Let's start with OTC anti-hyperlipidemics, you'll see these called anti-cholesterol drugs, or

things like that

there's, I put that they're over-the-counter

but they're also by prescription, and it's a little bit goofy

so the omega-3 acid ethyl esters are

actually Lovaza, which is a

which is a brand name for the prescription

omega-3 acid ethyl esters, and then niacin has a brand name of Niaspan, but you can still find

niacin and

fish oil

over the counter, which have essentially the same thing. So what's the what's the advantage of getting the prescription?

the FDA has tested those particular

medications the omega-3 and the niacin and to know that it's FDA-approved to know that it's at that level of purity

that can be an advantage.

The big OTC cardio drug is something that's been around for a long time

which is aspirin, but it's

used a little bit differently. So instead of the

325 milligram aspirin as an analgesic or for fever

we're talking about 81 milligrams

and

we used to have something called children's aspirin. We now know that aspirin can cause Reye's syndrome

spelled capital R-e-y-e-s, but pronounced rise like I rise in the morning and

this aspirin at 81 milligrams does a good job of keeping the platelets from getting sticky, and there's good

outcomes with morbidity/mortality

in terms of cardiac events like heart attack like stroke. So a daily aspirin

the physician tells the patient to take it but they can just find them over-the-counter.

But a very inexpensive way to help the patient and then just a reminder that this brand name, Ecotrin

is "enteric coated aspirin"

to help protect the stomach

from this non-steroidal, but again this aspirin is not being used for pain it's not being used for fever

It's being used because of its ability to thin the platelets.

Well the first prescription group

we have is going to be the diuretics and

with the diuretics what you want to do is in your mind picture the glomerulus and from the glomerulus

we want to go to the proximal convoluted tubule

then to the Loop of Henle

then to the distal convoluted tubule then to the collecting duct

and I say distal convoluted tubule and collecting duct as separate but

Really, we're talking early distal convoluted tubule but

that doesn't really matter as much as getting the order right

and the reason this order is so important is that diuresis

decreases as you get further away from the glomerulus

So if you think about being on a waterslide at the top of the waterslide

there's a lot of water coming out into that slide

But as you get to the bottom there's just a little trickle down at the bottom

same thing's true here, so the osmotic diuretic

mannitol [brand] Osmitrol. This is used for brain edema a very serious event but not used that often

So, the next group are the loop diuretics they work in the Loop of Henle, and we have furosemide and

This has a stem -semide stem. So there's torsemide, furosemide

other diuretics and the

the brand name comes from the fact that it lasts six hours so, Lasix

and this loop diuretic is used more for congestive heart failure or

severe edematous states where there's a lot of fluid that needs to be taken off

Or it might be used if the fluid needs to be taken off quickly.

When you're talking about treating hypertension, you could use furosemide,

but more likely you'll use a thiazide diuretic like

hydrochlorothiazide, abbreviated HCTZ

One of the brand names is Microzide, it was the capsule form.

And these thiazide diuretics are more used for somebody who has hypertension.

So if you look at again the diuresis, the mannitol would be the most, furosemide might be a little bit less,

hydrochlorothiazide less than that.

The issue with both furosemide and hydrochlorothiazide is that they decrease

potassium and because they decrease potassium we need to in some way get that potassium back.

So we have what's called a potassium sparing diuretic

Triamterene is one. It doesn't cause a significant amount of

diuresis because it really works closer to the collecting duct and the triamterene is

paired as a combination product with hydrochlorothiazide -- again the -thiazide stem

and triamterene's brand name was Dyrenium

and you take part of the hydrochlorothiazide or the ending to make the brand name Dyazide, so this was

d-y-r-e-n-i-u-m or used to be

but we don't really see that brand name on the shelf ever.

Potassium sparing: so

some triamterene alone is potassium sparing, spironolactone is another one. It's known as Aldactone

and while there's no stem here, know that

spironolactone

affects aldosterone and that a-l-d that's in the front of aldactone

is really referring to that

aldosterone that will retain sodium and water and then by blocking that sodium and water

Then we'll have some amount of diuresis and we'll hold on to the potassium, so they'll be an exchange

electrolyte replenishment

often with loop diuretics just adding a potassium

sparing diuretic wouldn't be enough. So you would need to have electrolyte replenishment

with potassium chloride and to make the brand name they took

the K from kalium which is the

symbol on the periodic table of elements for potassium and then D-U-R for duration, long duration.

So a potassium supplement that has a long duration

and again with diuretics you really want to memorize them in this order

from the glomerulus to the proximal convoluted tubule up the ascending Loop of Henle to the distal convoluted

tubule and then to the collecting duct to remember which has the most diuresis,

which has the least, where are the potassium sparings all the way on the other side by the collecting duct.

So from the diuretics we're going to go to the alpha

antagonist, the alpha agonist, the beta blockers, and talk a little bit about hypertension.

So the first thing I want to go over is alpha and beta

if you weren't in a Greek letter society you might not know the Greek alphabet

but the first two letters of the Greek alphabet are like our A and B

except we call it beta [Bay-tuh] if you were to go to the UK they call it Beta [Bee-tuh]

which actually makes a little more sense that it sounds like the B and our A

and B in the first two letters of the alphabet,

but the important thing to know is that if you

block the alpha-1 receptor you're going to get

vasodilation and then if you activate it you get vasoconstriction, so to treat hypertension

we want a lower blood pressure. To lower blood pressure, we would need to vasodilate

so we would use an alpha-1

antagonist or an alpha-1 blocker, and then it looks like a little fish with a 1 if you want to make the little

Greek form of the alpha, but the -azosin is the

stem and there's other drugs: terazosin, doxazosin [docks AH zo sin]

I've also heard it pronounced doxazosin [docks uh ZO sin]

but I've always pronounced it doxazosin [docks AH zo sin]

and then Cardura, it alludes a bit to cardiac or some kind of long-duration drug

the alpha-2 agonist clonidine, you can see this as a patch and

clonidine it's also used with

ADHD treatments, but in this case you want to maybe think about the brand name as

"catabolize blood pressure" or to lower blood pressure in some way or another and again

I put up the fish or backwards fish the alpha-2 is how most people will refer to it

just because it's a lot easier than writing out a-l-p-h-a-2

beta blockers fall into three generations

there's the important

part of the beta blocker name or the stem is the -o-l-o-l

and if you put those l's together o-l-o-l

you get two backwards Bs and you can think beta blocker

Inderal is the brand name [of propranolol] and the

way that you want to think about it is it blocks all of the beta receptors, so first generation beta blocker

it's non-selective it affects beta-1 and beta-2

so that it affects beta-1 is good it reduces heart rate

that it affects beta-2 is not good because in an asthmatic this can be problematic if

you have a something that blocks beta 2 receptors

then you would cause bronchoconstriction.

So just remember we have one heart, beta-1. We have two lungs, beta-2.

Beta blockers second-generation: so atenolol

metoprolol

are all very common beta blockers the difference is that we're only affecting beta one

so in this way atenolol and metoprolol are

similar but what I want to call your attention to are these salts and these aren't

stems, these are salts and

if it's a tartrate salt then it is short acting or shorter acting and if it's succinate

then it's longer-acting.

So someone might take one tablet a day versus two tablets a day depending on

which salt they have, so

if you just say metoprolol sometimes you're not giving enough information

to let us know, well, which one did you mean?

Beta-Blocker third generation: so carvedilol

I see a lot of

videos that say the -lol is a stem. It's not.

-alol is a stem. -olol is a stem and -dil- is a stem or at least an approved stem.

What it looks like they've done with this generic is they've recognized that Coreg affects beta-1 receptors

beta-2 receptors

but also has a vasodilatory property to it, so

having that d-i-l in there lets you know that it's a vasodilator and that d-i-

that d-i- really took the place of what would have been that first "o" to make -olol. So to remember it,

just think, okay

I would have had -olol, but I added this d-i-

and then I have the -dil- to let me know it's a vasodilator, and it has beta blocking activity as well.

Why would this be something that we want to do? Well if you lower heart rate, then your body is naturally going to

vasoconstrict to get the blood pressure back up. The body doesn't want the blood pressure to be down

so by vasodilating and lowering

heart rate then we're doing two things to maintain that

hypertensive patient in a normotensive state

So that's the alphas and betas

this next group comes from something called the

RAAS so the Renin Angiotensin Aldosterone System

so renin is an enzyme that converts angiotensinogen

it's a zymogen. If you want to think of a fire extinguisher with the pin in it

That would be a zymogen and if you pull the pin then you use the fire extinguisher

so angiotensinogen becomes angiotensin 1

but you still have to do something before the fire extinguisher will fire

so you can think of angiotensin converting enzyme

as the hand that actually pushes that fire extinguisher

making I guess would be carbon dioxide I'm not sure what gas is in there [to] make it work

so by going from angiotensinogen to angiotensin 1 to angiotensin 2

you now have a potent vasoconstrictor, so that's how it works

physiologically to raise blood pressure.

So, what we want to do though is lower blood pressure

so we would block that second enzyme, the angiotensin converting enzyme itself, and we have an ACE inhibitor

so an angiotensin converting enzyme inhibitor

and sometimes people call them the "pril's" because they always end in -pril or

enalopril lisinopril

So the renin was that first enzyme, the angiotensin is second,

the angiotensin one is second then angiotensin II is third, but then what about this aldosterone?

Well aldosterone

retains sodium and water as its physiologic purpose, so we're going to want to block that

to allow for the secretion of sodium and water and then in secreting the sodium,

it exchanges from potassium as a potassium sparing medication so

understanding the way that the electrolytes work is critical in the RAAS, and then it all comes together as a system

but what if a patient develops a dry unproductive cough?

And this can happen with angiotensin converting enzyme because of its effect on bradykinin.

What we do is not treat it. We don't give them codeine or we don't give them

dextromethorphan, what we do is we switch them to an ARB or an angiotensin II receptor blocker

So instead of affecting the enzyme, we're going to block the receptor itself

and some people call these the "sartans" because they all end in -sartan or s-a-r-t-a-n

and you can see some clues to

cardiac in the RAAS if you look at Cozaar backwards

It would be r-a-a-z or looks like RAAS and then Benicar, benefit cardiac.

Never came up with anything for Diovan

but the -van in Diovan takes the V and the last two letters of -sartan so again

understanding that ACE inhibitors, we've known them for a long time. They work very well

but you might switch a patient over to an ARB if there's some kind of non-productive cough caused by the ACE inhibitor.

All right, so let's go to calcium channel blockers and

two very different kinds of calcium channel blockers, one that

vasodilates and affects the heart and one that just vasodilates

so the non-dihydropyridine CCB's or calcium channel blockers

are the ones that affect both the heart and

cause vasodilation. Why is this important? Well beta blockers can be used as anti-dysrhythmics,

calcium channel blockers can be used as anti-dysrhythmics if they're in this non-dihydropyridine class.