Pepsi*Root Beer*Coke*Gingerale*Dr. Pepper

I’m already thankful for this rotation – it’s making the 1.5-hour drive round trip more bearable. My preceptor is really good at grilling me with questions, and doesn’t give in and help me out – she patiently waits while my mind fumbles through all the notes and lectures from class :). I’m understanding what my preceptor meant when she said she wanted me to be able to recognize what a medication does clinically as well as its ADRs just by knowing which receptors the drug acts on. Honestly, I feel like I had forgotten most of my pscyh drug knowledge by the end of that respective semester. I’m glad I have this rotation towards the end, since psych meds are important – A LOT of people here are on them, and it comes up a lot, even in the acute setting.

PTSD

I was working on a fairly complicated patient last week with PTSD from witnessing multiple suicides and burning bodies during the war. He even wakes up to the smell of burning flesh :(. I was taking a look at his chart because there was a nonformulary consult for Seroquel (quetiapine). We ended up denying it, since there were definitely other options for the patient – trialing another SSRI, trying venlafaxine, retrialing prazosin at a higher dose (had it before at a max dose of 6mg/day) for his nightmares, or D/C’ing the atypical antipsychotic altogether – since he has a history of drug abuse, and his psychotic sx could have been from that (he is clean now). When it comes to PTSD, there are 3 groups of sx you would look for: hyperarousal (does usually respond to meds), avoidance (usually does not respond to meds, but is most important to treat, since it’s linked to suicide), and flashbacks/nightmares. SSRI’s have shown to help with the hyperarousal sx.

Receptors

NE: is an activating neurotransmitter, and causes vasoconstriction

5HT: is an activating neurotransmitter, can cause insomnia, headaches

5HT2A: too much of it causes sexual dysfunction

5HT3: too much of it causes nause/diarrhea

DA: activating neurotransmitter

Ach: too much causes everything to become “more wet” – increased salivation, diarrhea, urinary frequency, N/V, sweating.

Alpha1: blocking this causes orthostatic hypotension

Alpha2: centrally acting adrenergic receptor. Agonizing this causes a negative feedback in the brain, and signals body to stop producing NE (mainly). Think of how clonidine works…agonizes alpha2, less NE, less vasoconstriction, tx for HTN.

H1: blocking histamine1 causes sedation and weight gain

About SSRI’s

My preceptor and I had an awesome discussion about this class of medications. My question to her was, “I realize that a pt with depression needs to be treated with an SSRI for an adequate amount of time (~4-6 weeks) before saying pt failed therapy. So, if increasing the dose of an SSRI, would the 4-6 weeks start over, or continue?” This led us to a discussion about how SSRI’s work…and this is illustrated by the picture. So what’s the connection between the picture and my question? Wish I had a more definite answer, but as always – depends on the patient! Although, as long as the patient is tolerating the medication but hasn’t completely reached remission, I would consider upping the dose at around 4 weeks. 

Fun facts:

*My grandpa always used to chew on this stuff called “Paak” in India after meals. He always told me it aided in digestion, and I tried it a few times (it’s not bad, but not really good either). It’s also known as “betel nut.” Apparently, arecoline is the active ingredient in this stuff, and it’s also a cholinomimetic alkaloid, which means increased acetylcholine! It causes extensive salivation, and also causes a mild euphoria ;).

The dark stuff is the betal nut.

 *Pepsi, Root beer, Coke, Gingerale, and Dr. Pepper were all invented by PHARMACISTS!! Back in the day, a pharmacist was someone who owned a drug store and sold medications (of course we know it’s so much more than that today). It was customary to also have a soda fountain in the store…so my guess is that these pharmacists experimented with a variety of concoctions and came up with these very popular drinks :).

Caleb Bradham - Pepsi

John Pemberton - Coke