from having their beneficial effects of opening up the airway. Enzyme Inhibition Medication metabolism is arguably the largest and most clinically significant source for drug interactions. Medications that are primarily metabolized by enzymes in the liver can be greatly affected if we affect how those enzymes work. CYP3A4 is one of the most well studied and well-known enzymes that can impact hundreds to maybe even thousands of drugs. Apixaban is an oral anticoagulant that is broken down at least in part by CYP3A4. By using a CYP3A4 inhibitor like erythromycin, there is the potential to raise concentrations of apixaban. This could lead to a higher risk of bleeding. Enzyme Induction Carbamazepine is a drug that you must know. This drug is a potent enzyme inducer. This differs significantly from an enzyme inhibitor and will have the exact opposite clinical effect. Drugs that are inactivated by liver enzymes will be inactivated more quickly in a patient taking an enzyme inducer. Going back to our prior apixaban example above, carbamazepine can induce CYP3A4 and facilitate a more efficient and swifter breakdown of the drug. Bleeding will be less likely. The risk for treatment failure, usually in the form of a blot clot, will be more likely.  Here’s more information from the past on carbamazepine. Alteration in Absorption Binding interactions can be consequential and are one of the most common types of drug interactions. Many medications have the potential to bind one another in the gut. This can lead to lower concentrations of a specific medication. Calcium and iron are two of the most common examples of medications that can bind other drugs. Alteration in Protein Binding By remembering that unbound drug is an active drug, you should appreciate the risk for protein binding alterations. A significant number of medications can bind proteins in the bloodstream. As this occurs, that drug is not freely available to create physiologic effects. When another medication is added that can also bind these proteins, this can displace other medications and increase the quantity of free drug in the bloodstream. This essentially allows for enhanced physiologic effects. Warfarin is a medication that is highly protein-bound. When another drug is added that can kick warfarin off of those protein binding sites, it can free up warfarin which will increase the likelihood of elevating the patient’s INR and increase their bleed risk. Alteration in Renal Elimination Some drugs can alter the way other medications are eliminated through the kidney. Chlorthalidone, like all thiazide diuretics, has the potential to block the excretion of lithium from the kidney. This can lead to lithium toxicity. This type of interaction, while significant, is much less common than drug interactions involve the liver and CYP enzyme pathways.   Effects on Transporters One of the last types of drug interactions is the effe...

On this podcast episode, I discuss insulin aspart pharmacology, adverse effects, drug interactions, and much more. Insulin apart is a rapid acting insulin product meant to bring down blood sugars quickly (most often after meals). It is important to remember a couple of medications that may counteract the effects of insulin and apart and raise blood sugar. I talk about corticosteroids and thiazide diuretics in the drug interaction section. Fiasp is a slightly modified insulin aspart molecule that allows for quicker absorption. This quicker absorption will allow for blood sugars to come down sooner than the Novolog formulation.

On this podcast episode, I discuss gentamicin pharmacology, adverse effects, monitoring, drug interactions and much more! Drug monitoring is critical with gentamicin. Trough and peak concentrations can guide therapy and identify someone at risk of toxicity. Nephrotoxicity is a major concern with gentamicin. There are numerous nephrotoxic agents that can increase this risk. I discuss them on the podcast. Ototoxicity is another risk associated with gentamicin. Loop diuretics like furosemide can increase this risk. Learn more on this podcast episode.

On this podcast episode, I discuss fenofibrate pharmacology, adverse effects, kinetics, drug interactions, and much more! Fenofibrate is typically only used for hypertriglyceridemia. The primary risk of hypertriglyceridemia is pancreatitis so we treat these levels because of this risk. LFTs elevation has been associated with fenofibrate use as well as myopathy. In the presence of myopathy, checking CPK may be considered. Fenofibrate is a weak CYP2C9 inhibitor. Warfarin and phenytoin are two important medications that may be affected by the use of fenofibrate.

On this podcast episode, I discuss levofloxacin pharmacology, adverse effects, boxed warnings, interactions, and much more. Levofloxacin is well known to cause QTc prolongation and many drugs can increase this risk such as antiarrhythmics, citalopram, antipsychotics, and many more. Binding interactions are important when discussing levofloxacin pharmacology. Calcium, iron, magnesium, and many other cations can block the absorption of this medication. I discuss tendon rupture in relation to levofloxacin use and what factors may increase the risk of this rare adverse effect.

On this podcast episode, I discuss darifenacin pharmacology, adverse effects, drug interactions and much more. CYP3A4 and CYP2D6 are important enzymes in relation to darifenacin. I breakdown the importance of these enzymes and how they can impact drug therapy. Darifenacin has anticholinergic activity but affects the central nervous system less than other agents in its class such as oxybutynin and tolterodine. Darifenacin's pharmacology is selective for the Muscarinic-3 (M3) receptor in bladder tissue which helps reduce the risk for CNS adverse effects.

In this podcast episode, I discuss naltrexone pharmacology, adverse effects, drug interactions, and much more. Naltrexone is an opioid antagonist and can blunt the effects of opioid agonists. Because of this, the medication can be used to manage opioid use disorder. Hepatotoxicity is a concern of naltrexone and because of this, it is recommended to monitor LFTs. There is an injectable, long-acting formulation of naltrexone that can be used for opioid and alcohol use disorder treatment.

On this podcast episode, I discuss acamprosate pharmacology, adverse effects, drug interactions, and much more! Acamprosate's most common adverse effect is diarrhea. It is a primary reason why patients will ask to stop taking this medication. It is critical to assess renal function prior to using acamprosate. Dose adjustments are recommended when patients have a CrCl of less than 50 ml/min. Unlike naltrexone, acamprosate avoids liver metabolism making it an alternative option in alcohol use disorder for patients who have liver impairment.

On this podcast episode, I discuss alfuzosin pharmacology, adverse effects, drug interactions, and much more! Alfuzosin is an alpha blocker used to help relieve the symptoms of BPH. Low blood pressure is a possible adverse effect of alfuzosin and is more likely when combined with PDE-5 inhibitors like sildenafil. CYP3A4 is an important enzyme in the metabolism of alfuzosin. Inhibitors of CYP3A4 can raise concentrations and increase the chance of alfuzosin toxicity.

In this podcast episode, I discuss methadone pharmacology, adverse effects, drug interactions, and pharmacokinetics. Methadone is a full opioid agonist that may be used for pain management and opioid use disorder. Transitioning from methadone to another opioid is complicated. I discuss conversion in this podcast episode. Methadone can increase the risk of QTc prolongation and also has a lot of drug interactions. I discuss them in detail in this podcast episode.

On this podcast episode, I discuss meperidine pharmacology, adverse effects, pharmacokinetics, drug interactions, and much more! Meperidine is an opioid that is seldom used due to neurotoxicity. I describe how this can happen in this podcast episode. Meperidine has numerous drug interactions and using a CYP3A4 inhibitor may increase the risk for toxicity. Seizures are a risk with meperidine due to its neurotoxic metabolite normeperidine. I discuss this further in this podcast episode.

On this episode of the podcast, I cover guanfacine pharmacology, adverse effects, drug interactions, and much more. Guanfacine is a central acting alpha-2 agonist that has the brand names of Tenex and Intuniv. Because of guanfacine's mechanism of action, it suppresses the sympathetic response leading to a drop in pulse and blood pressure. It is important to remind patients that the onset of action is slow in the management of ADHD with guanfacine. I discuss this further in this podcast episode.

On this podcast episode, I discuss fluvastatin pharmacology, adverse effects, pharmacokinetics, and much more. Fluvastatin is only a low to moderate-intensity statin which explains its limited use compared to rosuvastatin or atorvastatin. I discuss drug interactions in the podcast but one important one to recognize is drugs that can inhibit CYP2C9. Fluvastatin is considered a lipophilic statin. I have previously discussed this on the Meded101 blog which you can find here.

In this episode, I discuss oxymorphone pharmacology, adverse effects, drug interactions, and more! Oxymorphone is approximately 3 times more potent than morphine. I break down some common opioid comparisons in this episode. Oxymorphone avoids many of the CYP interactions. I discuss some of the common interactions in this episode. I discuss histamine release in relation to opioids and oxymorphone and specifically how this may impact our patients.

On this podcast episode, I discuss diclofenac pharmacology, adverse effects, drug interactions, and much more. Diclofenac is one of the highest-risk NSAIDs when it comes to cardiovascular risk. You can find more information on this in the Meded101 NSAID comparison table. Diclofenac carries two boxed warnings. One is for GI bleed risk and the other is for cardiovascular risks. Anticoagulants, antiplatelets, diuretics, and ACEs/ARBs are all common medication classes that can interact with diclofenac.

On this episode, I discuss aliskiren pharmacology, adverse effects, drug interactions, and much more. Aliskiren should not be used with ACE Inhibitors or ARBs. I discuss why that is in this episode. Aliskiren has a long enough half-life at approximately 24 hours so it is recommended to only take this once daily. Hyperkalemia is a major concern with aliskiren. It is important to monitor potassium levels and renal function.

On this episode, I discuss the use of buprenorphine/naloxone in managing opioid use disorder. I cover the kinetics, dosage forms, adverse effect, interactions and much more. Buprenorphine/naloxone has numerous dosage form and they are not interchangeable. I discuss this further on the podcast. Liver impairment is a potential reason to avoid the use of buprenorphine. I discuss this on the podcast. You must keep an eye out for withdrawal symptoms when initiating and adjusting doses of buprenorphine/naloxone. They include sweating, nausea, tachycardia, and mood changes.

On this episode, I discuss spironolactone pharmacology, adverse effects, drug interactions and much more. Spironolactone has numerous indications including hypertension, CHF, ascites, and acne. I break them all down in this podcast episode. Hyperkalemia is a major concern with spironolactone. Patients with baseline levels at 5 or above should generally avoid this medication. Gynecomastia is one of the most commonly tested adverse effects of spironolactone. Be sure you don't miss this one on your board and pharmacology exams!

I discuss meloxicam pharmacology, adverse effects, drug interactions, and much more on this episode of the Real Life Pharmacology Podcast. Meloxicam tends to have a greater affinity to COX-2 versus COX-1. I discuss what this means clinically on this episode. Important meloxicam drug interactions include anticoagulants, antiplatelet medications, renal impairing drugs, and lithium amongst others. Meloxicam has a longer half-life than many NSAIDs and because of this can be dosed once daily for pain relief.

On this episode, I discuss enalapril pharmacology, adverse effects, drug interactions, and much more! Enalapril has a shorter half-life compared to some of the other ACE inhibitors so it may need to be dosed twice daily in patients with adequate renal function. Hyperkalemia, cough, renal impairment, and angioedema and four adverse effects associated with enalapril that you should monitor for. NSAIDs and diuretics can increase the risk of acute renal failure when an ACE inhibitor like enalapril is being used.

On this very special episode of the Real Life Pharmacology podcast, we tackle asthma pharmacotherapy and some of the things that Beth sees in her everyday practice as an ambulatory care pharmacist. When discussing asthma pharmacotherapy with pediatric patients and their families, it is critical to address the concern of suppressed growth with corticosteroid use. Beth shares her expertise and thoughts on this topic. The GINA update a few years ago has been a game changer in asthma, hear from Beth how this has been implemented in her practice. Beth also discusses some of the everyday drug interactions and adverse effects of asthma medications in this podcast episode. Neither Beth nor I have any conflicts of interest in regard to discussing these medications. If you'd like to contact Beth, you can reach out to her at zerr@arizona.edu

On this podcast episode, I discuss lisdexamfetamine (Vyvanse) pharmacology, adverse effects, drug interactions, and much more. Lisdexamfetamine is a stimulant medication that is used in the management of ADHD. Stimulants like lisdexamfetamine can increase heart rate, raise blood pressure, and suppress appetite. Lisdexamfetamine is a schedule 2 controlled substance and has a high potential for abuse and dependence.

On this podcast episode, I cover etanercept pharmacology, adverse effects, drug interactions and much more. Etanercept is classified as a DMARD but is different from older DMARDs in that it is a biologic agent and needs to be injected. Vaccination assessment in patients is important prior to initiating etanercept due to the fact that the medication may blunt the effectiveness of the vaccines. Immunosuppression from etanercept can lead to an increased risk for infection and malignancy.

On this podcast episode, I discuss the pharmacology, adverse effects, and drug interactions of insulin lispro (Humalog). I spend some time on this podcast episode discussing carb ratios and sliding scale insulin when using insulin lispro. Potassium is critical to monitor in diabetic ketoacidosis as insulin therapy can cause significant hypokalemia. Sliding-scale insulin lispro is discouraged in the overwhelming majority of situations. Ideally, we should be more proactive about insulin administration to reduce the risk of hyperglycemia spikes.

On this podcast episode, I discuss (Lyrica) pregabalin pharmacology, adverse effects, drug interactions, and much more. I compare pregabalin and gabapentin in this episode and one important difference is the percent absorption of gabapentin compared to pregabalin. Pregabalin can exacerbate the risk of respiratory depression and overdose in patients who are taking opioids. Pregabalin is most frequently used in practice for neuropathic pain syndromes.

On this podcast episode, I discuss tamoxifen pharmacology, adverse effects, drug interaction, and much more. Tamoxifen is converted to a more active compound in the body by CYP2D6. CYP2D6 inhibitors such as paroxetine, fluoxetine, or bupropion can essentially reduce the effectiveness of tamoxifen. Hot flashes are a common adverse effect of tamoxifen and I discuss a few pharmacologic options to manage this adverse effect.

On this episode of the Real Life Pharmacology Podcast, I cover phenobarbital pharmacology, adverse effects, important drug interactions and much more. Phenobarbital is an enzyme inducer. It is an inducer at CYP3A4 so this can lead to numerous drug interactions. Phenobarbital can exacerbate the risk for opioid overdose and increase the risk for respiratory depression and death. Phenobarbital can deplete numerous vitamins such as vitamin D, folic acid, and vitamin B12. Monitoring of these is important.

On this episode, I discuss isotretinoin pharmacology, side effects, drug interactions, and much more. The iPLEDGE program is in place to ensure that pregnant patients do not receive this medication. I discuss this in more detail on this episode. Sun sensitivity is an important adverse effect that patients should be aware of during seasons of high sun exposure. Hepatic issues, myalgia, and psychiatric changes are rare adverse effects associated with isotretinoin.

On this episode of the Real Life Pharmacology Podcast, I discuss lovastatin pharmacology, adverse effect, drug interactions, and more! Lovastatin is broken down by CYP3A4 so drugs like clarithromycin, diltiazem, and others may increase concentrations. Lovastatin is a lipophilic statin and I discuss the importance of this on the podcast. Lovastatin has a very short half-life which means that it is ideal to dose this medication at night for maximal efficacy.

On this podcast episode, I discuss clindamycin pharmacology, adverse effects, drug interactions, and much more! Clindamycin (oral administration) can cause esophageal irritation and it is recommended to take this medication with a full glass of water. C. Diff risk and frequent dosing are two of the biggest downsides to using clindamycin to manage infections. Clindamycin has good activity against many gram-positive organisms like Staph and Strep as well as anaerobic activity.

On this podcast episode, I discuss dextroamphetamine's pharmacology, adverse effects, drug interactions, and much more! Dextroamphetamine is a stimulant medication. Weight loss, insomnia, tachycardia, and hypertension are all possible complications. There is a patch dosage form of dextroamphetamine available called Xelstrym. I discuss it on this episode. Vitamin C can reduce GI absorption of dextroamphetamine due to its ability to increase the acidity of the GI tract.

On this podcast episode, I discuss vardenafil pharmacology, adverse effects, drug interactions, and much more. Vardenafil is a PDE-5 inhibitor used primarily for erectile dysfunction in males. Using nitrates with vardenafil is contraindicated due to the risk of profound hypotension. I have discussed how long to wait between vardenafil and nitrates in a previous post on Meded101.com.

On this podcast episode, I discuss niacin pharmacology, adverse effects, drug interactions, and much more. Niacin has historically been used to manage lipids but has fallen out of favor due to adverse effects, and newer, more effective therapies being developed. Niacin can elevate uric acid. Be sure to use this medication cautiously in patients with gout. Flushing is one of the most common adverse effects of niacin. High doses, immediate-release formulations, and the use of alcohol can increase the risk.

I discuss dextromethorphan pharmacology, adverse effects, drug interactions, and more on this podcast episode. CYP2D6 metabolizes Dextromethorphan. A commonly used antidepressant is a CYP2D6 inhibitor. I discuss this on the podcast. Dextromethorphan is a commonly used OTC cough suppressant. There is potential for abuse with this medication. In excessive doses, dextromethorphan may cause euphoria, hallucinations, and other CNS effects, but also cause cardiovascular complications.

On this podcast episode, I discuss bexagliflozin pharmacology, adverse effects, drug interactions, and much more. I wasn't wowed by the A1C reduction of this medication. I get into the specifics on bexagliflozin in the podcast episode. SGLT2 inhibitors like bexagliflozin increase the glucose in the urine which can facilitate the growth of bacteria and fungi in the genitourinary tract. Limb amputation and euglycemic DKA are two rare, reported adverse effects to be aware of with the use of bexagliflozin.

On this episode, I discuss cefuroxime pharmacology, adverse effects, drug interaction, pharmacokinetics, and much more. Cefuroxime is a 2nd generation cephalosporin that binds Penicillin-binding proteins and prevents bacterial cell wall synthesis. Medications that create a higher pH in the stomach such as antacids can ultimately reduce the concentrations of cefuroxime. Cefuroxime is primarily eliminated by the kidney. Dose adjustments are recommended for patients with a CrCL less than 30 mls/min.

On this episode, I discuss risperidone pharmacology, adverse effects, monitoring, and common indications. There are numerous drug interactions that I discuss in this podcast episode. CYP2D6 inhibitors may increase drug concentrations. Risperidone increases prolactin more than most 2nd generation antipsychotics. This can lead to sexual adverse effects. QTC prolongation is a concern with all antipsychotics like risperidone. We can monitor EKG to monitor for this risk.

On this podcast episode, I discuss vortioxetine pharmacology, adverse effects, drug interactions, and much more. Because of vortioxetine's long half-life, antidepressant discontinuation syndrome is going to be less prominent compared to ADPs with shorter half-lives. Vortioxetine is metabolized by CYP2D6. Drugs that inhibit this enzyme will likely raise concentrations and place the patient more at risk for adverse effects. I discuss rare vortioxetine adverse effects like hyponatremia and bleeding in this podcast episode.

On this episode, I discuss isosorbide mononitrate pharmacology, adverse effects, and important drug interactions. Isosorbide mononitrate is a vasodilator that works by relaxing and widening the blood vessels (primarily veins) through nitric oxide action. This reduces the preload and oxygen demand on the heart. The primary use for isosorbide mononitrate is angina prevention. It is important to remember that it is NOT meant for acute relief of chest pain. Headache is a major adverse effect of isosorbide mononitrate and can be very bothersome for patients. Vasodilation is primarily responsible for this adverse effect. PDE-5 inhibitors are notorious for causing drug interactions with any nitrate medication. I discuss management strategies in this podcast episode.

On this episode of the RLP podcast, I discuss azelastine nasal spray pharmacology, adverse effects, administration, and much more! While most nasal sprays for allergic rhinitis are corticosteroids, azelastine is classified as an antihistamine. Systemic absorption of azelastine is about 40%, so while not common, systemic adverse effects like sedation can happen. On this podcast episode, I use azelastine to remind you about important education points regarding the use of nasal sprays.

On this episode of the Real Life Pharmacology Podcast, I discuss amlodipine pharmacology, adverse effects, and important drug interactions. I break down why edema occurs with amlodipine on this episode of the Real Life Pharmacology podcast. While beta-blockers are typically the first-line agent for the prevention of chronic angina symptoms, CCBs like amlodipine can be used as an alternative. There are some potential CYP3A4 interactions with amlodipine. I discuss the severity of these interactions and how to monitor patients.

On this episode, I discuss pyridoxine pharmacology, adverse effects, and important clinical uses. Pyridoxine is most well known for its potential to reduce the likelihood of isoniazid-induced neuropathy. Another common indication of pyridoxine is its use for nausea and vomiting associated with pregnancy. Pyridoxine plays an important role in the production of heme, so deficiency will increase the risk for anemia.

On this episode of the Real Life Pharmacology podcast, I discuss vibegron pharmacology, adverse effects, drug interactions and more! I spend some time comparing and contrasting vibegron to mirabegron. Both are beta-3 agonists used for overactive bladder. Vibegron dosing is very simple. It is dosed once daily with no alternative dosage forms available. The starting dose is the target dose. Being primarily excreted in the feces and urine, vibegron doesn't have many drug interactions.

Bempedoic acid, also known as Nexletol, is a once-daily medication used in lipid management. I discuss its pharmacology, side effects, and much more on this podcast episode. Bempedoic is a once-daily medication that doesn’t need to be titrated. Standard dosing is 180mg once daily which can be taken with or without food.  What are the most common side effects of bempedoic acid? One of the most notable adverse effects is hyperuricemia. This is usually seen within the first 4 weeks of being on the medication but could happen throughout the treatment. Tendon problems can happen as well, especially in patients who are greater than 60 years old, on fluoroquinolones, have renal failure, or are taking corticosteroids. If Bempedoic acid is taken along with Simvastatin, it is recommended to avoid doses greater than 20mg. This is partly because Bempedoic Acid 180mg along with 40mg of Simvastatin was found to increase Simvastatin AUC by 2-fold. The mechanism of this interaction has yet to be reported. Pravastatin doses greater than 40mg are to be avoided as well due to an increased risk of myopathy. Atorvastatin and Rosuvastatin didn’t have any maximum dose considerations.

On this podcast episode, I discuss exenatide pharmacology, adverse effects, drug interactions, and much more! Exenatide has an immediate release formulation (Byetta) and a long acting formulation (Bydureon). I discuss the differences in this podcast episode. Byetta use has fallen out of favor due to frequent dosing, patient inconvenience and needing to time the dose 60 minutes prior to meals. I discuss the risk of pancreatitis related to GLP-1 agonists like exenatide in this podcast episode.

I discuss Pyridostigmine Pharmacology in this podcast episode in addition to adverse effects, drug interactions, and much more! Pyridostigmine is an acetylcholinesterase inhibitor that can be used for myasthenia gravis or orthostasis. Pyridostigmine can blunt the effect of neuromuscular blocking agents so patients undergoing surgery should be sure to have a game plan with their surgery team. Similar to donepezil, pyridostigmine can cause diarrhea and bradycardia.

On this podcast episode, I discuss simethicone pharmacology, adverse effects, drug interactions, and much more! Simethicone is primarily used for anti-gas purposes. It is most often used on an as needed basis for relief of flatulence and bloating associated with gas. Systemic absorption is minimal with simethicone so the occurrence of any systemic-type side effects at therapeutic doses is low. Simethicone may interfere with levothyroxine absorption. Timing levothyroxine at least a few hours prior to simethicone should help reduce the significance of this interaction.

On this podcast episode, I discuss fosinopril (Monopril) pharmacology, adverse effects, drug interactions and much more. Fosinopril is an ACE inhibitor so it should absolutely NOT be used in pregnancy as it poses fetus risks. Like other ACE inhibitors, hyperkalemia, cough, angioedema, and acute renal failure represent possible risks in using fosinopril. Drugs that can raise potassium when used in combo with fosinopril include spironolactone, trimethoprim, calcineurin inhibitors, and heparin.

On this episode of the Real Life Pharmacology podcast, I discuss haloperidol pharmacology, adverse effects, drug interactions and much more. Haloperidol comes in multiple dosage forms. Be very careful with the use of injectable haloperidol as there is an immediate and extended release formulation. Haloperidol is a dopamine antagonist which means that EPS adverse effects are going to be concerning. In hospice patients, haloperidol is frequently used for its antiemetic properties as well as its potential to help end-of-life restlessness and agitation.

In this promethazine pharmacology podcast, I discuss its mechanisms of action, side effects, important drug interactions, and much more. Promethazine has anticholinergic and dopamine-blocking activity which contributes to the adverse effect profile as well as its efficacy. There is a boxed warning with promethazine to avoid the use of this medication in patients under the age of 2 due to respiratory depression. Promethazine IV is considered a high-risk route of administration and should be avoided if possible.

In this episode, I discuss loperamide (Imodium) pharmacology, adverse effects, and drug interactions. Loperamide has opioid-type activity in the gut but has extremely low oral bioavailability. This allows it to be used for diarrhea but at lower doses won't cause systemic opioid-like effects. Loperamide abuse has been reported. Excessive dosages can increase the risk of cardiac arrest and other cardiovascular concerns. Medication causes of diarrhea should be ruled out prior to starting a medication like loperamide. I discuss numerous medications that can cause diarrhea in this podcast.

I discuss calcium carbonate pharmacology, adverse effects, drug interactions, and more in this podcast episode. Calcium tends to have a constipating effect and the higher the dose, the more likely patients are to experience this adverse effect. Binding interactions are a major problem with oral calcium carbonate. I lay out numerous examples of this on the podcast. There are a few medications that can increase calcium levels in the blood. Thiazide diuretics are a commonly used antihypertensive that may contribute to hypercalcemia.

On this episode, I discuss the pharmacology, adverse effects, and drug interactions of ramelteon (Rozerem). Ramelteon is primarily only helpful for sleep onset and generally is not that helpful in sleep maintenance. CNS depressant drug interactions will be a common concern to monitor. Opioids, benzodiazepines, and alcohol are common sedatives that can add to the effects of ramelteon. Some of the CYP enzymes break down Ramelteon. I discuss this in greater length in this podcast episode.

In this podcast episode, I discuss thiamine pharmacology and its important role in energy production. In patients with alcohol use disorder, thiamine deficiency can be somewhat common. Wernicke's encephalopathy can result from thiamine deficiency in patients with alcohol use disorder. Common symptoms from Wernicke's encephalopathy can include confusion, lethargy, and other central nervous system issues. Thiamine replacement can help treat this issue.

Dutasteride (Avodart) is a 5-alpha-reductase inhibitor. I discuss the pharmacology, adverse effects, and drug interactions on this podcast. Dutasteride reduces the size of the prostate over time. It takes a significant amount of time to provide symptom relief (usually at least 3-6 months). Dutasteride is broken down by CYP3A4 to a minor extent which means that strong CYP3A4 inhibitors may increase drug concentrations. When using dutasteride for BPH, remember to review the medication list for drugs that can cause urinary retention such as anticholintiercs and alpha-agonists.

On this episode, I discuss prazosin pharmacology, adverse effects, drug interactions and much more. Prazosin is an alpha-blocker but lacks selectivity. A reduction in blood pressure is expected, but it is notorious for causing orthostatic hypotension. Prazosin may be used off-label for nightmares, when this is the case, you will likely only see this drug dosed at bedtime. Alpha agonist medications (such as pseudoephedrine and ADHD stimulants) may counteract the effects of prazosin.

On this episode I discuss the pharmacology of tirzepatide. I'm appreciative of Derek Borkowski who operates Pyrls for providing a free PDF of the 2023 ADA Diabetes Guidelines when you subscribe for an account at Pyrls.com/rlp - Tirzepatide makes its first appearance in the diabetes guidelines for its ability to promote weight loss. Tirzepatide is a combination GIP and GLP-1 agonist that is currently indicated for diabetes with reductions of A1C in the range of about 2 points. Much like GLP-1 agonists, tirzepatide can cause GI upset and other gastrointestinal adverse effects like diarrhea. Tirzepatide doesn't have a large number of drug interactions which is nice. Corticosteroids can counteract its blood sugar-lowering effects while sulfonylureas and insulin may significantly increase the risk for hypoglycemia.

On this episode of the Real Life Pharmacology podcast, I cover methimazole adverse effects, mechanism of action, drug interactions, and much more! Methimazole and propylthiouracil are from the same class of medications and are used for hyperthyroidism. I go over some of the differences between these agents in this podcast episode. Methimazole is dosed once daily but can be split if the patient experiences significant GI adverse effects. T3 plays an important role in hyperthyroidism. I discuss the physiologic of T3 production and how methimazole creates its effects to lower thyroid hormone levels.

On this podcast episode, I discuss the pharmacology, adverse effects, and drug interactions of semaglutide. Semaglutide has two primary uses: Type 2 diabetes and Weight Management - the dosing varies depending upon the indication. When using semaglutide, pay attention to GI adverse effects. Nausea, diarrhea, and vomiting are the most common ADRs and are dose-dependent. Pay attention to corticosteroid bursts. They can cause substantial hyperglycemia and counteract the effects of diabetes medications like semaglutide.

Minocycline is a tetracycline antibiotic. I discuss pharmacology, adverse effects, and drug interactions. Minocycline can cause sun sensitivity. Be sure to educate patients about this risk. Metal cations like iron, zinc, calcium, and magnesium can bind minocycline and reduce the oral absorption of the medication. Tooth discoloration is a possible adverse effect if minocycline is given to pediatric patients. I discuss it further in this episode.

In this podcast episode, I cover propylthiouracil pharmacology, adverse effect, drug interaction, and much more! Propylthiouracil carries a boxed warning for hepatotoxicity which is a significant downside compared to the other agent in its class (methimazole). What about dosing? I discuss why this medication has to be dosed multiple times per day. Drug interactions aren't incredibly common with propylthiouracil but it can affect warfarin differently than most drug interactions. I discuss it further in this episode.

Brexpiprazole (Rexulti) is a second generation antipsychotic. I discuss its pharmacology, adverse effects, drug interactions, and more in this podcast episode. I like to associate brexpiprazole with aripiprazole. They have a lot of overlapping characteristics, particularly in relation to the adverse effect profile. Brexpiprazole tends to have a low incidence of metabolic adverse effects which makes it a nice selection for patients who have diabetes, hypercholesterolemia, or who are overweight. CYP3A4 and CYP2D6 are the two primary enzymes that break down brexpiprazole. I discuss the pharmacogenomic considerations associated with this medication.

On this episode, I discuss indapamide pharmacology, adverse effects, drug interactions, and pharmacokinetics. I discuss how indapamide differs from other thiazide diuretics. Particularly, I discuss indapamide compared to hydrochlorothiazide. Frequent urination, hypokalemia, and dehydration are all possible risks with indapamide. Pay attention to medications that can increase the risk for acute renal failure when added to indapamide. NSAIDs, ACEIs, ARBs, and other diuretics can increase this risk.

On this episode, I discuss tadalafil pharmacology, adverse effects, pharmacokinetics, and drug interactions. Tadalafil has a significantly longer half-life than sildenafil. I discuss how this is going to impact a patient that may need a nitrate. PDE-5 inhibitors like tadalafil are most commonly used for erectile dysfunction but I talk about other unique indications in the podcast. Daily use or as-needed use of tadalafil are both acceptable options but there are some quirks you need to know with these two methods of use.

Sitagliptin is a DPP4 inhibitor. I discuss the pharmacology of this medication on the podcast. Which diabetes medication works similarly to sitagliptin? I discuss that further on this episode of the Real Life Pharmacology podcast. Renal elimination plays a significant role with sitagliptin. I discuss how this impacts the appropriate dosing. Cost is a significant issue with sitagliptin at this time. In addition, it's A1C-lowering effects aren't anything to write home about. I discuss how much it will lower A1C in this podcast episode.

On this podcast episode, I discuss gabapentin (Neurontin) pharmacology, adverse effects, drug interactions, and much more! Gabapentin's GI absorption is a little wacky. I discuss on the podcast the clinical effects that this may have on our patients. Renal elimination is critical to gabapentin. Worsening renal function will significantly impact the action of the drug. CNS sedation can be a problem with gabapentin, especially in combination with other CNS depressants. I discuss this further on the podcast.

Ranolazine is primarily used for chronic angina management. I discuss pharmacology, drug interactions, adverse effects, and more in this podcast episode. Ranolazine is well known to have drug interactions. CYP3A4 is of major importance but there are other subtle drug interactions that are important. QTc prolongation has been reported with ranolazine so it is important to recognize risk factors and other medications that may contribute to this concern. Enzyme inducers like carbamazepine, phenytoin, and St. John's wort are all associated with reducing the concentrations of ranolazine.

On this podcast episode, I discuss lorazepam (Ativan) pharmacology, adverse effects, and common drug interactions. Lorazepam has numerous dosage forms and the IV formulation does contain propylene glycol which can accumulate if it is used for longer periods of time. There is a boxed warning for lorazepam when it is used with opioids. The risk for opioid overdose, coma, and death increases significantly. Lorazepam is an intermediate acting benzodiazpine. It's half-life for most adult patients is in the 12-18 hour range.

On this podcast episode, I discuss valsartan pharmacology, adverse effects, drug interactions, and much more. Valsartan is a fairly common ARB. I mostly see losartan and valsartan used as the most common ARBs in hypertension management. Valsartan has a longer half-life than losartan which is why we can often get away with once daily dosing compared to losartan which sometimes requires twice daily. Hyperkalemia is a major concern with ARBs like valsartan. Trimethoprim and spironolactone are two medications that can increase this risk.

On this podcast episode, I discuss famotidine pharmacology, adverse effects, uses, and drug interactions. Famotidine is generally pretty well tolerated, but one thing I look out for with chronic use is B12 deficiency. Famotidine is eliminated by the kidney so you should pay attention to the dose in patients with CKD. Famotidine is occasionally used as a pretreatment to help prevent infusion-type reactions for certain chemotherapy agents.

On this podcast episode, I discuss clonazepam pharmacology, adverse effects, pharmacokinetics, and drug interactions. Clonazepam is a benzodiazepine that enhances the activity of GABA which is an inhibitory neurotransmitter in the central nervous system. It is important to try to avoid using benzodiazepines like clonazepam with opioids as it can increase the risk of respiratory depression and death. Clonazepam is an intermediate-acting benzodiazepine that is only commercially available as an oral dosage form.

In this podcast episode, I break down the pharmacology, adverse effects, pharmacokinetics, and drug interactions of phentermine. Phentermine has some CNS stimulant activity so adverse effects like insomnia, hypertension, and tachycardia are possible. Pay attention to drugs that can oppose the effects of phentermine and cause weight gain such as mirtazapine and sulfonylureas. Phentermine is a controlled substance so the risk of addiction and dependence is possible.

On this podcast episode, I discuss glimepiride pharmacology, adverse effects, hypoglycemia symptoms, and drug interactions. CYP2C9 is an important enzyme in the breakdown of glimepiride. I discuss a few drugs that can cause interactions via this enzyme. Renal function is important to consider with glimepiride. The active metabolites are cleared by the kidney and can accumulate in CKD. Hypoglycemia and weight gain are problematic adverse effects of this medication and are the primary reasons it has fallen out of favor.

On this podcast episode, I discuss cephalexin pharmacology, adverse effects, drug interactions, and much more! Penicillin allergies and cross-reactivity are common questions with regard to the use of cephalexin and I discuss this briefly in the podcast episode. Cephalexin is a first-generation cephalosporin with its primary sweet spot being gram-positive bacteria like Staph and Strep species. Warfarin, probenecid, zinc, and a couple of others are potential medications that can interact with cephalexin. I discuss this further in this podcast episode.

On this episode, I discuss ceftriaxone pharmacology, adverse effect, coverage, and drug interactions. Ceftriaxone is currently a drug of choice for the STI Gonorrhea. Pyrls.com has an amazing chart on all the STIs and their drugs of choice that you can get for free when you sign up for a free account! Ceftriaxone is a third-generation cephalosporin that is used for numerous indications such as pneumonia, meningitis, gonorrhea, and many more. It is important to remember that ceftriaxone can cover many staph and strep species but it does NOT cover MRSA. Ceftriaxone does have some risks, particularly in pediatric patients. I discuss elevated bilirubin and calcium binding risks in the podcast.

Lactulose is an osmotic laxative but it is rarely used for this purpose. I discuss lactulose pharmacology in this episode. Elevated ammonia levels are an issue in hepatic encephalopathy. Lactulose can help manage this issue. Lactulose is dosed to 2-3 soft stools per day when used to reduce ammonia levels. Lactulose can increase the effect of warfarin and raise INR; I discuss this further on this episode.

On this episode, I discuss ticagrelor pharmacology, adverse effects, and important drug interactions. Ticagrelor has a warning with regards to the use of aspirin. Higher doses of aspirin can impair the effectiveness of ticagrelor and I discuss this further on this episode. Bleeding is the major adverse effect from ticagrelor and naturally, hematocrit and hemoglobin are important monitoring parameters. I discuss CYP3A4 drug interactions on this episode and how it may affect ticagrelor.

On this podcast episode, I discuss lurasidone pharmacology, adverse effects, and drug interactions. CYP3A4 is an important enzyme in the breakdown of lurasidone. I discuss this further on this episode. Lurasidone is best taken with food as this enhances absorption and helps improve drug concentrations. Lurasidone tends to have a lower risk for metabolic syndrome compared to other antipsychotics which is a nice advantage.

Isavuconazole is an azole antifungal that can be used for various fungal infections. In this episode, I discuss isavuconazole pharmacology, adverse effect, drug interactions, and pharmacokinetics. Isavuconazole is interestingly associated with QT shortening which is different from most azole antifungals that cause QT prolongation. Oral bioavailability of isavuconazole is nearly 100% so dose conversions between IV and oral are typically not difficult to navigate.

On this episode, I cover ethinyl estradiol pharmacology. This is a common component of oral contraceptives. You have to check out this free resource (with free account) from Pyrls.com/rlp which lists all the different combinations and brand names. All it takes is to simply sign up for a free account here. Ethinyl estradiol dosing can vary. Breakthrough bleeding is a major reason why a patient might prefer a higher dose. Blood clot risk is a real problem with ethinyl estradiol. There are numerous situations where we should avoid ethinyl estradiol and I cover them in this episode. Be careful with enzyme inducers like carbamazepine, rifampin, etc. as they can reduce the concentrations of oral contraceptives

On this episode, I discuss olmesartan (Benicar) pharmacology, adverse effects, drug interactions, and pharmacokinetics. Olmesartan can cause a unique GI adverse effect called enteropathy. I discuss this on this podcast episode. Important monitoring parameters for olmesartan include potassium, renal function, and blood pressure. Olmesartan has a longer half-life than losartan. I discuss how this might be advantageous in clinical practice.

On this episode, I discuss desvenlafaxine pharmacology, adverse effects, pharmacokinetics, and drug interactions. Desvenlafaxine is a serotonin and norepinephrine reuptake inhibitor that can be used for depression. Renal elimination is an important method of deactivation of desvenlafaxine. Dose adjustments may be recommended as renal function drops below 50 mls/min. Withdrawal syndrome due is a risk with desvenlafaxine as it has a significantly short half-life.

Pramipexole (Mirapex) is a dopamine agonist that can be used in Parkinson’s disease and Restless Legs Syndrome. Dopamine agonists like pramipexole can worsen psychiatric symptoms in some patients by causing hallucinations, and obsessive/compulsive symptoms. Nausea, vomiting, hypotension, and fatigue are the most common adverse effects of pramipexole. Pramipexole is primarily eliminated through the urine. I discuss how this matters clinically in greater detail in this podcast episode.

I mentioned prednisolone to prednisone conversion in this podcast. Please go check out Pyrls.com for a free steroid conversion downloadable PDF with a free account! On this episode, I discuss prednisolone (Orapred, Pediapred) pharmacology, adverse effects, practice pearls, and drug interactions. Prednisolone is a systemic corticosteroid that can cause insomnia, elevations in blood sugars, and numerous effects if used long-term. CYP3A4 is an important enzyme in the breakdown of prednisolone. Inhibitors or inducers may raise or lower drug levels respectively.

On this episode, I discuss bisoprolol (Zebeta) pharmacology, adverse effects, drug interactions, and other important clinical pearls. Bisoprolol is a beta-1 selective antagonist that can be used for atrial fibrillation, angina, and other cardiovascular indications. It is important to remember that bisoprolol and other beta-blockers are not considered first-line agents for hypertension alone. Beta-receptor selectivity does start to disappear with bisoprolol as you get to higher dosages. I discuss this further in the podcast.

Lansoprazole is a proton pump inhibitor that can be commonly used for GERD, PUD, and GI prophylaxis. Lansoprazole can inhibit CYP2C19 which can cause concentrations of drugs like escitalopram and citalopram to rise. Hypomagnesemia, low B12, osteoporosis, and an increase in C. Diff risk are potential complications with longer-term PPI use. PPIs like lansoprazole are best given 30-60 minutes before meals. This is something that patients often forget. I discuss important drug interactions on the podcast, be sure to check out my latest project which is a 200+ page book on managing drug interactions in primary care. Be sure to check out our free Top 200 study guide – a 31-page PDF that is yours for FREE!

Ropinirole (Requip) is a dopamine agonist that can be used in Parkinson's disease and Restless Legs Syndrome. Dopamine agonists like ropinirole can worsen psychiatric symptoms in some patients by causing hallucinations, and obsessive/compulsive symptoms. Nausea, vomiting, hypotension, and fatigue are the most common adverse effects of ropinirole. Ropinirole has drug interactions with antipsychotics and CYP1A2 inhibitors. I discuss these in greater detail in this podcast episode.

On this episode of the podcast, I cover budesonide (Pulmicort) pharmacology. Our sponsor (Pyrls.com/rlp) for this episode is providing a FREE PDF of their inhaled corticosteroid categorizations chart (i.e. low/medium/high dose ICS) when you sign up for a free account! The onset of action of inhaled budesonide is several hours up to a few days. Patient education is critical to ensure that patients stick with its use. Budesonide does have a nebulized formulation that is often used in pediatrics and geriatrics. There aren't a ton of critical drug interactions, but you should think about medications that inhibit CYP3A4 and may have additive immunosuppressive effects.

Epoetin alfa (Epogen, Procrit) is an erythropoiesis-stimulating agent that can be used for various types of anemia. ESA's like epoetin carry a boxed warning as they increase the risk of cardiovascular events like MI, stroke, and blood clots. Assessing iron stores is critical when epoetin is used to ensure that a non-response is not due to deficiency. I discuss dosing adjustments of epoetin in the podcast. One must be careful about raising hemoglobin too quickly.

Canagliflozin is an SGLT2 inhibitor. I discuss the pharmacology, dosing, adverse effects, and drug interactions of this medication. Canagliflozin reduces blood sugar, by facilitating its exit through the urine. This can increase the risk of genitourinary infections. A diuresis type effect can happen due to canagliflozin and this effect may be exacerbated by the use of thiazide and loop diuretics. Hyperkalemia has been reported with the use of canagliflozin; the risk for this is increased with the use of medications like ACE inhibitors, ARBs, and aldosterone antagonists.

Cabergoline is a dopamine agonist. I discuss the pharmacology, adverse effects, and drug interactions in this podcast episode. Be on the lookout for drugs that could oppose the effects of cabergoline such as antipsychotics and metoclopramide. Cabergoline can be used for hyperprolactinemia management and may cause adverse effects like hypotension and GI upset. Cabergoline has a very long half-life so it is most often only dosed 1-2 times per week.

In this episode, I discuss venlafaxine pharmacology, adverse effect, dose conversion of IR to ER, and drug interactions. Venlafaxine is notorious for producing withdrawal symptoms when discontinued abruptly. I discuss these in detail on the podcast. How significant is the interaction of venlafaxine with antiplatelet agents? I discuss that in this episode. The onset of action is a critical education point that patients must be aware of as it takes some time for venlafaxine to work.

On this episode I discuss chlorthalidone pharmacology, adverse effects, and recent literature regarding cardiovascular disease reduction. Our friends at Pyrls.com are offering a free diagram of the nephron including the mechanism of action AND a summary of diuretic effects that I discussed on the podcast - Go sign up and get these for free and support this awesome sponsor! Chlorthalidone is a thiazide diuretic that uniquely raises blood calcium levels compared to loop diuretics which lower calcium levels. There was a recent piece of literature (2020) comparing chlorthalidone versus hydrochlorothiazide. It found that chlorthalidone was no more effective than HCTZ. Remember that chlorthalidone can raise uric acid and increase the risk of gout flares.

On this episode, I discuss verapamil pharmacology, adverse effects, and important drug interactions. There are numerous drug interactions to be aware of with verapamil as it inhibits the enzyme CYP3A4. Verapamil is a calcium channel blocker (non-dihydropyridine) that blocks calcium channels in the heart and vessels. In addition to hypotension and bradycardia, verapamil can cause constipation which may be more prominent in our geriatric patients.

In this episode, I cover salmeterol (Serevent) pharmacology, adverse effects, drug interactions and special warnings with this medication. Salmeterol is a long acting beta agonist that can be used in combination with inhaled corticosteroids for management of asthma. Salmeterol can be used as monotherapy in COPD and should not be used as monotherapy in asthma. Elevations in pulse and blood pressure can happen with a beta agonist like salmeterol.

On this episode, I discuss esomeprazole (Nexium) pharmacology, adverse effects, tapering, kinetics, and drug interactions. I spend a good amount of time discussing the esomeprazole and clopidogrel interaction in this podcast episode. Esomeprazole inhibits CYP2C19. This can cause an increase in citalopram concentrations and raise the potential for QTc prolongation. It is critical to reassess the length of therapy and the dose of PPIs like esomeprazole.

On this episode of the Real Life Pharmacology podcast, I discuss carvedilol pharmacology, drug interactions, and adverse effects. Carvedilol is one of the few beta-blockers that has alpha-blocking activity. Carvedilol is almost exclusively metabolized by various CYP enzymes so renal function changes typically don't change drug concentrations to a significant extent. Beta-blockers like carvedilol are well known to cause the adverse effects of fatigue and sexual dysfunction.

On this episode, I discuss umeclidinium pharmacology, adverse effects, patient education pearls, and drug interactions. Umeclidinium is used in the management of COPD. Below is an excellent quick overview of the COPD guidelines from pyrls.com - You can get the full PDF by signing up for a free account at pryls.com/rlp Umeclidinium is a long-acting anticholinergic (anti-muscarinic) LAMA and as you can see from the figure above drugs from this class are frequently used in COPD management. The brand name of umeclidinium is Incruse Ellipta. Ellipta refers to the device and not the drug umeclidinium.

On this episode, I discuss denosumab pharmacology, adverse effects, clinical pearls, and drug interactions. Whenever I see an osteoporosis medication like denosumab used, I review the medications to ensure that we avoid medications that can cause osteoporosis. Denosumab is often used as a potential alternative in osteoporosis management for those that cannot tolerate bisphosphonates. We need to monitor calcium levels when using denosumab as levels can be dangerously low, especially when used in combination with other calcium lowering drugs. Loop diuretics and cinacalcet can have additive hypocalcemia effects when used in combination with denosumab.

On this episode I discuss roflumilast (Daliresp) pharmacology, adverse effects, and important drug interactions. Roflumilast is indicated to reduce the incidence of COPD exacerbations. Roflumilast is significantly broken down by CYP3A4 so there are numerous drug interactions that we have to take into account. Psychiatric issues, GI upset, and weight loss are all potential adverse effects due to roflumilast.

On this episode, I breakdown trihexyphenidyl (Artane) pharmacology, adverse effects, and drug interactions. Trihexyphenidyl is highly anticholinergic and can cause constipation, dry eyes, dry mouth, and urinary retention. Dementia medications like donepezil can have their effects blunted by the use of trihexyphenidyl. Trihexyphenidyl is an older anticholinergic that is rarely used for the management of EPS caused by antipsychotics.

On this episode, I discuss liraglutide pharmacology, drug interactions, and adverse effects. Liraglutide is well known to cause nausea. It is important to assess the severity of nausea as it may subside in some patients as they gain tolerability to the medication. We mentioned the 2022 Diabetes Guideline Cheat Sheet in the podcast - you can get that for free at pyrls.com/rlp Liraglutide has a fairly low risk of hypoglycemia when used alone, but this risk increases when it is used with insulin or sulfonylureas. Saxenda is the weight loss formulation of liraglutide and dosing is higher for weight management than it is for diabetes management.

On this episode, I discuss losartan pharmacology, adverse effects, drug interactions, and appropriate monitoring. Losartan is an ARB and can increase potassium levels. Keep an eye out for medications like spironolactone and trimethoprim which can increase this risk further. Losartan has been shown to lower uric acid levels which could potentially be helpful in patients with gout. Monitoring renal function is very important with losartan. The risk of ARF goes significantly higher when used with NSAIDs or diuretics.

On this episode, I breakdown pravastatin pharmacology, adverse effects, drug interactions and when you might see this drug used in practice. Pravastatin is a statin and will lower LDL. Its use is a little limited in the fact that it is not as potent as other agents in its LDL lowering effects. Pravastatin is hydrophilic which differentiates it from simvastatin, atorvastatin, and lovastatin. I describe rhabdomyolysis in this podcast as it is a potential rare adverse effect of pravastatin.

On this episode, I discuss clomiphene pharmacology, adverse effects, clinical practice pearls, and drug interactions. Clomiphene is a commonly used medication to help manage female infertility. Clomiphene is oral and relatively inexpensive compared to other agents that are used for infertility management. Clomiphene is a SERM so you can anticipate that some patients may report vasomotor symptoms like flushing and hot flashes.

Fluticasone (Flonase) is a nasal corticosteroid that is used in the management of allergic rhinitis. A primary adverse effect that I have seen in practice with fluticasone is the risk for nose bleeds. Flonase can have some interactions via CYP3A4. Inhibitors of CYP3A4 like clarithromycin can increase concentrations. While the risk for systemic exposure is low with nasal fluticasone, long-term, high dose, and frequent use should be monitored appropriately.

On this episode, I discuss (Carafate) sucralfate pharmacology, adverse effect, kinetics, and drug interactions. Sucralfate is notorious for drug binding interactions and can reduce the concentrations of many drugs which I cover in the podcast. Four times daily dosing is a big downside to sucralfate and why it isn't used terribly often for GI issues like esophagitis. The suspension formulation of sucralfate does contain some sugar so be aware of this in our diabetes patients.

On this episode, I discuss atenolol pharmacology, adverse effects, pharmacokinetics, and drug interactions. Atenolol is primarily cleared by the kidney which should tell you that we need to pay attention to dose adjustments as renal function declines. Atenolol is a beta-1 selective agent that is NOT a preferred beta-blocker in HFrEF. Pulse and blood pressure monitoring is essential with any beta-blocker like atenolol.

On this episode, I discuss hydromorphone pharmacology, adverse effect, and drug interactions. I discuss the pharmacokinetics of hydromorphone and also discuss the relative potency compared to other opioids. Hydromorphone drug interactions are mostly additive effects. Drugs that cause sedation or constipation can have additive effects on hydromorphone. Be extremely careful with hydromorphone dosage forms. There are numerous different concentrations and strengths. I discuss this in this episode.

On this episode, I discuss duloxetine pharmacology, adverse effects, and common drug interactions. Duloxetine is an SNRI that is used for depression, anxiety, and various pain syndromes like neuropathy and fibromyalgia. Duloxetine can inhibit CYP2D6 which can lead to higher concentrations of clozapine and propranolol and lower activity of tamoxifen. CYP1A2 inhibitors like ciprofloxacin can raise concentrations of duloxetine leading to an increased potential for adverse effects.

Lasmiditan (Reyvow) is an agent that is utilized for acute migraine treatment. It works slightly differently than triptans which I discuss on this episode. Lasmiditan is a relatively new agent and cost will often limit its use at this time. Rosuvastatin and sulfasalazine are two common medications that may have concentrations increase when lasmiditan is used. I discuss this in detail on this episode. Lasmiditan is an oral tablet that is only recommended to give once per day which differs from commonly used triptans where the dose can be repeated.

On this episode, I discuss sumatriptan pharmacology, adverse effects, drug interactions and more. Dosage forms can provide different methods of drug delivery and I talk about many different sumatriptan dosage forms in this episode. Cardiovascular risks need to be assessed when using a drug like sumatriptan. I discuss this in greater detail in the podcast. Sumatriptan has serotonergic activity and we need to assess the risk of serotonin syndrome in our patients.

On this episode of the Real Life Pharmacology Podcast, I discuss bumetanide pharmacology, adverse effects, and drug interactions. Bumetanide is a loop diuretic and it is critical to monitor renal function and electrolytes with this medication. Ototoxicity is a rare adverse effect that is dose-dependent and can be worsened by aminoglycosides. It is critical to look for drugs that can worsen edema when using bumetanide to ensure that we avoid the prescribing cascade.

On this episode, I discuss oxycodone pharmacology, adverse effect, pharmacokinetics, and drug interactions. Oxycodone is broken down by CYP3A4 and CYP2D6. I discuss this further on the podcast and how interactions may alter concentrations. When a patient stops taking oxycodone after being on it for some time, you must recognize common symptoms of withdrawal. Oxycodone comes as in an extended-release and immediate-release oral formulation.

On this episode of the Real Life Pharmacology podcast, I explore doxycycline pharmacology, adverse effects, and drug interactions. Doxycycline can be bound by numerous minerals like calcium, magnesium, and iron. Coadministration can lead to reduced concentrations. Sun sensitivity is a really important adverse effect that can be caused by doxycycline. Be sure to educate your patients. Doxycycline can be used as an alternative to beta-lactams and macrolides in the management of community-acquired pneumonia.

On this episode, I discuss tolterodine pharmacology, adverse effects, and drug interactions. Tolterodine (Detrol) is an anticholinergic medication used to manage the symptoms of overactive bladder. Tolterodine's anticholinergic activity can lead to a significant number of adverse effects like dry mouth, dry eyes, constipation, and urinary retention. Elderly patients may be at greater risk for anticholinergic adverse effects from tolterodine compared to younger patients. Tolterodine can have additive effects from other anticholinergics like diphenhydramine or TCAs which enhance its potential for side effects.

On this episode, I discuss clarithromycin pharmacology, adverse effects, and drug interactions. Clarithromycin is a macrolide antibiotic that can be used for many similar indications as azithromycin. Clarithromycin has numerous drug interactions as it can inhibit CYP3A4. This limits its use in practice. Clarithromycin can be used in the treatment of H. pylori in combination with other antibiotics and a PPI.

On this episode, I discuss azathioprine pharmacology, adverse effects, monitoring parameters, and drug interactions. Azathioprine is classified as an immunosuppressive agent so it is naturally going to be used for autoimmune type disorders and transplantation. Azathioprine has a boxed warning for myelosuppression. I talk more about this in the episode. Genetic testing is recommended by the AGA prior to the use of azathioprine. I discuss which tests might be helpful to reduce the risk of toxicity.

On this episode, I discuss amitriptyline pharmacology, adverse effects, and drug interactions.

On this episode of the podcast, I discuss my approach and strategies to handle grapefruit juice interactions. Grapefruit juice causes drug interactions by inhibiting the CYP enzyme system. More specifically, it inhibits CYP3A4 which is responsible for the breakdown of many medications. Quantity is always an important consideration when assessing grapefruit juice interactions. The more that is taken, typically, the more drug concentrations will be affected. It is important to assess the use of grapefruit juice when your patient has a history of cardiovascular disease, cardiac conditions, pain, mental health disease, or gout as some medications used to treat these diseases can interact with grapefruit juice. If you are looking for more content on drug food interactions, be sure to check out my book in the links below.

On this episode, I cover pantoprazole pharmacology, adverse effects, and drug interactions.

On this episode, I discuss rosuvastatin pharmacology, adverse effects, drug interactions and pharmacokinetics. Rosuvastatin is a hydrophilic statin which differs from some of the most commonly used statins like simvastatin and atorvastatin. Rosuvastatin is minimally affected by CYP3A4 drug interactions so that is a small potential advantage over simvastatin and atorvastatin. At dosages of 20-40 mg, rosuvastatin is considered a high intensity statin and can bring down LDL by over 50%.

On this episode, I discuss atorvastatin pharmacology, adverse effects, monitoring parameters, and drug interactions. Atorvastatin (Lipitor) is an HMG-CoA reductase inhibitor, the rate-limiting step in the production of cholesterol. It is used to prevent atherosclerotic cardiovascular diseases by decreasing cholesterol. Atorvastatin is more lipophilic in comparison to other statins such as rosuvastatin. If a patient does not tolerate a statin, switching from a lipophilic to a hydrophilic or vice versa may decrease the chances of those side effects reoccurring. It can be a high-intensity statin depending on the dose. 10-20mg is considered moderate and 40-80mg is classified as high intensity. Not all statins can reach high-intensity doses, which is why atorvastatin is so commonly used.             The FDA as of July 2021, has requested to remove the contraindication of pregnancy from the prescribing information. Here’s more information on that specific change and why it was requested. I’d encourage you to read it.  Atorvastatin is commonly found to have adherence issues so it should be taken whenever it is going to be best remembered by the patient. Common adverse effects include myopathy, muscle pain, and soreness. Many elderly patients can be overlooked when they experience aches and pains, so it is important to take their medications into consideration. There are rare risks of liver injury and rhabdomyolysis. CPK and LFTs do not need to be regularly monitored if no symptoms are present.   Remind patients that their cholesterol will not be lowered right away. They will usually have their levels rechecked in 3-6 months. Drugs that increase rhabdomyolysis risk when used concurrently include fibrates, red yeast rice, niacin, daptomycin. Monitor these patients closely for symptoms of muscle pain. Can also monitor CPK and decrease the dose of the statin in these patients. 3A4 interactions can increase the concentration of statins. These include clarithromycin, grapefruit juice, amiodarone, amantadine, and verapamil. 3A4 inducers can decrease the concentration of statins. These include St. John’s Wort and carbamazepine. 

On this episode, I discuss gemfibrozil pharmacology, adverse effects, and important drug interactions.

On this episode, I discuss trospium pharmacology, adverse effects, and important drug interactions you should know. Trospium chloride (Sanctura) is a bladder antimuscarinic or anticholinergic. It blocks the action of acetylcholine in bladder smooth muscle. It is used for urinary frequency and overactive bladder. The immediate-release formulation is taken twice a day. There is an extended-release version that is more expensive. As its classification suggests it is going to have anticholinergic effects that include dry eyes, dry mouth, constipation, urinary retention, GI tract slowing down, CNS sedation, and increased risk of falls. Compared to older bladder anticholinergics such as oxybutynin or tolterodine there is less CNS penetration. Hopefully, this will cause the patient to experience fewer CNS side effects. A downside to this being a newer medication is that it costs more. Trospium is on the BEERS list. Look for medications started after the trospium that indicate anticholinergic side effects such as saliva substitutes, an increase in BPH medications, artificial tears, or constipation medications. It should be administered on an empty stomach as food can block absorption. If the patient is currently taking it with food and seeing results there is no need to change how they are taking it. Trospium is not metabolized by CYP enzymes minimizing drug interactions. Most interactions occur because of additive effects. Avoid using it with other medications on the BEERS list, especially other anticholinergic medications. Be cautious using other medications with sedative effects and CNS depression (benzodiazepines, sleep medications, opioids, alcohol) as they may have additive effects.

On this episode, I discuss propranolol pharmacology, adverse reactions, and important drug interactions you should know. Propranolol (Inderal) is a non-selective beta-blocker. There are many indications for it including hypertension, tachycardia, atrial fibrillation, post-MI, chronic stable angina, essential tremors, migraine prophylaxis, esophageal varices, performance anxiety disorder, lithium-induced tremor, psychotic induced akathisia, and thyroid storm. Propranolol blocks beta-1 receptors that are commonly referred to as the cardiac receptors and beta-2 receptors that are in the lungs. Albuterol is a beta-2 agonist meaning that propranolol can block its effects. This may lead to bronchospasms and worsening of respiratory conditions. This is one of the major issues when using a non-selective beta-blocker vs a selective one. Other adverse effects include a drop in blood pressure and pulse. Fatigue is also seen in many geriatric patients so it is important to be titrating them up slowly. If you notice patients increasing caffeine intake, starting a stimulant, or experiencing new depression symptoms that can be a sign of fatigue. Sexual dysfunction has also been seen in patients taking propranolol. Propranolol may mask symptoms of hypoglycemia. Closely monitor patients that are taking insulin and/or sulfonylureas. Abrupt discontinuation can increase the risk for acute coronary syndromes, especially if the patient is already at risk. Make sure that the medication is taken consistently and there aren’t periods of multiple missed doses. Propranolol comes in multiple dosage forms that have been mixed up. When dispensing or administering take extra caution that the medication is correct. Propranolol is a weak CYP1A2 inhibitor that could increase concentrations of tizanidine or theophylline. Propranolol also gets broken down by CYP1A2. Medications that inhibit this enzyme can increase the concentration of propranolol. Examples of these are ciprofloxacin and fluvoxamine. Inducers of CYP1A2 can reduce concentrations. These are rifampin, carbamazepine, and phenobarbital. A unique CYP1A2 inducer is smoking tobacco. Medications can cause additive effects when it comes to blood pressure and pulse. Be careful with any blood pressure-lowering medications including antihypertensives, PDE5 inhibitors (sildenafil), and Parkinson’s medications (Sinemet). Drugs that can lower pulse include centrally acting alpha 2 antagonists (clonidine) and acetylcholinesterase inhibitors (donepezil, rivastigmine).

On this episode, I discuss quetiapine pharmacology, adverse effects, pharmacokinetics, and drug interactions. Quetiapine (Seroquel) is a medication seen a fair amount, particularly in the geriatric population where there is psychosis associated with dementia. It is classified as an antipsychotic. Mechanistically it's going to block dopamine receptors, specifically D2. It also has some serotonin receptor blockade antagonism. It does have other activity as well from a mechanism of action standpoint. There is alpha-blocking activity potentially as well as an antihistamine/anticholinergic type of activity. Uses of this medication are schizophrenia, bipolar disorder with associated mania, miscellaneous psychotic disorders, and Parkinson’s type disease with psychosis. Off-label you may see it used for OCD, or augmentation for PTSD and depression. There is a boxed warning of increased risk of mortality in elderly/dementia patients. As a class, antipsychotics have extrapyramidal symptoms, metabolic syndrome, anticholinergic activity, QTC prolongation, sexual dysfunction, hyperprolactinemia, neuroleptic malignant syndrome, sedation, fall risk, and potentially a drop in blood pressure as well. With quetiapine, it is important to recognize that antipsychotics can have varying degrees of how much these adverse effects happen and a lot of them are dose-dependent. There are three important points in comparison to other antipsychotics. Quetiapine is not that great as far as metabolic syndrome risk goes. It's in the middle of the other antipsychotics. Its extrapyramidal symptoms are better than most, which is why it’s used so often in Parkinson’s. Quetiapine tends to be more sedating than other antipsychotics. This can be helpful when patients are having psychosis worse in the evening or at night. Metabolic syndrome is something to worry about more in younger patients. The long-term risk of diabetes and hyperlipidemia is going to be a lot higher for them than an 80-year-old using a low dose for dementia-related aggression. 3A4 is a pathway of breakdown for quetiapine drug interactions. With larger food intakes absorption can increase about 15% to 25% and that's in the area under the curve. This is not something to be very concerned about unless patients change the way they take it.  Quetiapine’s drug interactions are mostly additive effects. Watch out for other sedative drugs such as alcohol, opioids, and benzodiazepines. The same goes for drugs causing QT prolongation. Quetiapine has alpha-blocking activity and an added effect on patients with borderline low blood pressure or at risk for falls. It also mechanistically has a potential antihistamine burden that can play a role in adding on to anticholinergic effects. Then lastly it is metabolized partly by CYP3A4 so there is some potential there for drug interactions. Classic enzyme inducers are St. John's Wort and carbamazepine which would lower the concentration of quetiapine. Eric Christianson, PharmD, BCPS, BCGP Information for the podcast is obtained from various sources including the Highly Rated Flippin' Pharmacology Flashcards which you can find on Amazon by clicking here!

On this episode, I discuss phenazopyridine pharmacology, adverse effects, and potential drug interactions.

On this episode, I discuss fluvoxamine pharmacology, adverse effects, and most importantly, drug interactions.

On this episode, I discuss oxybutynin pharmacology, drug interactions, and adverse effects.

On this episode, I will discuss glyburide pharmacology.

On this episode, I discuss the pharmacology of zaleplon including side effects, drug interactions, and important clinical pearls. Zaleplon is a non-benzodiazepine sleep aide commonly known as Sonata. It is commonly used for sedation and the management of insomnia. Zaleplon is a controlled medication, with a high risk for dependence, and because of that, it is best used to treat short-term insomnia. The pharmacology of zaleplon is similar to other sleep aids like Ambien, and Lunesta; they all have an impact on GABA. Specifically, zaleplon regulates the GABABZ receptor. The GABABZ receptor has been shown to be responsible for the pharmacological properties of benzodiazepines which produce sedative, anxiolytic, relaxant, and anticonvulsive effects. For pharmacokinetics, zaleplon has a general onset of action around 30-60 minutes, because of that it is best dosed closer to bedtime.  For sedatives, and other drugs similar to zaleplon, it is generally better to start at lower doses in geriatrics and smaller patients. The commonly accepted dosing is between 5-20 mg, but it is best to use non-pharmacological therapies, instead of pharmacological whenever possible. The most common side effect that may be experienced with zaleplon is next-day sedation, also known as hangover sedation. Loss of mental clarity, dizziness, and confusion may also be present. Serious side effects of taking zaleplon are abnormal sleep behaviors, which it carries a US boxed warning for, and risk of dependence. Zaleplon is also on Beer’s list because of the increased risk of falls, delirium, and increased complications while driving due to sedation and lethargy.  When a sedative is first prescribed, it’s important to first look at the other medications a patient may be taking to see if that’s what may be causing insomnia. For example, a diuretic administered at night can cause excessive urination that can lead to insomnia. The addition of stimulants too late in the day can also cause that, and similarly, lifestyle changes like increased intake of caffeine can increase the risk for insomnia as well.  Most of the drug-drug interactions that zaleplon has are due to additive depressive effects. Examples include alcohol, opioids, older antihistamines, trazodone, or any medication that can cause sedation. There is also a smaller risk for CYP3A4 interaction. Concurrent administration of an inducer, like St. John’s Wort, or carbamazepine, can lower the concentrations of zaleplon. Likewise, inhibitors may increase concentrations. In cases of overdose, the signs and symptoms that will most likely precipitate are exaggerations of zaleplon’s adverse effects. The manifestations of CNS depression can range from drowsiness to coma. More mild cases might have drowsiness, confusion, and lethargy; while more serious cases may have ataxia, hypotonia, hypotension, respiratory depression, coma, and death. To treat a zaleplon overdose, symptomatic and supportive measures are necessary along with gastric lavage. Animal studies suggest that flumazenil is an antidote as an antagonist to zaleplon, but there is no human data. With proper treatment, recoveries have been made with overdoses greater than 200 mg. In instances where the outcome was fatal, it was most often associated with the use of additional CNS depressants. Resources Paragraph 1: taken from podcast, also taken from https://go.drugbank.com/drugs/DB00962#pharmacodynamics Paragraph 2: taken from podcast Paragraph 3: taken from podcast Paragraph 4: taken from podcast Paragraph 5: taken from FDA label

On this episode, I breakdown the pharmacology of hydrochlorothiazide including adverse effects, drug interactions, and other clinical pearls. Hydrochlorothiazide has common brand names of Microzide, Hydrodiuril, and its common abbreviation is HCTZ. Extra caution should be taken with “HCTZ”; it may be mistaken for other abbreviations. Hydrochlorothiazide works pharmacologically by blocking the reabsorption of sodium in the distal tubule of the kidney. The result of the pharmacology of hydrochlorothiazide is increased water, sodium, and potassium excretion. Due to hydrochlorothiazide’s mechanism of action, it makes it advantageous when used for blood pressure, edema, and heart failure in addition to loop diuretics. Hydrochlorothiazide’s adverse reactions are due to its pharmacology. Frequent urination should occur so, dosing hydrochlorothiazide at night should be avoided. Loss of electrolytes should also happen, and the risk for hypokalemia, hyponatremia, and hypomagnesemia increases. Other adverse reactions include the increased risk of dehydration, increased uric acid concentrations, and hypercalcemia. The risk for hypercalcemia is not as concerning in lower doses. There is a potential for a sulfonamide allergy. If the patient has had an anaphylactic reaction with a sulfonamide-containing medication, hydrochlorothiazide may want to be avoided, or at least a risk/benefit assessment should be done. Another potential adverse reaction is an increase in blood sugar, but that is not typically concerning at lower doses. Electrolytes, as well as creatinine clearance, should be monitored to make sure kidney function, and electrolyte levels remain stable.  Drug-drug interactions that can occur with hydrochlorothiazide are additive effects that may happen when taken with other medications. The risk for an unsafe drop in blood pressure may increase if it is taken with PDE inhibitors, Sinemet, or SGLT2 inhibitors. Hydrochlorothiazide should be avoided with Lithium, the risk for toxicity increases when the two are taken concurrently due to Lithium concentrations being increased. The risk of an AKI increases if it’s taken with NSAIDs, ACE inhibitors, or ARBs; increased monitoring is warranted. Topiramate may increase the risk for hypokalemia, while vitamin D and calcium supplements may increase the risk for hypercalcemia. Hyponatremia may be more likely to occur if it’s taken with SSRIs, carbamazepine, or oxcarbazepine. Hydrochlorothiazide may blunt the effect of allopurinol if it’s used for gout. Since blood sugar levels may be increased, hyperglycemia can occur, but it’s typically not clinically significant.  In cases of intolerability, or overdoses, the manifestations are extensions of hydrochlorothiazide’s adverse effect profile. Most commonly, electrolyte depletion and dehydration will occur.

On this episode, I discuss torsemide pharmacology, adverse effects, drug interactions and pharmacokinetics. Torsemide is commonly known as Demadex. It is a loop diuretic, and like other loop diuretics, it acts by inhibiting the reabsorption of Na+ and Cl- in the ascending loop of Henle. What results is a decrease in the reabsorption of water, causing a loss of electrolytes as well as water. The pharmacology of torsemide makes it useful in cases of heart failure, cirrhosis, or hypertension. Torsemide, and other loop diuretics, can also be a part of the prescribing cascade. For example, pregabalin and gabapentin, along with amlodipine and pioglitazone can cause or worsen edema, resulting in a new prescription of torsemide.  Torsemide is typically initially dosed between 5-20 mg, depending on the use. If the indication isn’t very severe it might be dosed lower, between 5-10 mg, or higher if it’s a more severe indication starting at 20 mg and titrated up. It should be cautioned in patients with a history of dehydration and renal failure, and it is contraindicated in cases of anuria, hepatic coma, and hypersensitivity. It may sometimes be necessary to be converted to furosemide or bumetanide, or torsemide from the other two. The conversion is, 20 mg of torsemide is equivalent to 40 mg of oral furosemide, which is equivalent to 1 mg bumetanide.  The adverse effects go hand-in-hand with its pharmacology, these include dehydration, increased urination, increased risk of acute renal failure, electrolyte imbalances, and ototoxicity. Also related to the pharmacology of torsemide, electrolytes, renal function, as well as blood pressure should be monitored. Kinetics may vary depending on what loop diuretic it is. It is generally more consistent with furosemide, but torsemide can sometimes have less variability as well as a longer half-life in comparison. For drug-drug interactions, additive effects are the main concern. When combined with Sinemet or PDE inhibitors, there may be an unsafe drop in blood pressure. If it’s combined with SGLT2 inhibitors there can be increased diuresis. There can also be an increased risk of renal issues when taken with an NSAID, ACE inhibitors, or ARBs; if an NSAID is necessary, the dose or duration should be limited, and the kidney function should be monitored. The risk for ototoxicity increases when taken with aminoglycosides, and drugs that can cause edema should be monitored. The main signs and symptoms of intolerance, or overdose, are extensions of its adverse effects and are related to its pharmacology. Commonly, it will be dehydration, hypotension, or symptoms of either. When treating overdoses, symptomatic relief is necessary; it is commonly achieved by fluid and electrolyte replacement.

In the podcast this week, I talk about doxylamine pharmacology. Doxylamine is a first-generation antihistamine; it is commonly an active ingredient in night-time medications like Unisom, Nyquil, and Mucinex. The pharmacology of doxylamine is similar to other first-generation antihistamines, it competitively inhibits the binding of histamine at H1 receptors. Its main uses are as sleep aides, in cough-and-cold medications, but doxylamine has also been given with pyridoxine to treat nausea and vomiting during pregnancy. Doxylamine’s adverse reactions are related to its anticholinergic properties, they include dry eyes, dry mouth, increased fall risk, sedation, urinary retention, constipation, and confusion. Contraindications include concurrent use with a monoamine oxidase inhibitor, known hypersensitivities, concomitant alcohol use, and if the patient has the following conditions: elevated intraocular pressure, narrow-angle glaucoma, asthma, peptic ulcer disease, urinary bladder neck obstruction, or gastric outlet obstruction. It is also a Beer’s list drug due to its anticholinergic effects. The normal dose in adults is 25 mg. In cases of overdosage, the most common manifestation is exacerbations of its anticholinergic effects. The major complications of an overdose include arrhythmia, respiratory failure, seizures, hyperthermia, rhabdomyolysis, and coma.  When you know a patient is taking doxylamine, it’s important to be cognizant of their occupation, as well as what other conditions they may have. For example, doxylamine should be used with caution in patients that drive heavy machinery due to its sedating properties. You might be able to tell if a patient’s experiencing an adverse reaction exacerbation if they begin having worsening dementia symptoms or increased urinary retention. Other indications include the use of artificial tears, or saliva, or increased complaints of constipation. To monitor for doxylamine, it’s important to monitor the patient’s tolerability. The onset of doxylamine is relatively quick as well, with a peak concentration within 2-4 hours. For drug-drug interactions, CYP interactions aren’t as concerning as usual. The main interaction to consider when a patient is taking doxylamine is additive anticholinergic effects. Sedative effects can increase when benzodiazepines, skeletal muscle relaxants, opioids, or antihistamines are concurrently taken. Doxylamine can also counteract the usefulness of dementia or BPH medications due to its anticholinergic properties. There is also a risk of increased anticholinergic burden when taken with skeletal muscle relaxants or tricyclic antidepressants.  Show notes provided by Chong Yol G Kim, PharmD Student.

On this episode, I breakdown the sacubitril valsartan pharmacology. The drug for this week is the combination drug sacubitril/valsartan, also known as Entresto. Entresto has a novel dual mechanism of action to treat HFrEF. Sacubitril, currently, is the only FDA-approved medication that is a neprilysin inhibitor. For background, neprilysin is an enzyme that breaks down natriuretic peptides. The inhibition of neprilysin results in an increase in natriuretic peptides, which causes vasodilation, fluid loss, and a decrease in blood pressure. Valsartan is an angiotensin II receptor blocker; it prevents angiotensin II from binding to AT1 to reduce blood pressure by reducing vasoconstriction, synthesis, and release of aldosterone and ADH, cardiac remodeling, and renal reabsorption of sodium. The unique pharmacology of Entresto makes it advantageous to use in HFrEF and is even now one of the preferred agents. Common adverse reactions that occur when taking Entresto are related to its dual mechanism pharmacology. The most common adverse reactions of Entresto are hyperkalemia, angioedema, hypotension, and renal impairment. Entresto is contraindicated in pregnancy due to fetotoxicity; it requires a 36 hour washout period when transitioning from an ACE inhibitor due to the increased risk of angioedema.  Entresto is initially dosed at 24/26 mg twice a day if the patient is on a low dose ACE inhibitor/ARB, or if the patient has not taken anything. If a patient is taking over 10 mg of enalapril equivalents a day or 160 mg of valsartan equivalents a day, then the preferred initial dose is 49/51 mg twice a day. Regardless of initial dosing, the target dose is 97/103 mg twice a day. In cases of severe renal impairment, or moderate hepatic impairment, the initial dosing should start at 24/26 twice a day; titration remains the same.  The pharmacology of Entresto leaves room for many potential drug-drug interactions. There’s a risk of duplicate therapy with other ACE inhibitors or ARBs. An exacerbation of adverse drug reactions can also occur when taking medications that can lower blood pressure, like Sinemet, or medications that can increase the risk for hyperkalemia, like trimethoprim, and spironolactone, or medications that can increase the risk of renal impairment, like NSAIDs. Entresto has also been shown to increase the risk of lithium toxicity. Show notes provided by Chong Yol G Kim, PharmD Student.

Glipizide, or Glucotrol, is a sulfonylurea used for the treatment of Type 2 Diabetes. Pharmacologically, glipizide acts by stimulating beta-cells in the pancreas to release insulin. Specifically, glipizide will block the opening of ATP-sensitive potassium channels on the plasma membrane of beta-cells on the pancreas. The result of that is depolarization, which then causes stimulation of voltage-sensitive calcium channels, eventually causing the exocytosis of insulin. The increased insulin will then promote the storage of glucose, decreasing the amount of glucose in the blood.  Due to the pharmacology of glipizide, the concerning adverse drug reactions are hypoglycemia and weight gain. Other adverse drug reactions include diaphoresis, dizziness, syncope, nervousness, anxiety, tremors, and diarrhea. The contraindications include hypersensitivity, Type 1 Diabetes, and DKA. Glipizide is not used as often due to the risk of hypoglycemia and weight gain. Glipizide is usually dosed once daily, but it can be split up if the dose is escalated. There are differences in administration depending on the formulation. For immediate release formulations, glipizide should be taken 30 minutes before meals to ensure that absorption is stable. For extended formulations, it can be given with breakfast or any other meal.  Of all the sulfonylureas, glipizide is preferred in CKD. Other sulfonylureas, like glyburide, are not preferred due to a decrease in elimination that can result in dose accumulation. In geriatric populations, dosing is less aggressive to lessen the risk of any adverse drug reactions and more specifically hypoglycemia. There’s a risk of cross-reactivity with sulfonamide allergies, but the risk will vary and is low risk. If SJS occurs due to a sulfonamide-containing drug, glipizide likely wouldn’t be recommended. The drug-drug interactions of glipizide include medications that can increase the risk of hypoglycemia, for example, medications like quinolone antibiotics and B-blockers can mask the symptoms of hypoglycemia. Other interactions include the type where it can counteract the effect of glipizide, for example, medications that can increase blood glucose levels like corticosteroids, antipsychotics such as olanzapine and clozapine, stimulants, and transplant medications like cyclosporine and tacrolimus. There are also CYP interactions that can impact glipizide since it’s metabolized by CYP2C9. More monitoring is warranted when medications that can inhibit CYP2C9, like fluconazole, and medications that can induce CYP2C9, like rifampin, are also given. In cases of overdose, hypoglycemia is most likely to occur. Correction of decreased glucose levels is necessary. Show notes provided by Chong Yol G Kim, PharmD Student.

On this episode of the Real Life Pharmacology Podcast, I discuss cetirizine pharmacology. Cetirizine, commonly known as Zyrtec, is a 2nd generation antihistamine. Compared to 1st generation antihistamines, like diphenhydramine and chlorpheniramine, 2nd generation antihistamines have fewer anticholinergic effects. Pharmacologically, cetirizine works by selectively blocking histamine from binding to the H1 receptor. The uses for cetirizine are allergic rhinitis, itching, and sometimes acute allergic reactions. Commonly, cetirizine is dosed at 10 mg daily, and can even be escalated to 10 mg twice daily in rare situations. In adults 77 years old and older, the manufacturer recommended dose tops out at 5 mg daily. There are also liquid and chewable formulations for children.  The adverse drug reactions cetirizine are mostly dose-dependent and related to its pharmacology. Out of all of the 2nd generation antihistamines, like fexofenadine and loratadine, cetirizine is the most sedating. Other adverse drug reactions related to its anticholinergic effects are urinary retention, constipation, confusion, fatigue, and dizziness. Lab monitoring is not necessary when taking cetirizine. It is important to monitor the adverse drug reactions when taking cetirizine, as well as improvement in the signs and symptoms of what it’s used for.  Cetirizine does not undergo metabolism through liver CYP enzymes, so drug-drug interactions involving those enzymes are uncommon. The interactions that are concerning are additive effects of cetirizine’s adverse drug reactions. Drowsiness can be compounded when cetirizine is taken with opioids, sleep medications, alcohol, or other older anticholinergics with sedative effects. There is also a risk of an increased anticholinergic burden when taking medications like Cogentin, oxybutynin, TCAs, and inhaled anticholinergics.  The manifestation of overdoses will vary depending on age. In adults, the most common observation made was sedation and somnolence. In children, restlessness and irritability were observed initially, then drowsiness. Cetirizine is not removed by dialysis. When treating overdoses, the symptoms that manifest should be treated.   Show notes provided by Chong Yol G Kim, PharmD Student.

Folic acid is a water-soluble vitamin; compared to fat-soluble vitamins, accumulation is not as much of an issue. It is responsible for the formation of coenzymes, DNA synthesis, erythropoiesis, and certain metabolic processes. Due to the mechanism of folic acid, if there is a deficiency present, anemia can manifest. Although the recommended dietary intake is 0.2 mg, supplementation may be necessary. Some situations where supplementation may be desired are prevention of neural tube defects in pregnancy, patients suffering from alcohol abuse disorder, bariatric surgery patients, and certain types of GI disorders where malabsorption may be present. If a patient is taking certain medications folic acid supplementation may be necessary as well. Notable drugs where a patient may require folic acid include methotrexate and phenytoin.  The dosages used most often when supplementing folic acid are in the 1-5 mg range, and most of the time it will be 1 mg. Folic acid has a relatively safe adverse drug reaction profile. Some possible adverse drug reactions are flushing, malaise, erythema, skin rash, and hypersensitivity reactions. Although uncommon, the chance for an adverse drug reaction occurring increases as the dose increases. For monitoring folic acid, the normal levels can vary between 2-20 ng/mL, but they can vary based upon the lab. A type of anemia that can manifest with a folic acid deficiency is megaloblastic anemia. When assessing megaloblastic anemia, vitamin B12 levels should also be assessed.  Folic acid levels can be impacted by phenytoin, methotrexate, trimethoprim and sulfamethoxazole, sulfasalazine, triamterene, and alcohol. When a patient is only taking trimethoprim and sulfamethoxazole for acute treatment of a UTI, folic acid levels aren’t as concerning. Whenever it changes from acute treatment to prophylaxis, folic acid levels should be monitored more closely. Theoretically, folic acid can lower concentrations of phenytoin, and phenobarbital, so closer monitoring may be warranted.   Show notes provided by Chong Yol G Kim, PharmD Student.

On this episode, I discuss insulin glargine pharmacology. Insulin glargine is a long-acting insulin that has the common brand names Lantus, Basaglar, and Toujeo. Due to the pharmacology of insulin glargine, it provides a baseline coverage of insulin. It cannot manage acute elevations in blood glucose like target-specific meals. Instead, insulin glargine is used to decrease blood sugar throughout the day.  It is normally dosed once a day, and sometimes a patient will have another type of insulin that’s rapid-acting, like Humalog. The daily insulin dose will vary, but it’s frequently a 50/50 split between long-acting, and rapid-acting. Dosing of insulin glargine in Type 2 diabetes is usually started at 10 units, but that can vary based on the patient or pertinent clinical data. Whenever doses need to be changed, it’s typically done in the range of 3-7 day intervals. Generally, when dose increases are desired, and the risk for hypoglycemia is low, a 10-20% increase is mostly what’s done. When converting between different types of insulin, the majority are 80% to 1:1 equivalent. Clinical monitoring is vital with any conversion. Insulin glargine is best suited in long-acting situations due to its formulation. Its solubility varies at different levels of acidity. The pH of the injected solution is 4, where insulin glargine is completely soluble. When the solution is at physiological pH, around 7.4, micro-precipitations can form causing small amounts of insulin glargine to be released over 24 hours. The onset of action of insulin glargine is roughly 3-4 hours, and hypoglycemia is not an immediate concern because of this. If a medication error occurs with insulin glargine, it likely wouldn’t be noticed immediately due to its kinetics. For rapid-acting insulin like Humalog, it would be noticed more quickly. Monitoring for insulin glargine is individualized, but it’s generally done through measuring A1c levels. Serum potassium levels can also be monitored, but with longer-acting insulins, it is less of a concern. The most common adverse reactions of insulin glargine are hypoglycemia, weight gain, peripheral edema, and immunological reactions. Drug-drug interactions aren’t a large concern with insulins, due to the amount of monitoring of patients on them. There are risks of potentiation of hypoglycemia or masking of the signs and symptoms of hypoglycemia. With diabetic patients, the compounded risk of hypoglycemia might be greater if they’re taking other medications like metformin, GLP-1 agonists, sulfonylureas, SGLT2 inhibitors, etc. Some other drugs that can increase the risk of hypoglycemia are quinolone antibiotics, B-blockers, or thiazide diuretics. The efficacy of insulin glargine can also be decreased by corticosteroids, stimulants, antipsychotics, or transplant medications. In cases of overdose, because of the pharmacology of insulin glargine, hypoglycemia is common. The milder cases of hypoglycemia can be treated with oral carbohydrates, and simply adjusting the dose, meal patterns, or exercise may suffice. In severe cases of hypoglycemia, coma, seizure, or neurologic impairment may occur. Symptoms of severe hypoglycemia can be treated with glucagon or glucose and these patients typically need to be hospitalized. Once an overdosed patient recovers from hypoglycemia, clinical observation, and carbohydrate intake may be necessary to avoid recurrence. Show notes provided by Chong Yol G Kim, PharmD Student. Resources Paragraph 1: taken from podcast Paragraph 2: taken from podcast Paragraph 3: pH solubility (https://go.drugbank.com/drugs/DB00047#mechanism-of-action), medication error taken from podcast Paragraph 4: taken from podcast, ADRs taken from Lexicomp Paragraph 5: overdose information (“FDA Approved Drug Products: Lantus (Insulin glargine) for subcutaneous injection”)

On this episode, I discuss primidone pharmacology, adverse effects, and drug interactions. Primidone, or Mysoline, is an anticonvulsant most commonly used for essential tremors. The primary pharmacological mechanism of action of primidone is similar to other anticonvulsants, like phenobarbital. It causes a reduction in the activity of neurons. Both primidone and its metabolites are potent anticonvulsants. Primidone alters the transmembrane Na/Cl transport channel to reduce the frequency of nerve firing. Phenobarbital, one of primidone’s active metabolites, interacts with GABA-A receptors and chloride channels to reduce nerve excitability.    Typically B-blockers are used first for essential tremors, then primidone is the next option if B-blockers are ineffective. The dose of primidone can change depending on the use. At lower doses, around 250-700 mg/day (often lower doses than 250 mg will be used), it can indicate that it is being used for essential tremor. When it’s administered at higher doses, up to around 750-1500 mg/day, it can indicate that it is being used for seizures. When used for seizures, it’s important to taper more slowly to not cause seizures with lower minimum effective concentrations. When first dispensing phenytoin, it’s also important to look through a patient’s medication to check that it’s truly essential tremors, and not drug-induced.  Primidone has common adverse drug reactions of CNS depression, sedation, dizziness, confusion, fatigue, GI issues, ataxia; the adverse drug reactions are similar to alcohol toxicity. Special consideration should be taken in patients with a history of depression; primidone can cause or exacerbate suicidal ideation. It’s important to monitor the blood concentrations of phenobarbital when primidone is taken at higher doses, at lower doses, it’s not as important. Vitamin deficiencies should also be monitored. Primidone can cause a vitamin D deficiency, along with vitamin B12 and folic acid deficiencies.  Drug-drug interactions of primidone are those that can cause additive effects of CNS depression. For example, other anti-seizure medications, opioids, and first-generation antihistamines. Primidone also has enzymatic interactions. It is metabolized into its active metabolites by CYP2C9, CYP2C19, and CYP2E1. It should be monitored more closely when taken with drugs that can induce, or inhibit, the activity of those enzymes. Primidone, and phenobarbital, also induces CYP3A4 as well as CYP1A2. Certain drugs like apixaban, rivaroxaban, aripiprazole, prednisone, quetiapine, amlodipine, alprazolam, and olanzapine should be monitored more closely.  The signs of primidone overdose are extensions of its adverse drug reactions. Common signs of an overdose are CNS depression, respiratory depression, lowered reflexes, and hypotension. In cases of severe primidone overdose, removal of the unabsorbed drug with hemoperfusion has been shown to be effective and show improvement in a patient’s clinical condition. In non-severe cases, symptomatic and supportive treatment may be necessary. Show notes provided by Chong Yol G Kim, PharmD Student. References Paragraph 1: taken from episode, information on MOA taken from drugbank (https://go.drugbank.com/drugs/DB00794#mechanism-of-action) Paragraph 2: taken from episode Paragraph 3: taken from episode Paragraph 4: taken from episode, information on metabolism taken from drugbank (https://go.drugbank.com/drugs/DB00794#metabolism) Paragraph 5: taken from drugbank (https://go.drugbank.com/drugs/DB00794#toxicity)

I cover melatonin pharmacology on this episode of the Real Life Pharmacology Podcast. Melatonin, commonly taken by patients for insomnia, is an endogenous hormone produced by the pineal gland. It is an over-the-counter supplement available in dosage forms such as liquid drops, gummies, and tablets. The pharmacology of melatonin is primarily through the activation of melatonin receptors in the suprachiasmatic nucleus; it is also a derivative of L-tryptophan. The production and secretion of melatonin is stimulated by darkness and is inhibited by light. Melatonin concentrations are also shown to vary with age. Its production primarily begins between months 3-4 post-birth, and it peaks between years 1-3. The production and secretion decrease with age and can play a role in insomnia in adults. The doses of melatonin can vary but is commonly found in 1 mg, 3 mg, 5 mg, and 10 mg. Although it is usually taken in higher doses, doses between 0.1-0.5 mg may be adequate.  Certain things need to be taken into consideration when a patient is taking melatonin. Some of the things that should be taken into consideration are if it works as it’s expected to or if the patient is already on stimulating medications that can cause insomnia. If the patient is taking other medications like zolpidem, trazodone, or mirtazapine, melatonin may not be needed. Other things that should be taken into consideration are if the patient tolerates melatonin well and if a lower dose of melatonin can be used. Melatonin is commonly well-tolerated, but it can occasionally cause CNS issues at higher doses such as oversedation, cognitive impairment. It can even cause hyperprolactinemia that can cause sexual dysfunction, fertility risk, lactation, and is associated with lower bone mineral density.  Common adverse drug reactions associated with the pharmacology of melatonin are headache, CNS depression, irritability, and daytime sedation. With long-term use, melatonin can cause suppression of the hypothalamic-pituitary axis. Melatonin is primarily metabolized by CYP1A2, CYP2C9, and CYP2C19. The concentration and efficacy of melatonin can potentially be impacted by medications that induce or inhibit the CYP enzyme system, such as propranolol, calcium-channel blockers, and others. Interactions of melatonin that are not CYP mediated are additive effects when taken with other sedatives, caffeine, and ethanol that can reduce the efficacy of melatonin, or other medications that can increase the risk of adverse drug reactions.  Melatonin is regulated by the FDA as a dietary supplement, and not as a medication. Toxicology studies are limited. Show notes provided by Chong Yol G Kim, PharmD Student. Resources Information is taken directly from the podcast episodeLight/dark melatonin levels, concentrations with age paragraph 1: 10.1016/s0531-5565(98)00054-0 , podcastADRs paragraph 2: Lexicomp, podcastCYP interactions paragraph 3: LexicompToxicity paragraph 4: Lexicomp

Furosemide is a loop diuretic most commonly recognized by its brand name, Lasix. Pharmacologically, it acts by inhibiting the reabsorption of Na/Cl in the thick ascending limb of the loop of Henle. The inhibition of electrolyte reabsorption results in a loss of fluids causing diuresis. Since it has a diuretic effect, it is commonly used to treat congestive heart failure, general edema, ascites due to cirrhosis, and to aid in fluid elimination.  If a patient has a new prescription of furosemide, it’s important to look for drug-induced causes of edema. Common causes of drug-induced edema are the calcium-channel blockers (amlodipine, nifedipine, diltiazem, verapamil), some anticonvulsants (pregabalin, gabapentin), pioglitazone, and NSAIDs. In times when oral furosemide is not readily available, 40 mg of furosemide is equivalent to roughly 20 mg torsemide, or 1 mg bumetanide. If IV furosemide is desired and the patient is already on an oral formulation, generally, the approximate equivalent IV dose is 50% of the oral dose. Dosing is approximate and based on urine output. Serum creatinine, electrolytes, weight, blood pressure, should generally be monitored due to the pharmacology of furosemide. Common adverse drug reactions of furosemide associated with its pharmacology are hypokalemia, and its symptoms such as cramping and uncommonly cardiac problems, hypotension, hyponatremia, dehydration, decrease in renal perfusion, uric acid elevation, transient increases in glucose, angioedema and hypersensitivity reactions, ototoxicity, and nephrotoxicity. Drugs that can exacerbate furosemide’s adverse drug reaction profile are ARBs, ACEis, NSAIDs, aminoglycoside, SGLT2 inhibitors, PDE5 inhibitors, a1a blockers. Electrolyte supplementation may be provided to patients on furosemide to counteract any imbalances that may precipitate.  In cases of overdose, the common symptoms are exacerbations of the adverse drug reactions and mechanism, dehydration, electrolyte imbalances, hypochloremic alkalosis, reduction in blood volume, and hypotension. Supportive treatment of symptoms is necessary to treat furosemide overdoses, fluid and electrolyte replacement is a rational method of treatment. Serum electrolytes, CO2 level, and blood pressure should be monitored in overdose situations. Hemodialysis does not accelerate furosemide elimination. Show notes provided by Chong Yol G Kim, PharmD Student Resources Information taken directly from the podcast episodeDosing goals diuresis end of paragraph 2: 2013 ACCF/AHA guideline for the management of HF https://doi.org/10.1161/CIR.0b013e31829e8776Last paragraph on overdose, furosemide FDA label

Background: - Hydroxyzine Pharmacology Hydroxyzine, common brands Atarax, and Vistaril, is a first-generation antihistamine. It is a part of the piperazine drug class[1], sharing structural similarities to other antihistamines like Cetirizine, but also drugs of other classes like ranolazine, buspirone, clozapine. Being an H1 blocker, hydroxyzine is commonly used for itching, anxiety, analgesia, urticaria, and insomnia. The main adverse drug reactions associated with hydroxyzine are the anticholinergic effects common with most antihistamines, dry mouth, headache, urinary retention, QTC prolongation, drowsiness[2]. Interactions: Due to hydroxyzine’s pharmacology and mechanism of action, it can exacerbate or worsen gastroparesis by decreasing smooth muscle contraction in the GI tract, and has similar effects on benign prostatic hyperplasia by worsening urinary retention. Hydroxyzine is metabolized into its active drug, cetirizine, by CYP3A4 and CYP3A5[3]. As such, hydroxyzine’s efficacy can be increased with concomitant use of rifampin, carbamazepine, St. John’s Wort; and its efficacy can be decreased with concomitant use of certain azole antifungals, verapamil or diltiazem, or grapefruit juice. The anticholinergic effects can also be compounded when taken with other anticholinergic drugs and can decrease the efficacy of certain dementia medications, like clonidine. Although uncommon, the risk of QTC prolongation, and Torsades de Pointes, can be increased when taken with potassium channel blocking agents like amiodarone or sotalol, or other agents like certain antibiotics and antipsychotics[4][5]. PK/PD & toxicity: Hydroxyzine has an onset of action between 15-60 minutes and a duration of action between 4-6 hours[3]. The half-life of hydroxyzine varies with age. On average, it is 7.1 hours in children, 20 hours in adults[6], and 29 hours in the elderly, and should be dosed appropriately[7]. Its volume of distribution is 16±3 L/kg with high concentrations found in the skin than in plasma[3]. Its clearance is 31.1±11.1 mL/min/kg in children and 9.8±3.3 mL/min/kg in adults. The active drug of hydroxyzine is excreted around 70% unchanged in the urine[6]. Overdoses can be characterized by sedation, but can also cause nausea, vomiting, and seizures. General supportive care of the symptoms is needed for treatment. Vomiting should be induced if it has not occurred. Immediate gastric lavage is also recommended[8]. Show notes written by Chong Yol G Kim, PharmD Student References [1] Fifer EK. Drugs Used to Treat Ocular and Nasal Congestion Disorders. In: Roche VF, Zito SW, Lemke TL, Williams DA. Eds. Foye’s Principles of Medicinal Chemistry 8e. Lippincott Williams & Wilkins; Accessed May 15, 2021. [2] Katzung BG. Histamine, Serotonin, & the Ergot Alkaloids. In: Katzung BG, Vanderah TW. eds. Basic & Clinical Pharmacology, 15e. McGraw-Hill; Accessed May 15, 2021. [3] Altamura AC, Moliterno D, Paletta S, Maffini M, Mauri MC, Bareggi S: Understanding the pharmacokinetics of anxiolytic drugs. Expert Opin Drug Metab Toxicol. 2013 Apr;9(4):423-40. doi: 10.1517/17425255.2013.759209. Epub 2013 Jan 21. [4] Schlit AF, Delaunois A, Colomar A, Claudio B, Cariolato L, Boev R, Valentin JP, Peters C, Sloan VS, Bentz JWG: Risk of QT prolongation and torsade de pointes associated with exposure to hydroxyzine: re-evaluation of an established drug. Pharmacol Res Perspect. 2017 Apr 21;5(3):e00309. doi: 10.1002/prp2.309. eCollection 2017 Jun. [5] Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf. 2012;3(5):241-253. doi:10.1177/2042098612454283 [6] Paton DM, Webster DR: Clinical pharmacokinetics of H1-receptor antagonists (the antihistamines). Clin Pharmacokinet. 1985 Nov-Dec;10(6):477-97. [7] Simons KJ, Watson WT, Chen XY, Simons FE: Pharmacokinetic and pharmacodynamic studies of the H1-receptor antagonist hydroxyzine in the elderly.

On this episode, I cover clinical tips and practice pearls surrounding vitamin B12 pharmacology. Vitamin B12 deficiency plays a critical role in the development of macrocytic anemia. There are medications that you have to be aware that can deplete vitamin B12. Metformin, colchicine, and PPIs are some common examples. A lack of intrinsic factor can lead to B12 deficiency. Intrinsic factor is necessary for adequate GI absorption of vitamin B12.

On this episode, I discuss ketamine pharmacology. Ketamine is primarily broken down by CYP2B6 which fortunately does not have a lot of common medications that can interfere with its action. Ketamine can cause psychiatric type adverse effects such as hallucinations, nightmares, and vivid dreams. At lower to moderate dosages, ketamine does have some mild sympathetic activity which can raise blood pressure and heart rate.

On this episode of the Real Life Pharmacology Podcast, I cover topiramate pharmacology. Topiramate is indicated for migraine prevention, seizures, and weight loss which are the most common uses that I see this medication used for. Topiramate has carbonic anhydrase activity, so rarely, use of this drug may induce metabolic acidosis. By far, the most common patient complaint I get with the use of topiramate is that it causes cognitive slowing or impairment.

On this episode I discuss colchicine pharmacology, adverse effects, drug interactions, and pharmacokinetics. Colchicine ultimately works by reducing the activity of neutrophils that help contribute to pain and inflammation associated with gout. Colchicine does have some drug interactions with medications and grapefruit juice via CYP3A4. The most common dose limiting side effect of colchicine is diarrhea. Colchicine can be used as a potential alternative to NSAIDs or corticosteroids in the management of a gout flare.

Fexofenadine is a 2nd generation antihistamine that is primarily used for allergic rhinitis. I cover fexofenadine pharmacology on this podcast episode. Fruit juices can actually impair the absorption of fexofenadine and increase the risk of treatment failure. Fexofenadine is mildly anticholinergic but overall has low to no CNS penetration. Because fexofenadine has low CNS penetration, the risk for sedation and dizziness is much lower than older antihistamines like diphenhydramine.

On this episode I discuss empagliflozin pharmacology and how this medication lowers blood sugar. In this episode, I talk about empagliflozin pharmacology. Empagliflozin is more commonly known by the brand name Jardiance and is in the class of sodium-glucose co-transporter-2 inhibitors or SGLT2 inhibitors. Jardiance use has definitely escalated over the last few years in the management of type 2 diabetes, but this has been changing a little bit as well due to recent evidence for the cardiovascular benefits from this medication. The sodium-glucose co-transporter-2 is found in the kidney and is responsible for helping the body reabsorb glucose back into the bloodstream. The way empagliflozin works is by inhibiting this transporter, more glucose is excreted into the urine and ultimately lowering the blood sugar since it is not being reabsorbed. Empagliflozin has additional benefits outside of blood sugar reductions. Studies found that patients with or without diabetes receive cardiovascular protective effects from this medication, including a reduction in heart failure hospitalizations and reducing the risk of death in patients with ASCVD. Additionally, empagliflozin has shown some benefits in protecting renal function over time in patients with and without chronic kidney disease (CKD). Dosing is pretty straightforward for this medication. Empagliflozin is taken once daily and is an oral medication, which is nice for patients who do not want injectable therapy. Dosing starts at 10 mg once daily and may be increased up to 25 mg daily if tolerated. This increase is typically done after about 4 weeks to see if it is needed. In patients with renal dysfunction and an eGFR less than 45 mL/min, FDA labeling states that empagliflozin should not be initiated, although there is a gray area in the 30-45 mL/min range that needs further study. When thinking about the side effects of empagliflozin, it is helpful to keep the mechanism of action in mind, where we are increasing the urinary glucose. This can also lead to more fluid being excreted with the glucose, causing a decrease in blood pressure and dehydration risks. This is important to keep in mind for patients who are more prone to hypotension, including elderly patients. Empagliflozin also causes increased genitourinary fungal infections and UTIs due to the increase in sugar in the urine. Other rare adverse effects include ketoacidosis, necrotizing fasciitis risk, bone fracture, and lower limb amputation, however, this one has more controversial evidence. For monitoring parameters, assessing A1c reduction and blood sugars is definitely important in our patients with diabetes. Patients on empagliflozin should also have their renal function monitored, as well as any blood pressure lowering. It is also important to keep an eye on any prescribing of antifungals, the incidence of UTIs, and assessing for signs of ketoacidosis. The most important and common drug interactions are typically associated with additive effects with empagliflozin. Diuretic use can increase the risk for dehydration and hypotension. Additive blood sugar-lowering effects when empagliflozin is used with other agents such as insulin and sulfonylureas and can increase the patient’s risk for hypoglycemic episodes. Finally, blood pressure medication dosages may need to be reduced if empagliflozin is causing hypotension. Since empagliflozin is not hepatically metabolized, CYP450 drug interactions are not a problem. Resources:  Empagliflozin. Micromedex DrugDex. IBM Micromedex. Accessed July 29, 2021.Yusuf T, Raji YR, Lasisi TJ, et al. Predictors of taste dysfunction and its severity among patients with chronic kidney disease. Ear Nose Throat J. Published online July 19, 2021. doi:10.1177/01455613211019708.

On this episode, I discuss rifaximin pharmacology. Rifaximin is most commonly used in hepatic encephalopathy and C. difficile infection. Rifaximin systemic absorption is minimal so that is why it is primarily only used for GI conditions. Drug interactions with rifaximin are fairly minimal compared to its cousin rifampin which has tons of drug interactions.

On this episode of the Real Life Pharmacology Podcast, I discuss naproxen pharmacology. Naproxen can raise the concentrations of lithium and increase the risk for toxicity. Compared to most other NSAIDs, naproxen tends to have a lower cardiovascular risk. Naproxen can contribute to renal insufficiency, GI bleed risk, and CHF exacerbations.

On this episode, I discuss cyclosporine pharmacology. This medication is an immunosuppressant used to reduce the risk of transplant rejection. Cyclosporine has a long list of potential adverse effects such as hyperglycemia, renal impairment, GI toxicity, and hypertriglyceridemia. Important monitoring parameters for cyclosporine include drug levels, electrolytes, renal function, and blood sugars. CYP3A4 interactions are critical with cyclosporine. Inhibitors can raise concentrations and inducers can lower concentrations.

On this episode, I discuss leflunomide pharmacology. It is classified as a DMARD and is primarily used in rheumatoid arthritis. Leflunomide carries a boxed warning for hepatoxicity. LFTs must be monitored with its use. Leflunomide can inhibit CYP2C8 which plays an important role in pioglitazone metabolism. Concentrations of pioglitazone can go up on account of this interaction. TB screening should be done prior to beginning the immunosuppressant leflunomide.

Baclofen is primarily used for its ability to help relieve muscle spasms. I discuss baclofen pharmacology on this podcast episode. Baclofen should not be abruptly discontinued as it can cause a significant withdrawal reaction whose symptoms may include fever, spasticity, rhabdomyolysis, and death. While baclofen generally avoids any issues with CYP enzyme interactions, it is eliminated by the kidney. Renal function changes can alter drug concentrations. Sedation, confusion, dizziness, hypotension, and GI upset are some of the more common adverse effects of baclofen.

On this episode, I discuss bromocriptine pharmacology. It is a dopamine agonist that can be used for hyperprolactinemia and Parkinson's symptoms. One of the major side effects of bromocriptine is nausea which stems from its dopamine agonist action. Because bromocriptine is a dopamine agonist, it can counteract the action of antipsychotics. Bromocriptine is broken down by CYP3A4, so drug interactions can be common. Erythromycin, some of the azole antifungals, verapamil, grapefruit juice, and diltiazem are all medications that can increase concentrations.

On this episode, I discuss tacrolimus pharmacology. This medication is an immunosuppressant used to reduce the risk of transplant rejection. Tacrolimus has a long list of potential adverse effects such as hyperglycemia, renal impairment, GI toxicity, and hypertriglyceridemia. Important monitoring parameters for tacrolimus include drug levels, electrolytes, renal function, and blood sugars. CYP3A4 interactions are critical with tacrolimus. Inhibitors can raise concentrations and inducers can lower concentrations.

On this episode of the Real Life Pharmacology Podcast, I discuss ibuprofen pharmacology. Ibuprofen can raise the concentrations of lithium and increase the risk for toxicity. Compared to most other NSAIDs, ibuprofen has a relatively short half-life. This explains why it needs to be dosed more frequently than other agents. Ibuprofen can contribute to renal insufficiency, GI bleed risk, and CHF exacerbations.

Aripiprazole is metabolized by CYP2D6 and CYP3A4. Because of this, drug interactions can happen. I discuss specific examples in this episode. Partial dopamine agonist activity and serotonergic activity make up a significant amount of aripiprazole's pharmacology. Aripiprazole is classified as an antipsychotic and can be used in schizophrenia, bipolar disorder, and depression augmentation. Aripiprazole can cause significant akathesia. I discuss this adverse effect on this episode.

On this episode of the Real Life Pharmacology Podcast, I discuss escitalopram pharmacology. Escitalopram is an SSRI and can be used to manage depression, anxiety, OCD, PTSD, and other psychiatric disorders. If you consider fluoxetine the most activation SSRI and paroxetine the most sedating, escitalopram probably falls somewhere in the middle. Sexual dysfunction is a potential adverse effect with escitalopram. I discuss it further on this episode.

On this episode of the Real Life Pharmacology Podcast, I cover ziprasidone pharmacology. Ziprasidone has dopamine blocking activity and is classified as a second generation antipsychotic. Ziprasidone tends to have lower metabolic syndrome risks compared to other antipsychotics like clozapine and olanzapine. QTc prolongation is a significant risk with ziprasidone and be aware of drug interactions and electrolyte imbalances that may increase this risk.

On this episode, I discuss tiotropium pharmacology. In addition, I cover adverse effects, administration pearls, and drug interactions. Tiotropium blocks acetylcholine from binding the M3 receptor in the lungs. This leads to a relaxation of the bronchial smooth muscle. Because tiotropium has anticholinergic activity, there is a potential for anticholinergic adverse effects like constipation, urinary retention, and dry mouth. The tiotropium Handihaler can be confusing to patients. I discuss medication misadventures in this podcast episode.

On this episode, I discuss palivizumab pharmacology and how it is used in pediatric patients. Palivizumab is a monoclonal antibody that is used to prevent RSV infections in pediatric patients. Palivizumab is an IM injection that is dosed by weight. Learn more on this podcast episode. RSV can be devastating in pediatric patients under the age of two. Palivizumab can be used in select populations to help prevent the infection. Injection and skin reactions are possible with the use of palivizumab.

Varenicline is a partial nicotine agonist that can be used to help patients quit smoking. The two most common adverse effects that I have seen in clinical practice with varenicline are GI upset and insomnia/vivid dreams. GI upset with varenicline can be reduced by giving the drug with food and a full glass of water. A dose reduction may also be considered. Patients should identify a goal stop date for smoking cessation prior to begininng the use of varenicline.

Diphenhydramine is a first generation antihistamine that is highly anticholinergic. When using medications like diphenhydramine, be sure to watch for side effects like dry eyes, dry mouth, constipation, urinary retention, and CNS changes. Sedation is a primary effect of diphenhydramine. It can be advantageous in certain situations, and detrimental in others. Drugs like donepezil, memantine, laxatives, tamsulosin, and artificial tears can be indicators of anticholinergic side effects from diphenhydramine.

On this episode of the RLP podcast, I discuss fluconazole pharmacology. Fluconazole prevents fungi from producing essential components for their cell membrane and thus inhibits their growth. Drug interactions are common with fluconazole. Fluconazole inhibits CYP3A4, 2C9, and 2C19 to varying degrees. I discuss an interaction between fluconazole and phenytoin in this podcast episode. Hepatitis has rarely been reported with the use of azole antifungals like fluconazole.

On this episode of the RLP podcast, I discuss levetiracetam pharmacology. Levetiracetam is indicated for numerous types of seizures and possibly works by enhancing GABA activity. Sedation and dizziness are two common adverse effects of levetiracetam. On this episode, I discuss when and if we might do levetiracetam levels. Levetiracetam tends to have much fewer drug interactions compared to older agents like phenytoin and carbamazepine.

In this episode of the RLP podcast, I discuss scopolamine pharmacology. Scopolamine patches can be used in the management of motion sickness and surgery/anesthesia induced nausea and vomiting. Transdermal scopolamine has a slow onset of action so we need to be deliberate about the timing of placement (usually 4-6 hours prior to anticipated time of symptoms). Transdermal scopolamine is highly anticholinergic and can cause dry eyes, dry mouth, urinary retention, and confusion.

On this episode of the RLP podcast, I discuss tamsulosin pharmacology. Tamsulosin inhibits alpha receptors which helps improve urine flow in patients with BPH. As an off-label use, you may see tamsulosin used to try to aid in the passage of renal stones. Tamsulosin concentrations may be increased by CYP3A4 inhibitors and reduced by CYP3A4 inducers.

On this episode of the RLP podcast, I discuss finasteride pharmacology. Finasteride can be used in the management of BPH or male pattern baldness. By reducing overall androgen burden, finasteride can help to shrink the prostate and improve BPH symptoms. Finasteride takes a long time to work, so this is an important education point for patients.

On this episode of the Real Life Pharmacology podcast, I discuss the ins and outs of lamotrigine pharmacology. Lamotrigine has a very slow dose titration schedule due to the risk of drug induced rash. Sedation, GI upset, and CNS changes are the most common adverse effects associated with lamotrigine. Lamotrigine concentrations can be increased by valproic acid, so we tend to use lower starting doses. Phenytoin and carbamazepine can lower concentrations of lamotrigine.

On this episode of the Real Life Pharmacology podcast, I breakdown propofol pharmacology. Propofol is a CNS depressant that is used for general anesthesia. I discuss propofol infusion syndrome in this episode and what to look out for clinically. Adding a benzodiazepine or opioid to propofol may have a synergistic effect and the propofol dose may need to be reduced.

On this episode of the RLP podcast, I discuss glucagon pharmacology. It is important to remember with glucagon that patients will still require glucose following administration to improve their blood sugar numbers. Glucagon is typically reserved for moderate to severe episodes of hypoglycemia when patients have altered consciousness. The major adverse effect with glucagon is nausea and vomiting which often may prevent oral intake of glucose for some time after administration.

Dulaglutide is a GLP-1 agonist used in the management of diabetes. Dulaglutide has 4 different dosages that can be used to help lower A1C. As the dose goes up, so does the potential for adverse effects however. Like most of the GLP-1 agonists, dulaglutide is only available as an injection. Semaglutide is an exception to this. Nausea is the primary adverse effect of dulaglutide which some patients may get used to over time.

Dapagliflozin is an SGLT-2 Inhibitor that reduces blood sugar by increasing the excretion of sugar through the urine. Genital and urinary infections is a potential risk with the use of SGLT2 Inhibitors like dapagliflozin. Dapagliflozin has received FDA approval for use in heart failure (in patients even without diabetes). Be aware of agents that may enhance the risk for hypoglycemia such an insulin and sulfonylureas.

Omeprazole is a proton pump inhibitor that can be commonly used for GERD, PUD, and GI prophylaxis. Omeprazole can inhibit CYP2C19 which can cause concentrations of drugs like escitalopram and citalopram to rise. Hypomagnesemia, low B12, osteoporosis, and an increase in C. Diff risk are potential complications with longer term PPI use. PPI's like omeprazole are best given 30-60 minutes before meals. This is something that patients often forget.

Conjugated estrogens (Premarin) are most often used in the management of menopausal symptoms. Estrogen therapy can increase the risk for breast cancer and the risk should be assessed before beginning therapy. Blood clots are a potential consequence from the use of Premarin. Premarin can oppose the benefit of anticoagulation. Conjugated estrogens are broken down by CYP3A4. Inhibitors may increase concentrations while inducers may reduce concentrations.

Paroxetine (Paxil) is an SSRI that can be used in the management of depression. I discuss more on paroxetine pharmacology in this episode. Because paroxetine has some modest anticholinergic effects, it does show up on the Beers list as a potentially inappropriate medication. By inhibiting CYP2D6, paroxetine can have numerous drug interactions. Drugs like atomoxetine, aripiprazole, and metoclopramide can all have their concentrations increased. Tamoxifen is activated by CYP2D6 and paroxetine can ultimately reduce the effectiveness of the medication.

Olanzapine is a 2nd generation antipsychotic that blocks dopamine-2 receptors. Olanzapine Relprevv (long acting injectable) needs to be closely monitored after the injection is given due to risks of sedation and delirium. Sedation is a common occurance with the use of olanzapine. It is one of the more sedating second generation antipsychotics. Weight gain, hyperlipidemia, and hyperglycemia are all potential adverse effects with olanzapine.

Tizanidine is primarily broken down by CYP1A2. Ciprofloxacin can inhibit CYP1A2 and cause higher tizanidine concentrations. Tizanidine has a similar classification as clonidine. Pay attention to adverse effects like hypotension and bradycardia. When patients taking routine tizanidine stop taking it, there is potential for a discontinuation syndrome that may lead to rebound hypertension. Dry mouth and CNS depression are common adverse effects of tizanidine.

Valacyclovir can be used for various viral infections such as herpes virus and varicella. The primary clinical advantage of valacyclovir compared to acyclovir is that it is dosed less frequently. Valacyclovir may have some mild CYP1A2 inhibitory effect. I discuss the clinical relevance of this on this episode. GI upset can occur so I usually recommend to give it with food even though it may be given with or without food.

Abacavir is a nucleoside reverse transcriptase inhibitor used in the management of HIV. In patients who have the HLA-B*5701 allele, they are at much greater risk for hypersensitivity reactions. Lactic acidosis and hepatomegaly are potential complications with the use of abacavir. While abacavir is not known for a large number of drug interactions, I discuss a few that you have a chance to run into.

Sertraline is an SSRI. It has the highest potential to cause diarrhea of any SSRI. Sertraline is often called "Squirtraline" because of its potential to cause diarrhea. Sertraline has a much shorter half-life than fluoxetine. I discuss why that may be important in this podcast episode. I discuss the role of serotonin in platelet aggregation and how sertraline may affect this.

Fosfomycin is an antibacterial agents that can be utilized in the management of uncomplicated UTIs. Uniquely, fosfomycin comes as a packet that needs to be mixed with COOL water. I discuss this further on the podcast. Typhoid and Cholera vaccine effectiveness may be reduced when used with fosfomycin. When there is kidney or systemic infection involvement, it is recommended to avoid the use of fosfomycin.

Simvastatin use has declined over time due to more potent statins being available and due to numerous drug interactions. Grapefruit juice can inhibit CYP3A4 which will increase the concentrations of simvastatin. Genetic variations in SLCO1B1 can lead to patients being more susceptible to simvastatin toxicity. Simvastatin is a lipophilic statin. I discuss why this is important and how it might impact clinical decisions.

Citalopram is an SSRI used in the management of depression, anxiety, OCD, and PTSD. How do you manage the risk of citalopram causing QTc prolongation? I discuss it further in the podcast. Omeprazole can inhibit CYP2C19 which affects the metabolism of citalopram. I discuss the clinical impacts of this interaction in the podcast. Geriatric dosing with citalopram is recommended to be lower than traditional adult dosing. I discuss this further in the podcast.

Epoetin alfa is essential exogenous erythropoetin which can stimulate the production of red blood cells. It is critical to ensure adequate iron stores when using EPO. Risks for blood clots, strokes and heart attacks are critical to recognize with the use of epoetin. Dosage adjustments with epoetin are typically made with respect to the amount of change in hemoglobin. I discuss this further in the podcast.

Dexamethasone has numerous possible indications such as asthma, chemotherapy-induced nausea and vomiting, and pain associated with inflammation. Dexamethasone is more potent than prednisone. Approximately 0.75 mg of dexamethasone is equivalent to 5 mg of prednisone. When using dexamethasone, recall that it can raise blood sugars. Monitor this closely in patients with diabetes. A dexamethasone suppression test helps detect excessive endogenous production of cortisol.

On this episode, I discuss sildenafil pharmacology, adverse effects, and important drug interactions. Sildenafil's most common and concerning adverse effect is in relation to its ability to lower blood pressure. I discuss this further in the podcast. Sildenafil can cause rare visual changes that patients should be aware of and report immediately to their pharmacist or physician. The sildenafil nitrate interaction is essential to know. I discuss it in this podcast episode.

On this episode, I discuss codeine pharmacology and practical clinical practice pearls. Codeine is metabolized by CYP2D6 to the active metabolite morphine. I discuss how this can be affected by genetics as well as other medications. Constipation is a problem with codeine and all opioids in general. Education and making a plan with patients to combat this side effect is important. Codeine is less potent than other opioids such as fentanyl, hydromorphone, and hydrocodone.

Dexmedetomidine is a selective alpha-2-adrenergic agonist with sedative characteristics. Dexmedetomidine is commonly used in ICU and procedural sedation, as well as postoperative pain. A few of the more serious adverse effects of dexmedetomidine to keep an eye on including bradyarrhythmias/bradycardia and hypotension. Dexmedetomidine undergoes hepatic metabolism, meaning a dose reduction may be required in patients with impaired hepatic function. Major drug interactions to monitoring for with dexmedetomidine include co-administration with anesthetics, sedatives, hypnotics, and opioids, as it may lead to an enhancement of effects. It is also important to note that dexmedetomidine may produce withdrawal symptoms if used for longer than 24 hours.

On this episode, I discuss the pharmacology of calcitonin. Calcitonin has an indication for osteoporosis as well as hypercalcemia. When considering drug interactions with calcitonin, recall that it can lower calcium levels which could have a cumulative effect when combined with loop diuretics. Calcitonin nasal spray should be stored upright and primed prior to use.

Rivastigmine is an acetylcholinesterase inhibitor used in the management of certain dementias. I discuss rivastigmine pharmacology on this episode. Weight loss is a potential adverse effect of rivastigmine. It is important to monitor weights. Anticholinergic medications such as diphenhydramine can blunt the effects of rivastigmine. Rarely, acetylcholinesterase inhibitors like rivastigmine can cause bradycardia.

Caffeine is a commonly used supplement and is found in many food and beverages. I discuss caffeine pharmacology, adverse effects, and drug interactions. Caffeine can inhibit CYP1A2 and also be affected by CYP1A2 inhibitors. I discuss some examples in the podcast. It is critical to inquire about caffeine intake when patients are reporting insomnia. Caffeine has been associated with increases in pulse and blood pressure. Be sure to ask about caffeine intake when assessing these vital signs.

Colestipol is a bile acid sequestrant that can be used in the management of hyperlipidemia. By binding bile acid in the gut, colestipol can lower LDL that is bound to bile acid by eliminating it through the feces. Numerous drug interactions existed as colestipol can bind many drugs. This is a downside to its use and why it isn't a preferred hyperlipidemia agent. In patients with elevated triglycerides, colestipol should be avoided.

Metolazone (Zaroxolyn) is a thiazide-like diuretic. It promotes the loss of water and sodium through the kidney. The most common indication I see metolazone used for is for additional fluid loss in heart failure. Potassium must be monitored as it can cause significant hypokalemia which is exacerbated when metolazone is used in combination with loop diuretics. Hyperuricemia is a potential adverse effect with metolazone; this is critical to monitor for in patients at risk for gout attacks.

Ibandronate is a bisphosphonate that can be used in the management of osteoporosis. Bisphosphonates like ibandronate require a full glass of water for oral administration. Patients should remain upright for at least 30-60 minutes following taking ibandronate to help reduce the risk of esophagitis. Osteonecrosis has rarely been associated with bisphosphonates like ibandronate - I've discussed a couple of risk factors that may place a patient at higher risk.

Fluticasone, Umeclidinium, and Vilanterol is a combination medication used in the setting of COPD. I discuss the pharmacology of this agent further in this episode. Fluticasone is the inhaled corticosteroid portion of the drug while umeclidinium is a LAMA and vilanterol is a LABA medication. Drug interactions aren't incredibly common or strongly clinically significant, but I discuss some of them with Trelegy Ellipta. Having a once-daily dose can be advantageous to help improve patient adherence. Fluticasone, umeclidinium, and vilanterol comes as a once-daily combination.

Hyoscyamine is an anticholinergic medication that is primarily used for GI problems like spasms and pain associated with IBS. Because of the highly anticholinergic nature of hyoscyamine, it can cause dry eyes, dry mouth, urinary retention, and constipation. Be aware of the risk for the prescribing cascade with hyoscyamine. Saliva substitutes for dry mouth, artificial tears for dry eyes, etc. Sedation is a concern with hyoscyamine and this can be exacerbated by drugs like benzodiazepines, opioids, and older antihistamines.

Calcium Acetate (PhosLo) is used in the management of hyperphosphatemia associated with CKD. Important monitoring parameters for calcium acetate include phosphorus, calcium, PTH, and renal function. There are numerous binding interactions with calcium acetate. It can reduce concentrations of some HIV drugs, antibiotics, and thyroid supplements. I discuss more examples in the podcast. Thiazide diuretic in combination with calcium acetate may increase the risk for hypercalcemia.

Nortriptyline is a TCA that can be used for depression and various pain syndromes. I discuss other less common diagnoses in this podcast episode as well. There are a lot of drug interactions with nortriptyline. It is metabolized by CYP2D6, can have additive anticholinergic effects and has been associated with QTc prolongation. Nortriptyline is very anticholinergic and can blunt the effects of dementia medications. Dry mouth, dry eyes, sedation, urinary retention, and constipation are a few of the more common adverse effects of nortriptyline.

Hydroxychloroquine is classified as a DMARD and when used chronically, can be helpful in managing rheumatoid arthritis and Lupus. There have been reports of QTc prolongation with hydroxychloroquine. While not incredibly common, it is important to remember this consideration in patients at risk for QTc prolongation. Hydroxychloroquine is associated with causing retinopathy. Routine eye exams for monitoring purposes are critical. Rarely, hydroxychloroquine can be associated with blood disorders like neutropenia and thrombocytopenia. In addition, alterations in liver function have been reported.

Latanoprost is a prostaglandin F2 analog that can help reduce intraocular pressure and manage glaucoma. Excessive eyelash growth is a potential adverse effect of latanoprost, although some patients may appreciate this. Patients with a lighter color iris may notice that their eyes are turning more brown with the chronic use of latanoprost. Corticosteroids are known to increase intraocular pressure and potentially oppose the beneficial effects of latanoprost.

Terbinafine can inhibit CYP2D6 which plays an important role in the metabolism of many drugs such as metoprolol, fluoxetine, and clozapine. With terbinafine's ability to inhibit CYP2D6, it can also increase the risk of treatment failure with drugs like tamoxifen. When using anti-fungal drugs like terbinafine, remember that fungal infections can often require more time to treat. Terbinafine has the potential to cause liver impairment. I discuss this further on the podcast.

Alendronate is a bisphosphonate that is used in the management of osteoporosis. In this episode, I discuss osteonecrosis risk and what are some of the risk factors that may increase the chances of this very rare adverse effect. Binding interactions are so critical with alendronate. They can essentially make the drug useless. Esophageal irritation and ulceration is one of the possible complications with the use of alendronate.

Diazepam has numerous dosage forms. There are rectal, injectable, and oral formulations of the drug that are commonly used in clinical practice. Diazepam has 2 major metabolic pathways. It is broken down primarily by CYP3A4 and CYP2C19, leaving open the potential for numerous drug interactions. I discuss this further in the podcast. Diazepam is on the Beers list because it has a tendency to accumulate in the geriatric patient population and cause adverse effects like sedation, confusion, and falls. Respiratory depression, coma, and death are significantly more likely in overdose situations where opioids are used in combination with benzodiazepines like diazepam.

Dicyclomine is an anticholinergic agent that is used to help manage GI pain associated with IBS. Dicyclomine has a very short half-life which means that it can be dosed multiple times per day. Be careful with patients who have predominant constipation with their IBS as dicyclomine can exacerbate this. Bentyl is the brand name of dicyclomine. This drug blocks the action of acetylcholine.

Diltiazem is a non-dihydropyridine calcium channel blocker that can be used in atrial fibrillation as well as hypertension. One big downside to diltiazem is that it does have a few drug interactions via CYP3A4. Aripiprazole, apixaban, and certain statins are all examples of medication that can have concentrations increased by adding diltiazem to a patient's regimen. Diltiazem works a little differently from dihydropyridine calcium channel blockers (like amlodipine) as it works on the heart AND the vessels.

Zolpidem enhances the action of GABA which is an inhibitor neurotransmitter. Zolpidem metabolism can be impacted by the use of CYP3A4 inhibitors. Concentrations can rise on account of this potential interaction. It is important to remember to go slowly when tapering off zolpidem. Particularly in patients who have been on the drug for a long time or those who are on higher doses. Abnormal sleeping behaviors like sleep-walking, eating, or driving have been reported with zolpidem. Remember that CNS depressant drug interactions can happen with zolpidem. Take note of any other sedating medications prior to starting zolpidem.

On this episode, I discuss the pharmacology of oral semaglutide. It is a GLP-1 agonist that is the first one in the class to have an oral formulation. There is a recommended dose titration with oral semaglutide that can take a month or two to get therapeutic doses. I disucss this further in this episode. The most common adverse effect of oral semaglutide is nausea. Oral semaglutide is dosed once daily which is nice to try to maximize patient adherence.

Patients with G6PD deficiency who are taking probenecid are at increased risk for hemolytic anemia. In a patient taking probenecid, they need to have adequate kidney function for the drug to work. GI upset is likely the most common adverse effect of probenecid. It can be given with food. Probenecid can raise the concentrations of many common antibiotics like penicillins and cephalosporins. Remember that there are many medications that can oppose the beneficial effects of probenecid. Thiazides, niacin, and some immunosuppressants can raise uric acid.

Nicotine replacement therapy is an important tool in helping our patients quit smoking. There are lots of clinical pearls involving the pharmacology of nicotine patches and I explore them in this episode. Nicotine patches differ from the gum and other acute relief forms in that they are intended to provide a consistent level of nicotine in the body. The initial dosing of nicotine patches is dependent upon the number of cigarettes smoked by the patient. I discuss it further in the podcast. When applying nicotine patches, it is important to remember to utilize a clean, non-hairy area to ensure the patch adheres to the skin appropriately.

Doxepin is under the class of tricyclic antidepressants. It can inhibit the reuptake of serotonin and norepinephrine. In addition to the serotonin and norepinephrine reuptake inhibition mechanism, doxepin also has antihistamine type effects. Because of the anticholinergic activity of doxepin, it is recommended to avoid this medication in the elderly, particularly at high doses. Be aware that anticholinergics like doxepin can reduce the benefit of dementia medications. CYP2D6 is an important enzyme in the metabolism of doxepin and drugs like bupropion that inhibit CYP2D6 can increase the concentrations of doxepin.

Atomoxetine is a norepinephrine reuptake inhibitor that can be used in the management of ADHD. Atomoxetine is a non-controlled substance option for patients seeking this alternative to traditional stimulants. CYP2D6 is an important enzyme in the breakdown of atomoxetine. CYP2D6 inhibition or poor metabolizers via CYP2D6 can lead to higher concentrations of atomoxetine and put our patients at greater risk for adverse effects.

Fluoxetine is an SSRI used in the management of depression, anxiety, OCD, PTSD, and other psychiatric conditions. Fluoxetine has a very long half-life which can impact clinical management. I discuss how this matters in this podcast episode. Fluoxetine inhibits CYP2D6 which can alter the concentrations of many drugs. Prodrugs like codeine and tamoxifen can have their effects reduced because of fluoxetine. I explain this further in the episode. By inhibiting CYP2D6 concentrations of many drugs can be raised by the use of fluoxetine.

Metoprolol is a beta-blocker commonly used in the management of hypertension, heart failure, and atrial fibrillation. There is an extended release dosage form and immediate release dosage form with metoprolol. The advantage of the extended release product is that it doesn't require as frequent dosing. Metoprolol is selective for beta-1 receptors. It is less likely to interact with asthma medications. CYP2D6 plays an important role in breaking down metoprolol. Alterations in this enzyme's activity can alter concentrations of the drug.

Mometasone is an inhaled corticosteroid and a nasal corticosteroid. The inhaled steroid is called Asmanex by brand name and the nasal version is Nasonex. Nasonex is primarily used in the management of allergic rhinitis and can help with nasal congestion type symptoms. Remember that nasal mometasone takes a little while to have its full effect. It can take up to a week or two to provide its maximum benefit. Systemic absorption of both nasal and oral inhalation mometasone is very low at less than 1%.

Methylphenidate has an FDA approved indication for ADHD. In this podcast episode, I cover the pharmacology, adverse effects, kinetics, and drug interaction. Because methylphenidate has stimulant type effects, it can raise blood pressure and heart rate. Weight, blood pressure, and pulse are important monitoring parameters in patients taking a stimulant type medication like methylphenidate. There are numerous dosage forms of methylphenidate which can help accommodate many different patients' needs.

Cilostazol has antiplatelet and vasodilatory effects. Because of this, it can manage symptoms of intermittent claudication. GI upset, headache, and edema are common adverse effects associated with the use of cilostazol. Cilostazol is recommended to be given on an empty stomach. In patients with heart failure, cilostazol use is contraindicated. CYP3A4 interactions are prevalent with cilostazol. Inhibitors of CYP3A4 can increase the concentrations of cilostazol.

Metronidazole (Flagyl) is an antibiotic that is used for various infections. Metronidazole can certainly cause GI upset like most antibiotics, but uniquely may also cause a metallic taste. Metronidazole is also rarely associated with CNS changes and can induce the potential for peripheral neuropathy. Patients should avoid alcohol with the use of metronidazole and this is on account for the possibility of a disulfiram reaction. I discuss some of the symptoms of this reaction in the podcast. Metronidazole can substantially raise the concentrations of warfarin. INR monitor and a reduction in dose of warfarin may be necessary.

Testosterone replacement is primarily utilized in patients with hypogonadism. I discuss testosterone pharmacology, adverse effects, and drug interactions on this podcast episode. Testosterone is a controlled substance because it is most often diverted for its potential to build muscle in athletes for competitive sports. There is cardiovascular risks associated with the use of testosterone. Testosterone can raise blood pressure and also raise cholesterol levels which may be a contributing factor to its potential to cause cardiovascular events.

Morphine has opioid agonist activity that can cause respiratory depression and death in overdose. Morphine-6-glucuronide is the metabolite that can accumulate and cause CNS toxicity in renal failure. Be aware of CNS depressants that may enhance the effect of morphine and other opioids. Some examples of CNS depressants include gabapentin, benzodiazepines, older antihistamine, skeletal muscle relaxants, and pregabalin. Opioid withdrawal is a significant concern when patients have their morphine or another opioid abruptly stopped. Some signs of withdrawal include agitation, mood swings, anxiety, sweating, GI upset, pain, and insomnia.

Prasugrel is a P2Y12 inhibitor that is used in the setting of ACS. Be aware of patients who may be taking over the counter medications that can increase their bleed risk while taking prasugrel. Prasugrel is on the Beers list and in general, should be avoided in most situations for patients who are 75 years of age or older. Morphine has the potential to impact antiplatelet agents like prasugrel and make them less effective. Be sure this is clinically considered prior to using morphine with prasugrel.

Mirabegron is a beta-3 agonist that can help relax bladder smooth muscle and manage symptoms of overactive bladder. Mirabegron inhibits CYP2D6 which can negatively impact the effectiveness of tamoxifen. I discuss this in greater detail in the podcast. Tramadol and codeine effectiveness can be impacted by mirabegron. Be aware of this when using this medication. By inhibiting CYP2D6, mirabegron can increase the concentrations of many psychotropic medications such as fluoxetine, aripiprazole, clozapine, and paroxetine. I discuss this further in this episode of the podcast.

Erythromycin uniquely has some potential benefit in the setting of gastroparesis. Azithromycin you will likely not see used for this indication. Erythromycin binds the 50s subunit and ultimately prevents protein synthesis which is necessary for bacteria to grow and replicate. QTc prolongation is a risk with all macrolide antibiotics (erythromycin included). By inhibiting CYP3A4, erythromycin can be responsible for numerous drug interactions.

Naloxone is a life saving drug that can help manage an opioid overdose situation. Naloxone blocks opioids receptors so opioid agonists cannot bind there. One of the biggest risks with opioid overdose includes respiratory depression. Naloxone can help reduce the risk of this if administered in a timely manner. IV naloxone will have the quickest physiological onset of action, but nasal naloxone may be the best opportunity in the community to get this drug on board quickly.

Prochlorperazine has several potential mechanisms of action. It can block dopamine and alpha receptors as well as have anticholinergic effects. Prochlorperazine is classified as an antipsychotic and antiemetic. It is very seldom used as an antipsychotic in clinical practice and more used for its antiemetic effects. Because of the anticholinergic activity of prochlorperazine, there is potential for dry mouth, dry eyes, urinary retention, constipation, and other anticholinergic effects. Prochlorperazine does have the potential to have some alpha blocking activity. Keep an eye out for hypotension in patients who may be at risk.

Buspirone is an anti-anxiety medication that has the potential of having some serotonin agonist activity. Buspirone has a very high first-pass metabolism. This means that the body breaks much of the medication down prior to it getting into the systemic circulation. Buspirone is broken down by CYP3A4, so concomitant use with inhibitors or inducers can alter its concentrations Buspirone should not be used as needed as this medication takes a while to start to show benefit.

Ondansetron (Zofran) is a medication used for nausea and vomiting. In this episode, I lay out the pharmacology, adverse effects, drug interactions and more! Ondansetron has been reported to increase the risk of serotonin syndrome. I discuss this further on the podcast. Ondansetron can exacerbate QTc prolongation. Keep an eye out for patients who may have risk factors or be on other medications that can contribute to this. I discuss this further on this podcast. Ondansetron is often used for chemotherapy induced nausea and vomiting. I discuss this and other indications on the podcast.

On this episode "Acyclovir Pharmacology" I discuss the mechanism of action, important monitoring parameters, and drug interactions with acyclovir. I discuss why acyclovir has to be dosed so many times per day. Acyclovir can inhibit CYP1A2 which can impact a few drugs. I discuss a couple of those examples on this podcast episode. GI effects are one of the more common side effects of acyclovir. Rarely, neuropathy and nephropathy can be part of the adverse effect profile of acyclovir. I discuss this further on this episode.

Benzodiazepines act by enhancing the effect of GABA, an inhibitory neurotransmitter. Benzodiazepines can cause confusion, sedation, and respiratory depression. There are many potential indications for benzodiazepines. They can be used in anxiety, status epilepticus, insomnia, and alcohol withdrawal amongst other things. There is a boxed warning for the use of opioids with benzodiazepines. The primary risk of the combination is respiratory depression.

Celecoxib is easy to remember as its mechanism of action is "COX"-2 Inhibition. This can result in result in reduced prostaglandin formation and help with pain and inflammation. Kidney function is important to monitor in our patient on celecoxib. It is especially important in patients taking ACE inhibitors, ARBs, and/or diuretics. While GI bleed may be less likely with celecoxib compared to traditional NSAIDs like indomethacin and ibuprofen, it still needs to be monitored for. Digoxin concentrations may be increased with the use of celecoxib. Celecoxib is generally dosed twice per day as the half-life of the drug is in the ballpark of 10-12 hours.

Oseltamivir is an antiviral agent that is indicated for the treatment and prophylaxis of influenza. It is important to remember that oseltamivir is cleared at least in part by the kidney and dose adjustments should be made based upon kidney function. There is a low potential that oseltamivir could contribute to psych issues like delirium. Probenecid has the potential to raise the concentrations of oseltamivir.

Dolutegravir is an integrase inhibitor that is used in the management of HIV infection/ Carbamazepine along with other enzyme inducers can substantially lower the concentrations of dolutegravir. Dolutegravir can potentially increase blood sugars, this should be closely monitored in our patients with diabetes. CNS adverse effects like insomnia and dizziness can happen with dolutegravir.

On this podcast episode, I cover medroxyprogesterone acetate injection pharmacology (DMPA or Depo-Provera) Medroxyprogesterone acetate injection is given every three months for the prevention of pregnancy. Medroxyprogesterone acetate has a boxed warning for its risk of causing low bone mineral density. Classic enzyme inducers can cause lower concentrations of medroxyprogesterone which can potentially lead to contraceptive failure. Examples of enzyme inducers that can lower concentrations of medroxyprogesterone include carbamazepine, phenytoin, rifampin, and some agents used in the management of HIV.

Budesonide/formoterol inhalation is sold under the brand name Symbicort. Budesonide/formoterol is a combination agent that is used in the management of COPD and asthma. Budesonide/formoterol is a combination of an inhaled corticosteroid and long-acting beta-agonist. GINA guidelines now allow for the use of budesonide/formoterol in the management of acute asthma exacerbation.

Benztropine is a highly anticholinergic medication that is primarily used for movement disorders. Antipsychotics can cause extrapyramidal adverse effects that can help be managed with benztropine. Because benztropine is highly anticholinergic, it can cause dry eyes, dry mouth, urinary retention, constipation and contribute to falls and confusion, particularly in our elderly population. While benztropine is classified as an anti-Parkinson's agent, it is rarely used for that indication as it has a high incidence of anticholinergic adverse effects (particularly at the doses that are required for benefit).

Budesonide is a corticosteroid that can be given orally or rectally for management of Crohn's disease or ulcerative colitis. Because budesonide has a high first pass metabolism, the relative impact of systemic effects may be less than other steroids like prednisone. Remember that CYP3A4 inhibitors can increase the concentrations of budesonide. I discuss this further on the podcast. Different dosage forms of budesonide (oral versus rectal) can be used for different reasons. The site of the inflammation in Ulcerative colitis can determine which dosage form is most appropriate.

Cimetidine blocks histamine 2 receptors which can suppress acid production and reduce symptoms of heartburn. One of the major downsides to cimetidine is that it has a ton of drug interactions. I discuss many of the common ones in this episode. Cimetidine is one of a few drugs that has the potential to cause gynecomastia. I discuss the mechanism of this adverse effect in this episode. Phenytoin concentrations can rise due to the use of cimetidine. I discuss this in the drug interactions section of this episode.

Clopidogrel is an antiplatelet agent that is often used in combination with aspirin to help reduce the risk of an MI. The risk of bleed is a high priority with the use of clopidogrel. Patients must be monitored for signs and symptoms of bleeding and bruising. Clopidogrel is a prodrug that is converted to its active metabolite by CYP2C19. Fluconazole can inhibit CYP2C19 which may reduce the effectiveness of clopidogrel.

Sulfasalazine is a medication that can be used for diseases like rheumatoid arthritis, Crohn's disease, and Ulcerative Colitis. Because sulfasalazine can cause GI upset, this is a major reason why we try to break up the dose and give it multiple (at least two) times per day. LFT and CBC monitoring are recommended with sulfasalazine due to its low potential to cause liver dysfunction, aplastic anemia, and agranulocytosis. Sulfasalazine can impair folic acid absorption and lead to potential deficiency. A patient deficient in folic acid is at higher risk for developing anemia.

On this episode, I discuss the pharmacology of cholestyramine. Cholestyramine was originally developed as an agent to manage cholesterol, but has fallen out of favor for some of the more effective agents like statins. Cholestyramine is notorious for binding drug interactions. It can reduce concentrations of drugs like amiodarone, digoxin, oral contraceptives, immunosuppressive and many more! In patients with chronic diarrhea, cholestyramine is occasionally used off label to help manage symptoms because it tends to have constipating effects.

Rifampin is classified as an antibiotic and an antituberculosis agent. It primarily works by inhibiting bacterial RNA polymerase. While not extremely common, rifampin is well known to cause hepatic dysfunction. You should remind patients who are taking rifampin that it can alter the color of tears, sweat, saliva and urine. It can change these fluids to a reddish/brown color. Rifampin is very well known for causing drug interactions. It is an enzyme inducer that can reduce the concentrations of numerous medications such as warfarin, apixaban, cyclosporin, levothyroxine, and oral contraceptives to name a few. Rifampin can be used to help prevent meningococcal infection. Learn more on rifampin by listening to this podcast!

Heparin is an interesting drug with a lot of unique clinical quirks. This drug ultimately inhibits the formation of fibrin. Fibrin is an essential component of a blood clot. Because heparin has blood thinning effects, it is critical to assess a patient's bleed risk. Look out for other agents that may increase the risk of bleeding. Examples include; NSAIDs, antiplatelet agents, and other anticoagulants. One classic test question about heparin that often comes up is the reversal agent. Protamine can be used to help reverse the effects of heparin. Heparin-induced thrombocytopenia is a critical adverse effect to understand. I discuss both subtypes on the podcast and let you know what to look out for. Rarer side effects of heparin include hyperkalemia and osteoporosis (only with long term use).

On this episode, I discuss montelukast pharmacology Montelukast is a leukotriene receptor antagonist. Leukotrienes play an important role in causing inflammation and smooth muscle contraction in asthma and allergic rhinitis. Because montelukast blocks the effects of leukotrienes, it can be advantageous to use this medication for allergies and asthma. It is important to remind patients that montelukast is NOT a substitute for an acute relief medication like albuterol in the management of asthma symptoms. Montelukast has been reported to cause mood and behavioral changes and it is important to monitor our patients for these rare concerns.

On this episode, I discuss clozapine pharmacology. This drug has multiple mechanisms of action: Dopamine blockade, anticholinergic activity, and alpha blocking activity all contribute to the complexity of this drug. Smoking cessation can significantly increase the concentrations of clozapine. This is because smoking can induce CYP1A2. Listen to the podcast for more details on how this can impact our patients clinically. Clozapine has 5 boxed warnings. I discuss them all in this podcast. The most well-known boxed warning is for agranulocytosis. Because clozapine has alpha blocking activity, it can cause orthostasis. We need to monitor for this. Clozapine can cause QTc prolongation. Keep an eye out for other medications that the patient may be taking that can also cause this. Examples include: amiodarone, ondansetron, quinolones, and macrolides

On this episode, I discuss carbamazepine pharmacology. This drug is most commonly used for seizures, bipolar disorder, or trigeminal neuralgia. Carbamazepine is an autoinducer and can reduce the concentrations of numerous drugs. Some examples include apixaban, warfarin, rivaroxaban, diltiazem, verapamil, and many more! Carbamazepine has the potential to cause Steven Johnson's Syndrome. This has a much greater chance of happening in patients with certain genetics. Carbamazepine can contribute to SIADH and cause significant hyponatremia. Carbamazepine has boxed warning for numerous potential events like aplastic anemia, agranulocytosis, and the above-mentioned SJS.

On this episode, I discuss the pharmacology of commonly used stimulant laxatives like sennosides and bisacodyl. Stimulant laxatives "stimulate" the GI tract smooth muscle which helps propel fecal material out of the body and thus helping to relieve constipation. Patients who are having diarrhea and are unsure of what medications they are taking should have their regimen assessed for these medications. Chronic opioid therapy is a situation where chronic stimulant laxative therapy may be used. Stimulant laxatives have very few drug interactions. However, bisacodyl effectiveness can be reduced by the use of antacids like calcium carbonate.

On this episode, I discuss ezetimibe pharmacology. Ezetimibe works by inhibiting Niemann-Pick C1-Like1 (NPC1L1) transporter. This transporter aids in cholesterol absorption so by blocking it, we can reduce cholesterol levels (and LDL) in the bloodstream. Ezetimibe is usually very well tolerated. Diarrhea, myopathy, and elevations in LFT's are adverse effects that have been reported but do not occur at high rates. Ezetimibe is dosed at 10 mg once daily. This is a nice advantage because this is a starting dose and the usual treatment dose. With the most recent cholesterol guideline updates, I do expect ezetimibe to be utilized a little more than it used to be. They place more emphasis on a target LDL and getting patients to goal. Statins are going to be used first line for cholesterol and ezetimibe will be an add on therapy to consider. They don't, unfortunately, lower cholesterol as much as high-intensity statins do.

On this episode, I cover azithromycin pharmacology. This drug primarily acts by inhibiting protein synthesis. It binds to the 50s ribosomal subunit. GI adverse effects like nausea and diarrhea are going to be the most common with azithromycin. Azithromycin has been associated with prolonging the QT interval. Drugs like amiodarone, ondansetron, citalopram, antipsychotics, and quinolone antibiotics can also prolong the QT interval. One major advantage that azithromycin has over other antibiotics is that it has a long half life which allows for once daily dosing. Azithromycin has numerous uses like pneumonia, MAC, alternative for ear infections in patients with a beta-lactam allergy, certain STD's, and also is rarely used in long term COPD exacerbation prevention.

Rivaroxaban is a factor 10a inhibitor that inhibits clot formation and thins the blood. Rivaroxaban needs to be monitored for bleed risk. Checking periodic CBC can help us assess if hemoglobin and hematocrit are remaining stable. Enzyme inducers like rifampin, St. John's Wort, and carbamazepine can reduce concentrations and increase the risk of treatment failure. NSAIDs and antiplatelet medications can significantly increase the risk of bleed with rivaroxaban. Rivaroxaban should not be used with dual P-glycoprotein and CYP3A4 inhibitors. Examples include ketoconazole, itraconazole, and ritonavir.

Valproate (valproic acid, Depakote) has numerous uses which includes migraines, seizures, and bipolar disorder. In a patient who is taking valproate, it is important to monitor for signs and symptoms of confusion as this drug can cause elevated ammonia levels. When switching between dosage forms of valproate, you must recognize that the bioavailability is not the same between each different dosage form. This could lead to toxicity or treatment failure. Valproic acid has a boxed warning for hepatotoxicity and liver function needs to be monitored. Valproic acid can increase lamotrigine levels which ultimately could lead to an increased risk of lamotrigine induced SJS.

On this episode I discuss the pharmacology of donepezil. Donepezil is an acetylcholinesterase inhibitor. In dementia, that is a deficiency in acetylcholine and donepezil helps preserve this neurotransmitter. Donepezil can cause weight loss, GI upset, and diarrhea. This is an important monitoring parameter in our dementia patients. There is the possibility for donepezil to cause bradycardia and insomnia. Keep an eye out for these adverse effects as they can and do happen in real practice. Anticholinergics are notorious for blunting the effects of donepezil. We must look out for drug interactions from older anticholinergics like diphenhydramine, amitriptyline, and hydroxyzine.

Linezolid is an antibiotic used for bacterial infection. It primarily works by inhibiting bacterial protein synthesis. Linezolid is primarily bacteriostatic against most bacteria which means that it inhibits the growth and doesn't necessarily kill the bacteria itself. Caution must be used with linezolid and serotonergic drugs as there is a risk for serotonin syndrome. Clinical risk/benefit analysis needs to be done. Linezolid overall has good coverage for VRE and MRSA. It is an option for MRSA pneumonia where daptomycin is not. Linezolid has both an oral and an IV option which allows for good continuity of inpatient and outpatient use.

On this episode, I cover pioglitazone pharmacology. The primary mechanism of action with pioglitazone is that it is an agonist at Peroxisome Proliferator Activated Receptor Gamma receptor. This improves insulin sensitivty in the periphery. Two common side effects exist with pioglitazone. This drug can cause weight gain and also contribute to edema. Pioglitazone has a boxed warning and is contraindicated in patients who have symptomatic heart failure. There are a few potential interactions with pioglitazone. Trimethoprim and gemfibrozil can inhibit the breakdown of pioglitazone. A couple of advantages of pioglitazone include that it is generic (inexpensive) and that it is dosed once daily.

On this episode I breakdown nitrofurantoin pharmacology. Nitrofurantoin is an antibiotic that is used in the treatment of UTI's. Nitrofurantoin has activity by creating reactive metabolites that can disrupt protein synthesis and ultimately kills the bacteria causing the infection. It is important to remember with nitrofurantoin, that in the setting of systemic infection and/or kidney involvement, the drug may not be very effective. Nitrofurantoin can potentially reduce the effectiveness of certain vaccines. Be sure to look this up prior to administration. Nitrofurantoin can cause pulmonary symptoms as well as neuropathy. This is very important to monitor for.

Hydralazine Pharmacology Hydralazine works as a direct vasodilator. It primarily works on the arterioles versus the venous system. Hydralazine can cause a unique adverse reaction. It can cause a Lupus type syndrome that can result in fever, myopathy and symptoms that mimic arthritis. I discuss drug interactions with hydralazine and how you need to be aware of certain medications that can have additive effects and also those that can oppose the effects of the drug. One of the downsides to using hydralazine is that patients don't like to take it as often as it requires. It is typically dosed three to four times per day. Orthostasis is a risk with any drug that reduces blood pressure and hydralazine is no different.

On this episode of the Real Life Pharmacology Podcast, I discuss aspirin pharmacology. The two most common adverse effects with aspirin are GI upset and increasing the risk for bleeding and bruising. A commonly asked test question about aspirin is whether it can be used in pediatrics and what risk we encounter if we use it. Another rare effect with aspirin is tinnitus which I discuss further on this episode. It is critical to pay attention to other medications that can thin the blood in a patient taking aspirin. Examples include anticoagulants like warfarin, apixaban, rivaroxaban; antiplatelets like clopidogrel or prasugrel; or NSAIDs.

Clonidine is classified as an antihypertensive. Clonidine pharmacology involves having agonist activity at central alpha 2 receptors. This leads to lower sympathetic outflow and a reduction in blood pressure. Clonidine has numerous reported uses in addition to its antihypertensive effect. It can potentially be used for ADHD, menopausal type symptoms, and opioid withdrawal. Clonidine has historically been on the Beers' list of drugs as it can cause some CNS side effects like sedation, dizziness, and rarely delirium. Clonidine is unique in the antihypertensive class as it does have a patch formulation. Because of the blood pressure lowering effect of clonidine, we have to be aware of patients who report dizziness. Monitoring is critical. Clonidine can also lower heart rate and contribute to dry mouth. Keep an eye out for drugs that can have a cumulative effect on these symptoms. Drugs like beta-blockers, non-DHP CCB's, and digoxin can all have a cumulative effect with clonidine and lower pulses. Monitoring is important.

Memantine is classified as an NMDA receptor antagonist. Memantine pharmacology is complex as is the pharmacology of any medication working in the brain. This drug can help reduce the activity of glutamate, an excitatory neurotransmitter which can play a role in Alzheimer's dementia. Memantine has an extended release dosage form that is dosed once per day compared to twice per day for the immediate release. However, the cost of the extended release is much more expensive, so it is recommended to begin with the immediate release. Memantine is cleared by the kidney. In patients with reduced kidney function, you must review to assess if the memantine dose needs to be adjusted. When using memantine or other dementia medications, be sure to look out for medications that can cause dementia type symptoms. CNS depressants like benzodiazepines, sleep medicines, and anticholinergics are all examples of meds that could exacerbate dementia.

On this episode, I discuss magnesium pharmacology and the clinical applications. Magnesium plays numerous important functions in the body and you may see patients take these supplements under the direction of a healthcare professional and sometimes on their own. It is very important to remember that magnesium can cause GI upset and diarrhea. This is often overlooked in our polypharmacy patient. Magnesium can accumulate in renal disease. This is important to remember especially in patients who have a tendency to take a lot of supplements without discussing them with a healthcare professional. PPI's are a notorious cause of low magnesium. Loop diuretics can increase magnesium excretion and also cause low magnesium levels. Magnesium can bind up numerous drugs reducing concentrations and leading to treatment failure. A few examples include quinolone antibiotics, tetracycline antibiotics, and levothyroxine.

Trazodone pharmacology is complex. It can inhibit serotonin reuptake, block histamine receptors, and possibly have alpha-blocking activity. Side effects of trazodone include sedation, dizziness, and dry mouth. Rarely, priapism may occur. I've seen this nugget come up on pharmacology exams! While trazodone is classified as antidepressant, it is often used to help manage insomnia. Trazodone can possibly prolong the QT interval. Risk of other medications and patient specific parameters should be considered. Trazodone concentrations can be increased with the use of CYP3A4 inhibitors and reduced with 3A4 inducers.

The GLP-1's are a relatively newer class of medications used to lower blood sugars in diabetes. GLP-1's work by simulating the effects of incretin hormones in the body. They can help promote fullness, lower weight, and stimulate insulin release following a meal. GLP-1's can cause significant GI side effects. Nausea is by far the most common adverse effect. It can even lead to diarrhea and vomiting in some cases. There is boxed warning on the GLP-1 agonists. Be aware of patients who have had a history of thyroid cancer as this may be a contraindication. GLP-1 agonists can help lower A1C and stimulate weight loss which is a huge benefit for most patients with Type 2 diabetes.

Iron supplements frequently cause GI upset. Monitor patients for nausea, vomiting, and constipation issues. There are three main salt forms of iron. Ferrous fumurate has the most elemental iron, ferrous sulfate (2nd most), and ferrous gluconate has the least. Iron can bind up antibiotics and reduce their effectiveness. Two classic examples include the quinolone and tetracycline antibiotics. Anemia can be caused by numerous concerns, however, iron deficiency is a very common cause. Ferritin is a lab that we commonly monitor in a patient who may be iron deficient. Iron deficiency can also lead to symptoms of Restless Leg Syndrome.

On this episode, I cover common loop diuretics. They include furosemide, torsemide, and bumetanide. Loop diuretics are potent agents that can help in the management of heart failure and ascites. Loops diuretics help promote the loss of excessive fluid through the urine. A common patient complaint from loop diuretics is that they can cause frequent urination. Because of this, we typically dose these drugs earlier in the day. Kidney function and electrolyte monitoring is critical with the use of loop diuretics. Enjoy the episode!

On this episode of the Real Life Pharmacology Podcast, I cover the pharmacology of methotrexate. Methotrexate has a few different indications. It can be used for treatment of cancer. These doses are typically going to be much higher than standard low doses for other conditions. Lower dose methotrexate is often used for autoimmune type conditions like rheumatoid arthritis and psoriasis. Folic acid should be supplemented with use of methotrexate to help reduce the risk of adverse effects. Liver toxicity and immune system suppression are two important factors to monitor in a patient taking chronic methotrexate. I also talk about important cumulative drug interactions with methotrexate such as immunosuppressives and other agents that may impact liver function. Be sure to listen to the end as I talk about the potential impact of methotrexate on some vaccines!

On this episode, I discuss cyclobenzaprine pharmacology. Cyclobenzaprine is an older skeletal muscle relaxant. Cyclobenzaprine can have a significant number of anticholinergic side effects. The anticholinergic side effects of cyclobenzaprine can include sedation, dry eyes, dry mouth, urinary retention, and confusion. Cyclobenzaprine is not well tolerated in the elderly and cause more problems in that patient population. Cyclobenzaprine has a similar structure to the Tricyclic antidepressants.

Lithium is a drug that has a ton of clinical pearls.  On this episode, I talk about the pharmacology, side effects, drug interactions, and critical practice pearls. Kidney function is very important to monitor in our patients taking lithium.  Lithium can accumulate in renal impairment. Thyroid function can be altered by lithium.  Be sure to regularly monitor TSH in a patient on chronic lithium. Over-the-counter NSAID can interact and raise lithium levels.  This is something you need to watch out for as patients can begin taking these medications on their own without supervision. Be sure to assess lithium levels.  Signs of toxicity can include GI upset, tremor, motor movement issues, sedation, and CNS changes.

Pseudoephedrine is commonly used to help relieve nasal congestion. There are some adverse effects you need to be aware of with pseudoephedrine. Insomnia, increase in blood pressure, and urinary retention are all possible. When I assess a patient using pseudoephedrine, I like to investigate blood pressure, history of urinary problems and insomnia history. Pseudoephedrine can cause the prescribing cascade.  I lay out examples in the podcast. Pseudoephedrine should not be utilized with MAOI's if possible - I discuss the reason for this in the podcast. Enjoy the show and don't for get your FREE 31 page resource!

On this episode, I discuss fentanyl pharmacology. I address important considerations that you must remember with fentanyl patches. Those considerations include how pharmacokinetics can impact our patients. I also break down common side effects of opioids as well as potential common drug interactions. Drug diversion and illicit use is an important consideration when using fentanyl.  I also touch on this topic. Nearly 1,000 healthcare professionals have signed up and received this FREE Top 200 Study Guide - Why haven't you?

Quinolones are a class of antibiotics that can be used for various infections. I discuss the pharmacology, adverse effects, drug interactions and other items on this podcast episode. On this episode, I talk about the warnings associated with quinolones. Quinolone use has subsided over time, not due to the fact that they are ineffective, but to rising concerns and warnings about adverse effects. Quinolones can interact with quite a few medications.  I've seen a case of amiodarone and levofloxacin contributing to QTc prolongation which I discuss on this episode. It is critical to remember the binding interactions associated with quinolones as these can potentially lead to treatment failure. Enjoy the show and be sure to snag your FREE 31 page PDF on the top 200 drugs, a gift simply for following the podcast!

On this episode I discuss why we may need to use potassium supplements. I also talk about a medication error situation involving potassium that lead to a death. It is important to remember other medications that can raise potassium levels. I also talk about a dosage form of potassium that might make patients ask some questions. Enjoy the show and I hope you sign up to get our free 31 page PDF!  

On this episode, I talk about apixaban (Eliquis) pharmacology. I also cover adverse effects like bleeding and what to monitor. Drug interactions are a concern with apixaban and I discuss a few items that you may want to look out for. It is important to remember that apixaban does require dose adjustments in certain situations as well. Check out our free giveaway for healthcare professionals and students.  It is a top 200 study guide of highly testable pearls! (Free 31 page PDF)

Metoclopramide Pharmacology Metoclopramide can block dopamine receptors as part of it's mechanism of action.  I discuss the clinical implications from this in the podcast. Metoclopramide can exacerbate Parkison's disorder so you need to be careful in that type of patient. Metoclopramide is dosed frequently, which can potentially be a downside as far as patient adherence goes. Metoclopramide has a few potential interactions that you should be aware of.  I talk about those in this episode. Be sure to check out The Thrill of the Case on Amazon as I do have a clinical scenario about Reglan (metoclopramide) in that 200+ page book. As always, check out my free Top 200 study guide!

On this episode, I discuss the mechanism of action of the SGLT-2 Inhibitors and how they lower blood sugar. These drugs are classically used for diabetes and eliminate blood sugar through the urine. One of the potential side effects is that these drugs can increase the risk of genital infections and urinary tract infections. There is a boxed warning on canagliflozin for its potential to increase the risk of amputation. These drugs also have a mild diuretic type effect and can potentially cause hypotension. Enjoy the show and be sure to sign up to follow the podcast and get your FREE 31 Page Pharmacology Study Guide! If you find the show helpful, please leave us a kind rating and review wherever you are listening! Cheers! Eric Christianson, PharmD, BCGP, BCPS

On this episode, I discuss how the tetracyclines impact bacterial protein synthesis. I also remind you of several medications that fall in the tetracycline class.  Doxycycline is by far the medication I see used the most. You'll also learn about common side effects like GI upset and photosensitivity. I cover why this class of medication is typically avoided in pediatrics and pregnancy. I hope you enjoy the show and don't forget to snag your FREE 31 page PDF study guide!

I break down the mechanism of action, side effects, and important drug interactions you need to know. I give you a sense of what things you might actually encounter in practice when working with patients who take allopurinol. Allopurinol is a top 200 drug. Remember to subscribe to the website reallifepharmacology.com for the Free 31 page PDF where I give you three highly testable pearls on the top 200 drugs. In addition to the 31 page PDF for subscribing, you will get a free 100 question pharmacology test designed for healthcare professionals. I hope you enjoy this episode the pharmacology of allopurinol!

In this episode I discuss bupropion pharmacology.  I cover the mechanism of action, side effects, and some relevant drug interactions. Important information in this episode includes: Possible indications for bupropion like depression and smoking cessation Risk of lowering seizure threshold Inhibition of CYP2D6 Dosage form considerations Pearls for onset of bupropion's action

On this episode, I cover mirtazapine pharmacology. We will review how mirtazapine works in the body and how those cause adverse effects and benefit out patient. I will also look at the side effect profile and why mirtazapine may be harmful or helpful in our patients. We cover drug interactions for mirtazapine in the podcast as well. Mirtazapine is an antidepressant and I mention discontinuation syndrome as well as what I see as being done when converting a patient from one antidepressant to another. Enjoy the show and don't for get to get your free gift by subscribing!

The Serotonin and Norepinephrine Reuptake Inhibitors are a class of medication used for various mental health disorder and pain syndromes.  I talk about the pharmacology of the SNRI's and how it relates to their adverse effect profile.  The pharmacology of SNRI's also plays an important role in why they are efficacious for treatment of pain compared to the SSRI's.  In addition to the adverse effects, I will outline some common drug interactions and which medications might be affected by the SNRI's. Enjoy the episode and I hope you pick up some clinical practice pearls with the SNRI's!  Don't forget to take advantage of our free giveaway as well, nearly 1,000 healthcare professionals and students have already done so!

The TCA's are one of the older antidepressant type medications that can be used for a whole host of reasons.  They are not without potential concerns however.  I cover the MOA, drug interactions, side effects and clinical practice pearls of the tricyclic antidepressants in this episode.

Warfarin is one of the most notorious medications when it comes to drug interactions.  I cover the MOA, side effects, drug interactions, and pharmacology of the medication.  Enjoy the episode and don't for get to subscribe to get our free study resources!

On today's episode, I talk about the pharmacology of carbidopa/levodopa.  We cover drug interactions, adverse effects, mechanism of action and why is this drug dose so frequently? Hope you enjoy the show and take advantage of our FREE giveaway, simply for following the show!

On today's episode, I discuss spironolactone and eplerenone.  We cover the mechanism of action, monitoring parameters, adverse effects, and of course notable drug interactions.  Enjoy the show and please take advantage of our FREE giveaway by following the podcast via email!

On this episode, I discuss the pharmacology of hydrocodone.  We also cover adverse effects, clinical use, and important genetic and drug interactions.  Enjoy the show and don't forget to subscribe to the podcast and receive a couple of free gifts!

On today's episode, I breakdown the pharmacology of gabapentin and pregabalin and what you will see in clinical practice.  These drugs are most often utilized for pain syndromes.  I cover adverse effects, drug interactions, drug/disease interactions, mechanism of action in this episode.

Sulfonylureas are an older, cheaper class of medication that is used to stimulate insulin secretion and lower blood sugar.  I discuss the pharmacology and what to look out for in real life practice.  

On this episode, I discuss sulfamethoxazole and trimethoprim. We cover mechanism of action, adverse effects, and some really important, clinically relevant drug interactions.  Hope you enjoy the show and be sure to take advantage of our FREE 31 page PDF document on the highly testable pearls of the Top 200 Drugs.  A great resource for any nursing, pharmacy, or midlevel, or med student!

In this episode I discuss urinary anticholinergics and their effects.  I cover mechanism of action, side effects, clinical practice pearls, and of course some drug interactions to look out for.  Enjoy the episode and be sure to check out our free 31 page pharmacology study guide!

Thiazide diuretics are well-known to help with edema and hypertension. Thiazides need to monitored for electrolyte imbalances. Hypokalemia is a real and significant possibility. Thiazide diuretics can also raise uric acid which can impact our patients with gout. Pay attention to use in this patient population. I also cover drug interactions and the mechanism of action of thiazide diuretics on this episode. Enjoy the show!

On this episode we are going to break down the pharmacology of albuterol and levalbuterol.  Other items addressed; Difference between beta-agonists and beta-blockers Rule of 2 Administration pearls and clinical practice problems Enjoy the episode and share it with your friends if you are benefitting from it!

On today's Episode, I discuss Amoxcillin and Augmentin. Enjoy the education!

In this episode on tramadol I cover; Mechanism of action Adverse effects Precautions Drug Interactions Clinical Pearls Enjoy the episode!

Oh boy...Phenytoin is one of those medications that has a ton of clinical pearls.  I've seen mistakes with phenytoin that has led to hospitalizations.  You need to pay attention for this one!  Also be sure to check out our Top 200 drugs and 3 highly testable pearls!  A FREE 31 page PDF resource, simply for following the blog!

On today's episode, I cover the angiotensin receptor blockers. Pharmacology Drug Interactions Adverse effects Clinical Pearls

On today's episode I talk about the dopamine agonists and their role in Parkinson's as well as RLS.  I cover adverse effects, mechanism of action and drug interactions amongst other things! Enjoy! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you’ll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode, I discuss the pharmacology and side effects of alpha blockers as well as the differences between a selective alpha blocker versus a non-selective alpha blocker. Enjoy! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

5 Alpha-Reductase Inhibitors are most often used in the setting of BPH.  I discuss mechanism of action, uses, adverse drug reactions as well as some medications that can exacerbate BPH.  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode, I talk about the side effect profile of antipsychotics as well as how the mechanism of action plays into those adverse effects.  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On today's episode I discuss all the unique clinical pearls associated with amiodarone (Cordarone).  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode, I breakdown the Selective Serotonin Reuptake Inhibitors.  They are the first line medication often used in the management of depression, anxiety, OCD, and other mental health disorders.  I talk about drug interactions and the subtle differences between the agents.  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode, I discuss the pharmacology of calcium channel blockers.  There is a few common side effects with these medications and they can lead to the prescribing cascade.  I talk about an example in the podcast where they can cause edema which leads to a prescription for a diuretic.  I also talk about a really common drug interaction.  Hope you enjoy the episode, and please feel free to reach out with comments and questions! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode I explain digoxin pharmacology and also run through some scenarios where I've seen digoxin toxicity actually happen. I also discuss the relationship of low potassium and how digoxin can have an exacerbated effect in this setting.  Hope you enjoy the episode and please feel free to reach out and give me some feedback! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe Eric Christianson, PharmD, BCGP, BCPS

On this episode I discuss the basics with acetaminophen and which disease states and other medications to look out for when you have patients taking acetaminophen.  Other items discussed on the podcast Mechanism of action Adverse effects Dosing Drug interactions Comparison to NSAIDs All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

Proton Pump Inhibitors are one of the most commonly used agents for heartburn and other GI disorders.  In this episode I discuss the pharmacology, adverse effects, and a couple of really common drug interactions that are often tested on.  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In this podcast episode I discuss the pharmacology of NSAIDs and the potential collateral damage that can result from these medications.  We'll cover: Side effects Mechanism of Action Important Drug Interactions Pharmacokinetics between ibuprofen and naproxen Boxed Warnings Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In this episode, I talk about levothyroxine pharmacology and how it is one of the most commonly prescribed medications.  Levothyroxine gets converted from T4 to T3 in the body. I also talk about some of the side effects that are encountered if we oversupplement as well as what we look for as far as lab work goes. Drug interactions are important with levothyroxine and I do discuss this as well as mention a couple of really common medications that can cause issues with thyroid hormone. All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

On this episode, I will discuss aminoglycoside pharmacology.  Gentamicin and tobramycin are the two classic examples of aminoglycosides.  We will review how these medication work in the body, adverse effects, and the importance of pharmacokinetics and laboratory monitoring. All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In this episode, I talk about the most commonly used statins.  In my practice I see simvastatin, atorvastatin, rosuvastatin, and pravastatin used most frequent. In addition, I also discuss why statins are dosed at night, possible side effects, and important drug interactions. Statins can help lower cholesterol and reduce the risk of cardiovascular events like heart attack.  I mentioned cvriskcalculator.com on the podcast and wanted to give that link to you. Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

Beta-blockers are commonly used in the management of hypertension as well as rate control for atrial fibrillation.  On this episode, I breakdown some of the most common agent and what to look out for.  Enjoy the show! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In the episode, I break down the pharmacology of lisinopril (and all ACE inhibitors).  I also outline common adverse effects, drug interactions and its role in managing hypertension.  Hope you enjoy the show and please feel free to reach out with feedback! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In this episode, I talk about the most important and common adverse effects with metformin and what you will likely see in clinical practice.  I also will talk about the benefits of the medication and its role in the management of type 2 diabetes.  Hope you enjoy the episode! All subscribers to the website/podcast will get access to a FREE Top 200 Drug Study Guide where I highlight the 3 most highly testable pearls from each medication (this is a 31 page PDF!)  In addition, you'll get a free 100 question pharmacology test.  Both resources are free, simply for following the podcast!  What are you waiting for? Click Here to Subscribe

In this introduction episode of Real Life Pharmacology, I discuss the two major reasons why I wanted to start this podcast.  I also share a little bit about my background which you can also find here. Reason 1: I want to help young healthcare professionals by providing an alternative option to help them learn pharmacology. Reason 2: I have had professors in college that don't practice in the real world and really have a tough time relaying important and relevant clinical information.  I wanted a way to share some of my experiences as a clinical pharmacist, which I believe will help you provide better care for your patients. If you'd like to be updated about future episodes and get a free 100 question pharmacology test (with answers), feel free to subscribe!  If you have any questions, feedback or concerns, please shoot us a message! (function() { window.mc4wp = window.mc4wp || { listeners: [], forms: { on: function(evt, cb) { window.mc4wp.listeners.push( { event : evt, callback: cb } ); } } } })(); Email address: First Name Leave this field empty if you're human: